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Defines coverage, limits, provider qualifications, coding, and exclusions for acupuncture (including chronic low back pain) and dry needling for Medicare Advantage members under Blue Cross Blue Shield Rhode Island.
Policy last updated 06/15/2022; effective date 01/01/2021.
This policy covers acupuncture and dry needling for Medicare Advantage members under Blue Cross Blue Shield Rhode Island, defining provider qualifications, coding, limits, and exclusions. It applies to initial evaluations for new patients and ongoing acupuncture or dry needling visits. High-level visit limits: up to 20 visits for chronic low back pain (cLBP) and up to 12 visits per calendar year for all other indications. The coverage stance is mixed, with specific covered uses and explicit exclusions noted.
General Coverage / Provider Qualifications
Acupuncture and an initial evaluation (for a new patient) is covered when rendered by a licensed provider for covered indications:
Supported by provider qualification statements.
ACAOM accreditation requirement cited.
Not Covered / Exclusions
The following are not covered:
| 97810 | Acupuncture; 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient |
| 97813 | Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient |
| 97811 | Acupuncture, 1 or more needles; without electrical stimulation; each additional 15 minutes of personal one-on-one contact with the patient; with re-insertion of needle(s) |
| 97814 | Acupuncture, 1 or more needles; with electrical stimulation; each additional 15 minutes of personal one-on-one contact with the patient; with re-insertion of needle(s) |
| 20561 | Needle insertion(s) without injection(s); 3 or more muscles |
| 20560 | Needle insertion(s) without injection(s); 1 or 2 muscles |
| 97810 | Acupuncture; 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient |
| 97811 | Acupuncture, 1 or more needles; without electrical stimulation; each additional 15 minutes of personal one-on-one contact with the patient; with re-insertion of needle(s) |
| 99202 | Office or other outpatient visit for the evaluation and management of a new patient |
| 99203 | Office or other outpatient visit for the evaluation and management of a new patient |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient |
| 99205 | Office or other outpatient visit for the evaluation and management of a new patient |
| 99211 | Office or other outpatient visit for the evaluation and management of an established patient; may not require presence of a physician or other QHP |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient |
| 99215 | Office or other outpatient visit for the evaluation and management of an established patient |
Provider Qualifications and Documentation
Ensure provider meets applicable state requirements. Licensed doctors of acupuncture (D.Ac) or physicians (MD/DO) may furnish acupuncture per state rules. PAs, NPs/CNSs, and auxiliary personnel may furnish acupuncture only if they meet state requirements and hold a masters or doctoral level degree in acupuncture or Oriental Medicine from an ACAOM-accredited school. Document and verify new patient status (a patient who has not received any professional services from the physician within the past three years) to bill initial evaluation codes 99202-99205.
Acupuncture includes insertion and manipulation of needles and multiple variations such as shallow, intradermal, or intramuscular needling, which may produce sensations like numbness, tingling, electrical sensation, fullness, distension, soreness, warmth, or itching; practitioners may seek sensations of tenseness or a dragging feeling by twirling, plucking, or thrusting needles. Dry needling is considered within the same modality spectrum for cLBP and is included under the cLBP visit limit. The policy references CMS national coverage determinations for acupuncture, including the NCD for Acupuncture for Chronic Low Back Pain (30.3.3) and related NCDs for other indications.
| NCD Name | NCD Number/Type |
|---|---|
| Acupuncture for Chronic Low Back Pain | 30.3.3 (NCD) |
| Acupuncture | 30.3 (NCD) |
| Acupuncture for Fibromyalgia | 30.3.1 (NCD) |
| Acupuncture for Osteoarthritis | 30.3.2 (NCD) |
New patient: per CPT guidelines and this policy, a new patient is a patient who has not received any professional services from the physician within the past three years.
cLBP: chronic low back pain (cLBP) is defined as the CMS definition referenced in the policy and used to determine eligibility for the cLBP-specific coverage and the up to 20 visit limit for acupuncture or dry needling.
Policy effective date 01/01/2021.
Policy last updated 06/15/2022.
Published in Provider Update August 2022.
New patient definition per CPT guidelines.
Billing guidance for separately identifiable E/Ms.
Acupuncture for Chronic Low Back Pain (cLBP)
Covered when ALL of the following are met:
CMS defines cLBP per referenced NCD.
Specific exclusions listed in policy.
Visit limit includes acupuncture and dry needling.
Acupuncture for All Other Indications
Covered when ALL of the following are met:
Member benefit applicability noted.
Benefit limit for all other indications.
Dry Needling / Needling
Coverage statements for needling:
Policy explicitly includes dry needling in cLBP visit limit.
Non-coverage for needling outside cLBP.
Services not explicitly listed as covered in this policy are excluded from coverage. For example, needling for any condition other than chronic low back pain is not covered, and adjunctive therapies (moxibustion, herbs, oriental massage), precious metal needles, acupuncture used as an anesthetic during surgery, and acupuncture in lieu of anesthesia are specifically excluded. The policy references CMS National Coverage Determinations (NCDs) related to acupuncture and cLBP to align coverage decisions with Medicare guidance.
E/M and Acupuncture Same-Day Billing
Do not file an E/M service on the same date as an acupuncture service unless the visit meets the definition for use of Modifier -25 for a separately identifiable E/M. Affected E/M codes include 99202-99205 and 99211-99215. Affected acupuncture codes include 97810, 97811, 97813, and 97814.
Visit Limit Denials
Claims for acupuncture or dry needling that exceed the stated visit limits will not be covered. For chronic low back pain (cLBP), up to 20 acupuncture or dry needling visits are covered; services greater than 20 are not covered. For all other indications, up to 12 acupuncture visits per calendar year are covered; services greater than 12 visits per year are not covered.
Published in Provider Update December 2021.
Published in Provider Update December 2020.
Medical criteria: Not applicable.
Prior authorization: Not applicable.