CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Acupuncture and Needling Services Medicare Advantage Plans Dry

Defines coverage, limits, provider qualifications, and coding rules for acupuncture (including acupuncture for chronic low back pain) and dry needling for Blue Cross Blue Shield Rhode Island Medicare Advantage members. Includes visit limits, exclusions, provider licensing/education requirements, and applicable CPT codes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Acupuncture and Needling Services Medicare Advantage Plans Dry

Policy CodePolicy N/A

Change TypeOperational coding restriction; administrative update

Effective DateJan 1, 2021

Next Review Date

Key ActionEnsure provider holds an active unrestricted license and ACAOM-accredited masters/doctoral degree and document licensure and credentials.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2024, needling codes (20560 and 20561) are not covered on the same date of service as acupuncture codes.

Updated policy last updated date to 11/01/2023 (published Provider Update December 2023).

20Max visits for cLBP

12Max visits for other indications (per calendar year)

20560/20561Needling CPTs restricted from same-day use with acupuncture

Coverage Summary

This policy defines coverage for acupuncture and dry needling for Medicare Advantage members, with a mixed coverage stance: acupuncture and an initial evaluation are covered when rendered by qualified licensed providers for covered indications, dry needling is permitted only as part of the chronic low back pain (cLBP) benefit, and limits and coding rules apply. Effective date is 01/01/2021; policy status is CURRENT and the policy was last updated on 11/01/2023 (published Provider Update December 2023).

Numeric thresholds and same-day needling restriction

cLBP visit limit<= 20 visits (for chronic low back pain)

Other indications annual limit<= 12 visits per calendar year

cLBP duration requirement>= 12 weeks (chronic low back pain defined as lasting 12 weeks or more)

Needling same-day restrictionNeedling CPTs 20560 and 20561 not covered on same date of service as acupuncture (effective Jan 1, 2024); restriction count: 2 codes

Medical-Necessity Criteria

General Coverage / Licensed Provider Requirement

Acupuncture and an initial evaluation (for a new patient) is covered when rendered by a licensed provider for covered indication:

Provider qualifications: Provider is a licensed doctor of acupuncture (D.Ac) or physician (MD or DO) or other permitted practitioners (PAs, CNSs, auxiliary personnel) who meet applicable state requirements
License requirement: Provider holds a current, full, active, and unrestricted license to practice acupuncture in a U.S. State, Territory, Commonwealth, or District of Columbia
Education requirement: Provider has a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM)

Coding

Covered CPT - Chronic Low Back Pain and other acupuncture visitsCPTCovered

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; with re-insertion of needle(s)
97813	Acupuncture; 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814	Acupuncture; 1 or more needles; with electrical stimulation, each additional 15 minutes; with re-insertion of needle(s)

Covered CPT - Evaluation & Management (Initial/Established when separately identifiable)CPTCovered

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
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

Needling CPT (Dry needling) - ConditionalCPT

20560	Needle insertion(s) without injection(s); 1 or 2 muscle(s)
20561	Needle insertion(s) without injection(s); 3 or more muscles

Provider Actions & Billing Rules

Documentation Required

Provider licensing & education documentation

Verify and document that the provider holds a current, full, active, and unrestricted license to practice acupuncture in the applicable U.S. State, Territory, Commonwealth, or District of Columbia, and that the provider has a masters or doctoral level degree in acupuncture or Oriental Medicine from an ACAOM‑accredited school.

Copy of current state license (showing full, active, unrestricted status)
Copy of masters or doctoral degree in acupuncture or Oriental Medicine
Proof of school accreditation by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM)

Billing Rule

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 (separately identifiable E/M). Note that acupuncture codes (97810, 97811) include pre-, intra-, and post-service evaluation and management elements as part of the acupuncture service.

Background & Definitions

Background: Acupuncture is defined as insertion/manipulation of needles at specific points and includes several technique variations (e.g., shallow, intradermal, intramuscular needling, with or without sensations such as numbness, tingling, electrical sensation, soreness, warmth). The policy outlines provider qualifications (licensed D.Ac or physician MD/DO; PAs, CNSs and auxiliary personnel may furnish acupuncture if state requirements are met) and education requirements (masters or doctoral degree from an ACAOM-accredited school and an active, full, unrestricted license). It distinguishes dry needling (needling) from acupuncture, permits needling only as part of the cLBP benefit, and notes exclusions including acupuncture as an anesthetic for surgery, adjunctive therapies (e.g., moxibustion, herbs, oriental massage), and precious metal needles. The policy references CMS National Coverage Determinations for acupuncture and cLBP in support of these rules.

Term	Definition
Chronic Low Back Pain (cLBP)
Pain lasting 12 weeks or more, nonspecific (no identifiable systemic cause), not associated with surgery or pregnancy per CMS definition.
New patient (for initial E/M)
A patient who has not received any professional services from the physician within the prior three years (per CPT guidelines).

Evidence/citation: This policy references the Centers for Medicare & Medicaid Services National Coverage Determination for Acupuncture for Chronic Low Back Pain and related CMS NCDs, and the policy follows CMS definitions and limits for cLBP (including the CMS-defined duration threshold and visit limits) as noted in the referenced CMS materials.

Revision History

2024-01-01operationalLatest

Effective January 1, 2024, needling codes 20560 and 20561 are not covered on the same date of service as acupuncture codes.

2023-11-01administrative

Policy last updated date set to 11/01/2023 (published in Provider Update December 2023).