CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Acupuncture services coverage and reimbursement

Defines reimbursement and coverage rules for acupuncture services for Blue Cross Blue Shield - Rhode Island commercial products that include an acupuncture benefit, including provider qualifications, covered CPT codes, and excluded services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAcupuncture services coverage and reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review DateMay 11, 2025

Key ActionPrior authorization is not required for acupuncture services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97810–97814CPT codes listed as covered when acupuncture benefit purchased

99202–99205Initial evaluation E/M

RIGL 27-20-42State statute

AssistantsNot separately reimbursable

Moxibustion, herbs, etc.Excluded adjunctive therapies

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Coverage Criteria and Limitations

Coverage criteria and limitations

Coverage applies only for commercial groups that purchase a plan with acupuncture services and is governed by Rhode Island statute where applicable.

Eligibility limited to Commercial plans that purchase an acupuncture benefit (not a standard benefit) and as reflected in the group's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement; self‑funded groups may opt out of state mandates where applicable.

ALL of the following

Covered providers:
- Licensed doctor of acupuncture (D.Ac.)
- Physician (Rhode Island‑licensed MD or DO) who meets Rhode Island Department of Health medical acupuncture training requirements (minimum 300 hours of formal instruction and supervised clinical practicum)
Acupuncture assistants are not recognized for separate reimbursement and are considered inclusive of the acupuncture reimbursement (not separately reimbursable).

ALL of the following

Covered acupuncture CPT codes (when a plan with acupuncture services has been purchased): 97810 and 97811 (without electrical stimulation).
CPT codes 97813 and 97814 (with electrical stimulation) are covered when filed with a covered diagnosis and when the plan's acupuncture benefit applies (calendar year 2022 coverage effective per individual/group plan renewal).

ALL of the following

An initial evaluation E/M (99202–99205) is allowed only for new patients.
Definition of new patient: a patient who has not received any professional services from the physician within the past three years (per CPT guidelines).
Providers in Acupuncture Specialty (053) may file only the codes in this policy; do not file an E/M on the same date as an acupuncture service unless Modifier -25 criteria are met.

Exclusions and limitations: acupuncture with electrical stimulation for indications unrelated to low back pain is not covered; adjunctive therapies (for example, moxibustion, herbs, oriental massage) are not covered; acupuncture used as an anesthetic during surgery, precious metal needles, acupuncture in lieu of anesthesia, and any service not specifically listed as covered are not covered.

Applicability notes: actual applicability and any plan‑specific limits depend on the group's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement; Rhode Island statutory provisions (RIGL 27‑20‑42) inform availability as an optional rider for group health plans.

Codes, Definitions, and Billing Rules

Acupuncture CPT codesCPTCovered

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)
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 of personal one-on-one contact with the patient, with re-insertion of needle(s)

E/M codes referencedCPT

99202	Office or other outpatient visit for the evaluation and management of a new patient, 15-29 minutes
99203	Office or other outpatient visit for the evaluation and management of a new patient, 30-44 minutes
99204	Office or other outpatient visit for the evaluation and management of a new patient, 45-59 minutes
99205	Office or other outpatient visit for the evaluation and management of a new patient, 60-74 minutes
99211	Office or other outpatient visit for the evaluation and management of an established patient, may not require presence of physician
99212	Office or other outpatient visit for the evaluation and management of an established patient, 10-19 minutes
99213	Office or other outpatient visit for the evaluation and management of an established patient, 20-29 minutes
99214	Office or other outpatient visit for the evaluation and management of an established patient, 30-39 minutes
99215	Office or other outpatient visit for the evaluation and management of an established patient, 40-54 minutes

New patient definition (3-year lookback)

DefinitionA new patient is one who has not received any professional services from the physician within the past three years (per CPT guidelines).

Applies toInitial evaluation E/M codes (99202-99205) only; allowed for new patients as defined above.

Documentation implicationProviders must verify patient has not received professional services from the physician in prior 3 years before billing initial evaluation codes.

Provider Actions and Authorization

Prior Authorization

Prior authorization: Not applicable

Prior authorization is not required for acupuncture services under this policy.

Key Definitions

Doctor of acupuncture — statutory definition

Statutory definition'Doctor of acupuncture' means a practitioner licensed under chapter 37.2 of title 5 (RIGL § 27-20-42(b)(1)).

Scope of practice noteRhode Island statute and Department of Health rules/regs define licensing and practice standards for doctors of acupuncture.

Contracting discretionNon-profit medical service corporations retain sole discretion as to which doctors of acupuncture they contract with (RIGL § 27-20-42(c)).

Acupuncture assistant reimbursement

Reimbursement policyAcupuncture assistants are not recognized for separate reimbursement and are considered inclusive of the acupuncture reimbursement.

Billing implicationServices performed by acupuncture assistants should be billed under the supervising licensed provider's acupuncture codes, not billed separately.