CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy | Acupuncture Services for Commercial Products

Governs coverage and billing rules for acupuncture services under Blue Cross Blue Shield Rhode Island Commercial plans that include an acupuncture benefit; affects providers rendering acupuncture and groups that purchase acupuncture coverage in RI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy | Acupuncture Services for Commercial Products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionDo not bill an E/M on the same date as acupuncture unless Modifier -25 documents a separately identifiable E/M service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97810/97811 coveredCovered vs excluded CPT codes

99201-99205 allowedE/M allowance

RIGL 27-20-42State mandate context

RI DOH training/licensureProvider qualification requirement

Prior auth not applicableAuthorization requirement

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy | Acupuncture Services for Commercial Products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionDo not bill an E/M on the same date as acupuncture unless Modifier -25 documents a separately identifiable E/M service.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Coverage criteria for commercial acupuncture benefit

Covered when ALL of the following are met:

Applies to Commercial plans in which acupuncture services are a covered benefit (available only for groups that have purchased an acupuncture benefit; optional rider per RIGL 27-20-42).

ALL of the following

ONE of: Licensed doctor of acupuncture (D.Ac.).
ONE of: Rhode Island–licensed physician (MD or DO) who meets Rhode Island Department of Health training/licensure criteria for medical acupuncture (minimum training or supervised practicum as specified by RI DOH).

ALL of the following

ONE of: CPT 97810 — Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
ONE of: CPT 97811 — Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes, with re‑insertion of needle(s).
ONE of: Evaluation and Management (99201-99205) — initial evaluation allowed only for new patients (a new patient is one who has not received any professional services from the physician within the past three years). E/M codes are only used for separately identifiable procedures and should not be billed on the same date as acupuncture unless Modifier -25 criteria are met.

ALL of the following

Acupuncture with electrical stimulation (CPT 97813, 97814) — contract exclusions (non‑covered).
Adjunctive therapies such as moxibustion, herbs, oriental massage, etc. — not covered.
Acupuncture used as an anesthetic during a surgical procedure; acupuncture in lieu of anesthesia; precious metal needles (e.g., gold, silver); and any other service not specifically listed as covered — not covered.

ALL of the following

Acupuncture assistants are not recognized for separate reimbursement and are considered inclusive in the acupuncture reimbursement.
Local providers in the Acupuncture Specialty (053) may file only the codes listed in this policy. Providers should not file an E/M on the same date as acupuncture unless it meets the definition for Modifier -25. The acupuncture codes include pre-, intra-, and post‑service evaluation and management as part of the treatment.

Coding and Patient Status

Covered 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)
99201-99205	Initial evaluation (allowed only for new patients)

Not Covered / Contract ExclusionsCPTNot Covered

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)

New patient (per CPT guidance)

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

Coding impactInitial evaluation codes 99201-99205 are allowed only for new patients when acupuncture is rendered.

Use caseApplies when billing initial E/M in conjunction with acupuncture; verify patient has no professional services from the same physician in prior 3 years.

Provider Actions / Billing Guidance

Prior Authorization

Prior Authorization and E/M Billing Guidance

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

Do not file an E/M service on the same date as an acupuncture service (CPT 97810, 97811) unless the visit meets the definition for use of modifier -25 (separately identifiable E/M service).
The acupuncture codes 97810 and 97811 include pre-service, intra-service, and post-service evaluation and management related to history, evaluation, management and documentation as part of the daily treatment.
Evaluation and Management (E/M) codes may only be billed in addition to acupuncture when the E/M is a separately identifiable procedure and modifier -25 is appended as appropriate.
Covered acupuncture CPT codes when a plan includes acupuncture services: 97810, 97811.
Contract exclusions (non-covered acupuncture CPT codes): 97813, 97814.

Definitions

Doctor of acupuncture — qualifications

Definition/TitleDoctor of acupuncture (D.Ac.) = practitioner licensed under chapter 37.2 of title 5 (Rhode Island) or other licensed practitioner meeting RI DOH requirements.

Physician provisionRhode Island-licensed MD or DO may render acupuncture only after meeting RI Department of Health criteria (either meet D.Ac. licensure requirements or complete a physician course with ≥300 hours formal instruction plus supervised clinical practicum).

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

New patient (policy definition)

Policy definitionNew patient — as defined in CPT: a patient who has not received any professional services from the physician within the past three years.

Billing consequenceInitial evaluation (99201-99205) is allowed only for new patients in the context of acupuncture services.

Verification guidanceConfirm absence of professional services from the same physician in prior three years before billing initial E/M with acupuncture.