Current Procedural Terminology (CPT) codes

Updated for 2017 on 1/18/16

CPT codes are the Current Procedural Terminology codes. They describe which treatments were administered. There are only a handful of codes relevant to an acupuncturist. Codes are broken down into three major categories which include evaluation and management, procedures, and supplies.

Evaluation and Management (E & M) CPT Codes

Evaluation and management (E & M) codes are billable codes for assessing a patient’s condition, both initially and during regular intervals of re-evaluation. Most insurance companies will pay for an initial E & M evaluation. There are five initial E & M codes. Which one is used depends on how thorough the evaluation was. Initial E & M codes can only be used once every three years by any one acupuncturist. In other words, if you see a patient once, bill an initial code and don’t see them for another two and a half years, you cannot bill another initial E & M code. In the same way, if a patient returns after being gone for more than three years, one could charge an initial E & M code again. If a patient was seeing another acupuncturist in the same office within the past three years and now another practitioner is seeing them for the first time, an initial E & M should not be charged, but a re-eval E & M can and should be charged instead. The three year rule for charging initial E & M codes applies to the practitioner and anyone of the same specialty within the same office and does not apply to practitioners of the same specialty NOT in the same office. So if a patient were seeing an acupuncturist at a different office and just switched to you, it is acceptable to charge for the E & M code as you should be performing this service prior to any treatment.

Every acupuncture procedure, according to the CPT definition, includes a little time for a brief history and exam and therefore E & M codes should not and really cannot be billed for every visit.

E & M codes use three criteria for determining which one should be used. While time is not one of these factors it can be an indicator of the other three criteria. Initial E & M codes must meet all three of the given criteria in order to be considered at that code level. If the condition doesn’t meet all three criteria it needs to be down-coded. These criteria are history, examination, and medical decision making. Three other criteria can help influence the code chosen but is not a main determinant. These are counseling, coordination of care, and nature of presenting problem.

History is broken down into 4 major categories. These are focused, expanded, detailed, or comprehensive. Most of our initial histories are probably in the comprehensive or detailed area unless we are focusing on a specific injury. Exams also follow this break down and our exams are generally detailed or focused. They are rarely comprehensive given the amount of training of most practitioners. Medical decision making is a little more complicated.

The five initial E & M codes are each described as “office or other outpatient visit for the evaluation and management of a new patient.” They are:

Code	History	Exam	Medical decision making		Typical face-to-face time (minutes)	RVU
99201	Problem-focused	Problem-focused	Straightforward		10	0.76
99202	Expanded problem-focused	Expanded problem-focused	Straightforward		20	1.43
99203	Detailed	Detailed	Low		30	2.17
99204	Comprehensive	Comprehensive	Moderate		45	3.67
99205	Comprehensive	Comprehensive	High		60	4.78

Initial Evaluation and Management codes – all three major criteria must be met in order to justify a particular code. RVU stands for relative value unit and is used to determine how much should be paid for a given CPT code.

In general, 99203 is the most commonly used initial E & M, and should form the bulk of your billed codes. 99204 should be used rarely and 99205 should almost never be used, even if you do spend the time with the patient, it is a major red flag to insurers. Both 99204 and 99205 are used when there is a risk of a prolonged or severe functional impairment, disability, or dying from the patient’s condition (Collins, 2006).

When a patient is reassessed, a different set of E & M codes is used. These are often called re-eval E & M codes. These codes are used for re-evaluating patients on a regular basis. While a practitioner can use time as a factor for when to do and bill a re-eval E & M, a better criteria would be to establish an initial treatment plan that includes a re-eval every 4-12 visits. Re-evals have the same three criteria of the initial E & M codes, however, only two need to be met in order to bill a particular code. The description of these codes is “office or other outpatient visit for the evaluation and management of an established patient.” They include:

Code	History	Exam	Medical decision making		Typical face-to-face time (minutes)	RVU
99211	Not required	Not required	Not required		5	0.26
99212	Problem-focused	Problem-focused	Straightforward		10	.72
99213	Expanded problem-focused	Expanded problem-focused	Low		15	1.44
99214	Detailed	Detailed	Moderate		25	2.22
99215	Comprehensive	Comprehensive	High		40	3.14

Established patient Evaluation and Management codes – two of the three major criteria must be met in order to justify a particular code. RVU stands for relative value unit and is used to determine how much should be paid for a given CPT code.

Again, most re-evals should be billed with a 99213. 99214 should be rarely used, and 99215 should almost never be used.

Unless an evaluation is performed without doing a procedure on the same day, the E & M code must have a modifier of -25 attached. In other words, if one evaluates a patient for the first time and treats them with acupuncture in the same visit then 99203-25 needs to be billed, not 99203. See more about modifiers later in this chapter.

If you spend extra time with a patient doing a new or established patient E & M service, there are a couple of ways to bill this. The first is to add a modifier to the original E & M code. Adding a -21 modifier to an E & M code indicates a prolonged, continuous service. Many insurance companies will not pay extra for this modifier, and those that do will probably require additional documentation regarding the service provided. In general, it is probably better, if justified, to bill a higher code than to use this modifier (for example use 99203 rather than a 99202). Another way to bill for a prolonged E & M is to use a separate code. 99354 is for an additional hour of E & M service. Officially, it states: “Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (CPT Codes).” This is an additional code to a regular new or established patient E & M code. If you still need more time, the 99355 is for additional 30 minute increments. 99354 and 99355 are not paid for by most insurances, but is paid for by some workers comp systems, including California’s. In order to justify their use, documentation must show how much time was spent on each service. The simplest way to do this is to note next to each section how many minutes it took.

Other evaluation and management codes

Other E & M codes exist and acupuncturists can bill for them, however, they are rarely reimbursed by insurance companies with the possible exception of California’s workers comp. These include telephone call codes (99371-99373) and team conferences (99361 & 99362).

Code	Explanation	Minutes	RVU
99361	Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate patient care while patient is not present.	30	*
99362	Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate patient care while patient is not present.	60	*
99371	Simple or brief: Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals.		*
99372	Intermediate: Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals.		*
99373	Complex or lengthy: Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals.		*

* These codes do not have RVU’s attached to them

Other Evaluation and Management codes. RVU stands for relative value unit and is used to determine how much should be paid for a given CPT code.

Other E & M codes include consultation codes for new patients (99241-99245) and established patients (99251-99255). Again, these can be billed but are rarely reimbursed.

Procedures

While evaluation and management are about history, exam, and planning treatment, procedures are about the actual treatment. Almost every type of treatment is assigned a procedure code. These may be broken down into modalities and procedures. A procedure is any therapy applied to a patient. These would include acupuncture, massage, moxa, etc… A modality is a physical object applied to a body in order to affect a therapeutic change. They can be supervised or need constant attention. In the case of a supervised modality, a practitioner may leave the treatment area which is not the case in a constant attendance modality. Examples of a supervised modality include the use of a heat pack or infrared lamp. Constant attendance modalities with the exception of manual electrical stimulation are rarely used in acupuncture but include ultrasound therapy.

Units

A unit is the number of times a particular CPT code is used. Some CPT codes can only have 1 unit attached to them, others can have several. Any CPT code that has the word “initial” in its description is probably a 1 unit CPT code. An example of this is 97810 the initial acupuncture code. Others can be billed for as many units as performed. For example, 97140 manual therapy (which may include massage) is billed in 15 minute units. So if you spent 45 minutes on a massage, billing 3 units is possible.

Time

Another factor in billing is time. Units are usually, when talking about procedures, about time. Acupuncture is billed in increments of 15 minutes. While that may seem very straight forward, there is a quirk. A unit is achieved when half that time is reached. In other words, a full unit of acupuncture is reached when 8 minutes of time is done, not the full 15 minutes. If we are billing for massage (which is billed in 15 minute units), 1 unit is reached at 8 minutes and continues to 22 minutes of massage, a second unit is achieved at 23 minutes (15 minutes plus ½ of another 15 minutes). With these definitions, hopefully the reader can see how important it is to record the time spent on any procedure.

Acupuncture codes

The main procedures for an acupuncturist are the acupuncture codes. There are two sets of two codes each. The two sets are for acupuncture and acupuncture with electrical stimulation. Each of these is broken down into two codes, the first for the initial 15 minutes of basic history and insertion of needles and the second for an additional re-insertion for 15 minutes. Only 1 unit of the initial codes can be billed on any given visit while any number of units may be billed for the reinsertion code. Just remember, billing for multiple units does not mean getting paid for multiple units.

Code	Explanation	Minutes	Units	RVU
97810	Acupuncture without electrical stimulation, initial 15 minutes of contact with the patient	15	Single	.87
97811	Acupuncture without electrical stimulation, each additional 15 minutes of contact with the patient, with re-insertion of needle(s) [emphasis added]. Must be used with 97810.	15	Multiple	.72
97813	Acupuncture with electrical stimulation, initial 15 minutes of contact with the patient	15	Single	.94
97814	Acupuncture with electrical stimulation, each additional 15 minutes of contact with the patient, with re-insertion of needle(s) [emphasis added]. Must be used with 97813.	15	Multiple	.79

Acupuncture CPT codes. RVU stands for relative value unit and is used to determine how much should be paid for a given CPT code.

97810 cannot be billed with either a 97813 or 97814 and vice versa. In other words, a practitioner cannot combine non-estim acupuncture with estim acupuncture. If you start with a 97810 and do a reinsertion, even if it involves estim, you must bill 97811. And if you bill 97813, you must bill 97814 upon reinsertion regardless if there is estim or not. The take home message is: if you are going to do some acupuncture with estim and some without, start with the estim as it has a higher reimbursement.

An important concept here is that both 97810 and 97813 contain some basic history and exam within the code and pays more for it. This means you cannot bill an E & M code in addition to an acupuncture code on every visit; only on the initial visit and periodic re-evaluations. Both 97811 and 97814 require a re-insertion. That means if an acupuncturist puts needles in a patient and then leaves the room for 40 minutes, he or she can only bill for a 97810 not for a 97810 and 2 units of 97811. It also means if a practitioner does 25 minutes of acupuncture without reinsertion and then cups for 15 minutes, he or she cannot bill for a 97810 and a 97811 because there was no re-insertion of needles and cupping is not considered acupuncture. In this case, they may be able to bill for a 97140, manual therapy, for the cupping, in addition to the 97810, and hope the insurance company pays.

California workers compensation is almost a separate system in their coding. Instead of 97811 through 97814 they use just 97780 for no electrical stimulation and 97781 for acupuncture with electrical stimulation. These are based on the old CPT codes. When the rest of the country changed to 97811-97814 around 2004-5, the California workers comp system did not. This means there are no codes for an additional 15 minutes of re-insertion and you can use more than one unit of time for these codes. At the time of writing this, there are proposals to update the California workers compensation system to the coding system used by everyone else in the United States.

Other CPT codes

There are many other codes that can be used in an acupuncture practice, though not all insurance companies will pay for each of these codes. Some insurance companies allow you to ask for what codes they will compensate and others need to be determined by talking with other experienced acupuncturists or through trial and error.

Billing for massage is a somewhat controversial endeavor. A straight massage code exists (97124). The reimbursement for this is usually pretty low. Some acupuncturists prefer to bill another code for manual therapy technique (97140) because it pays more and yet the description still fits and is more widely accepted by insurance companies. Another code, 97250 for myofascial release, is not part of the CPT codes anymore but is billable under the California workers compensation system and should be used in that scenario as 97140 is not used in that system.

Code	Explanation	Notes	Minutes	Units	RVU
97010	Hot or cold packs applied to one or more areas			Single	.17
97012	Mechanical traction to one or more areas	Used when using a device to apply traction		Single	.46
97014	E-Stim Unattended, to one or more areas			Single	.45
97016	Vasopneumatic devices to one or more areas	Might be used for cupping		Single	.55
97026	Infrared Therapy	Use for employing a heat lamp			.17
97110	Therapeutic exercise to develop strength, endurance, range of motion, and/or flexibility*		15	Multiple	.92
97112	Neuromuscular reeducation of movement, posture, balance, proprioception for sitting and/or standing activities, and/or kinesthetic sense*		15	Multiple	.96
97124	Therapeutic procedure; massage		15	Multiple	.74
97140†	Manual therapy techniques, for example mobilization/ manipulation, manual lymphatic drainage, and manual traction, each 15 minutes	Many acupuncturists use this code instead of 97124 when doing massage as it pays more and can be justified	15	Multiple	.85

Other CPT codes

* These are controversial in that they are generally considered physical therapy codes. In some states, including California, they may fall into an acupuncturist’s scope of practice. Since they are controversial, careful documentation is even more important than usual.

† When using 97140 three things should be noted: what technique is used, location, and time.

Medical records

When a patient, insurance company, or other entity requests medical records, it is allowable and expected to charge for these requests. There are two codes that cover these requests. The first is an overall administrative fee and the second is a per page fee. Generally, one would charge for both, though certain state entities have their own dictated charges. For example, California evidence code (for lawsuits) dictates $24 per hour for administrative costs and 10 cents per page. (Collins, 2009, Sept.)

Code	Explanation	Units
S9981	Medical records copying fee, administrative	Single
S9982	Medical records copying fee, per page	Multiple

Medical records CPT codes

Tests & measurements

Depending on the scope of practice for acupuncturists in individual states, there are a slew of tests that could be performed in an acupuncturist’s clinic. Each of the following is probably within the scope of practice in California and possibly elsewhere. While they may seem to be very biomedical, they can be very useful for Chinese medical patients. For example, knowing if a patient is pregnant or not has a large impact on acupuncture point choice.

Code	Explanation	Minutes	Units	RVU*
81002	Urinalysis nonauto w/o scope		Single	$3.50
81025	Urine pregnancy test		Single	$8.67
82962	Glucose blood test		Single	$3.21
87880	Strep A assay w/optic		Single	$16.44
97750	Physical performance test for measurement (eg. musculoskeleteal, functional capacity) with a written report, each 15 mins	15	Multiple	.93

Test & Measurements CPT codes

* 8xxxx laboratory codes do not have RVU’s, just straight Medicare reimbursements. To distinguish these straight dollar amounts, the book includes dollar signs before non-RVU reimbursements.

Modifiers

Modifiers are designed to modify a CPT code where the procedure is essentially the same but circumstances are slightly different than the official definition of the procedure. Examples include taking a shorter or longer time with a given procedure or performing an evaluation at the same time as a procedure. Modifiers should be used when circumstances alter a procedure to the point where it may affect reimbursement. Or they can be for information only. Modifiers are two digit codes added to the end of a CPT code. Following are a list of common CPT modifiers used by acupuncturists.

-21	Prolonged Evaluation and Management (E & M) ServiceWhen face-to-face contact is greater than that usually required for the highest E & M level within a given category.Comment: Should be used rarely as reimbursement is iffy and almost always requires additional documentation. CPT codes 99354 & 99355 should be used for additional E & M services if services were provided intermittently. Use this modifier for continuous patient contact.
-25	Significant, Separately Identifiable E & M Service by the Same Physician on the Same Day of a Procedure or Other ServiceComment: This modifier should be used when an E & M Code is used at the same day as a procedure or another service. Remember that the initial acupuncture codes (97810 & 97813) include a small amount of evaluation and management, therefore E & M CPT codes should only be used on the initial visit and intermittently, as medically necessary, thereafter. If a separate E & M code is used in addition to a procedure such as acupuncture, it must be modified with this modifier.
-50	Bilateral ProcedureIf a procedure’s description doesn’t state it is applied to both sides, this modifier indicates a procedure has been performed bilaterally.Comment: The American Medical Association (AMA) has stated the proper use of this modifier is to apply it on one line with one unit applied to the procedure and reimbursement should then include a bilateral procedure. However, some insurance companies prefer adding the -50 modifier to a second CPT code.
-59	Distinct Procedural ServiceThis modifier states that a procedure is distinct or independent from other services performed on the same day. This can include a separate session or patient encounter, a different procedure, a different site, different injury.Comment: This modifier is used when an acupuncturist bills different therapies used on the same visit. For example, some insurance companies will deny a claim where an acupuncture treatment (97810) is performed at the same time as a manual therapy (97140). If a -59 modifier is used on 97140, it generally goes through with fewer issues.

CPT Modifiers

The Healthcare Common Procedure Coding System (HCPCS)

The Healthcare Common Procedure Coding System (HCPCS) is another billing system that encompasses the Current Procedure Terminology (CPT) codes. CPT codes are administered by the American Medical Association and are considered level I of the HCPCS codes. Level II of the HCPCS codes are a set of codes that begin with a letter from A to V followed by 4 numbers. They are administered by the Centers for Medicare & Medicaid Services (CMS) and includes quite a bit of overlap with the CPT codes. The level II codes also include codes for supplies that acupuncturists can bill for, but may not be reimbursed for on a regular basis. These include needles.

A4215

Needle, Sterile, Any Size, EachComment: When using this code, it is recommended to only charge once. Reimbursement for this code is iffy.

Herbs and other supplements

There are HCPCS codes for items other than prescription medicines. While we can bill these codes, almost no insurance company will reimburse for them. The only possible exception may be health savings accounts (HSAs), some of which do pay for herbs and supplements. The A9150 code is technically for a non-prescription drug and this may be a gray area for billing. However it is often interpreted as “non-prescription item.”

A9150

Misc/experimental non-prescription drug

Supplies

As above, acupuncturists can bill for needles using the Healthcare Common Procedure Coding System (HCPCS). Remember, however, billing an item does not mean getting paid for an item.

A4215

Needle, Sterile, Any Size, EachComment: When using this code, it is recommended to only charge once. Reimbursement for this code is iffy.

Advanced Billing Concepts (ABC) codes

Advanced Billing Concepts (ABC) codes were developed by a company called Alternative Link, Inc. They were developed because the Common Procedural Terminology (CPT) codes are developed by the American Medical Association and are geared to MDs and DOs and minimally towards other healthcare practitioners including complementary and alternative medical providers, physical and occupational therapists, and nurses. ABC codes were created to help breach this gap. While they are currently US government approved for use, no insurance company or entity accepts them for billing purposes. For this reason, they are not at all useful for acupuncturists today, and it is the authors’ opinions to avoid their use unless they become more accepted.

Time

Time is so important when billing insurance and so infrequently documented in acupuncture charts, it deserves it own subheading. Since many medical procedures are billed according to time, it is absolutely vital that time is charted. Examples abound. Acupuncture is billed in 15 minute increments as is massage. If there is no time noted in the chart, there is no justification for billing ANY of these CPT codes and the insurance company can and will deny your claim. In addition, insurance companies can request to audit your records more globally and retroactively bill you for a refund of previously paid reimbursements. This could amount to hundreds of thousands of dollars.

As an aside, just because an insurance company bills you for a refund, legally a practitioner may not need to pay it. If a practitioner is contracted (in-network) with the insurance company, they will be contractually required to repay the insurance company. However, if a practitioner is not contracted with a particular company (out of network), the law says the company cannot require a refund of previously paid fees.

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Collins, S. A. (2006, March). Choosing the Right E & M Codes [electronic version]. Acupuncture Today. 7(3). Retrieved June 14, 2008 from http://www.acupuncturetoday.com/mpacms/at/article.php?id=30337.

Collins, S. A. (2009, Sept.). Can you charge for requests for records? [electronic version]. Acupuncture Today. 10(9). Retrieved August 22, 2009 from http://www.acupuncturetoday.com/mpacms/at/issue.php?id=619&current=true.

CPT Codes. (n.d.). In CPT code/relative value search. Retrieved June 21, 2008 from https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp.