Dr. Greg Sperber is author of Integrated Pharmacology, Combining Modern Pharmacology with Chinese Medicine published by Blue Poppy. He received a masters and doctor of acupuncture and Oriental medicine from Pacific College of Oriental Medicine, San Diego, a medical degree from Flinders University of South Australia, and a master of business administration from National University. Currently he is the Director of Clinical Services, Clinical Chair, and Professor at PCOM and is a past president of the California State Oriental Medical Association.
Tiffany Andersen is the business manager for Pacific Center of Health, a multi-disciplinary practice, in San Diego CA. She is also the billing manager and a practice management consultant for Leucadia Chiropractic in Encinitas, CA. Ms. Andersen has been working in management and billing in the alternative medical field for the past 20 years. She has also earned her BS in dietetics from San Diego State University.
Both authors are available for consulting or speaking services. You contact us at gsperber@acu-insurance.com or tandersen@acu-insurance.com.
Unfortunately, your information about ASH is incorrect. The threshold does not get reset in July. Here’s a quote from the ASH acupuncture provider services agreement:
“The treatment form waiver is provided for the first five dates of service provided to a member who is new or established during the twelve month period of January 1st to December 31st.”
I was really excited about your website, but am now wondering if you really have accurate information since this one item is obviously very wrong.
Hi Christi. The threshold actually DOES reset in July. I am quoting from ASH’s site, taken moments ago: “The Clinical Treatment Form Waiver is available for the first episode of care provided to a member who is a new or established patient (over 12 years of age) during the twelve month period of July 1st through June 30th. If there are additional services that may be necessary beyond the Clinical Treatment Form Waiver you will need to submit a Clinical Treatment Form (CTF) to ASH. Once a Clinical Treatment Form (CTF) has been submitted during the calendar year the Clinical Treatment Form Waiver is no longer available.”
You can find this by searching on a patients eligibility, and in the bottom left corner there is a blue button that says : This member has a Clinical Treatment Form Waiver. Display CTFW. When you click on the DISPLAY CTFW button, it will give you the terms of the threshold.
The way it works is this and believe me, it is very difficult to wrap your brain around: On January 1st, a patients ANNUAL benefits start over, say for example 20 visits per calendar year, HOWEVER, the THRESHOLD doesn’t start over until July. Basically, every July you catch a break in that you can now see a patient (as long as they are over 12 y.o.) for the amount of visits you have under your threshold without needing authorization. If the patient were to see a different provider, you are still entitled to your threshold, it’s relative to you specifically as the practitioner. Let me give a complete example: New 30 y.o. patient Betty comes in on January 15th, we look her up on ASH and see that she has 20 visits per calendar year and she hasn’t used any yet. Since this is the first time you are seeing her, you get 5 visits (if that’s your threshold #) where you can see her without needing authorization. The patient uses her 5 “free” visits and still needs more care. You complete a CTF and request more visits. You get the authorization you requested and she comes in. You are amazing and cure her, so she stops coming in for a while. Then, on July 15th, she has a new condition and comes to see you. At this time, you can once again see her for 5 “free” threshold visits because the threshold period restarted on July 1. After these 5 visits, you would again request authorization, if needed.
One last note. If, for example, a patient comes in on June 15th and you are out of threshold and have to request authorization and do so from June 15th THROUGH July 15th, your threshold restarts AFTER that July 15th expiration. So, on July 16th you can now have 5 “free” threshold visits. Just be weary that if a patient comes in on July 2nd and you forget about the threshold and complete a CTF requesting authorization, you have now forfeited your theshold because the threshold time period already restarted. So, it’s one thing for an existing authorization to start PRIOR to the threshold it’s another to request an authorization after the threshold time period has begun. I hope this clarifies things.
First, thank you for your generosity. My question is I would normally place needles in for , let’s say 40 minutes. My problem seems to be the re-insertion after 15 minutes. For billing purposes would it be advisable to place 10 needles and then after 15 minutes ask the patient if the pain has gone away. If it remains, place an additional 10 needles and after 15 minutes ask the patient how they are doing. Then for the billing it would be 97810 and 97811 X 1. We can’t really pull the needles out after 15 minutes and then re-insert the same points, can we?
Thank you in advance
CP