NEW! Medicare to Reimburse for Acupuncture Services
CMS Creates New Reimbursement Pathway for Medicare Beneficiaries with Chronic Low Back Pain
On January 21, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized a decision (under National Coverage Determination (NCD) 30.3.3) to cover acupuncture for Medicare patients, specifically those with chronic low back pain (cLBP). This is a shift in policy as previously NCD 30.3 stated that acupuncture was nationally non-covered by Medicare for all indications. “We are dedicated to increasing access to alternatives to prescription opioids and believe that covering acupuncture for chronic low back pain is in the best interest of Medicare patients,” said CMS Principal Deputy Administrator of Operations and Policy Kimberly Brandt. “We are building on important lessons learned from the private sector in this critical aspect of patient care. Over-reliance on opioids for people with chronic pain is one of the factors that led to the crisis, so it is vital that we offer a range of treatment options for our beneficiaries.”
Chronic Pain, Opioids, and Acupuncture
According to the Kaiser Family Foundation, one in five Americans say they know someone who has died from prescription painkiller overdose. Every day, more than 130 people in the United States die after overdosing on opioids. Opioid-related deaths have skyrocketed in recent years, and the financial impact of the crisis has been similarly shocking. The Centers for Disease Control and Prevention estimates that the total "economic burden" of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement. In addition to providing grants and creating new reimbursement pathways for the treatment and study of opiate-related death and disease, the U.S. Government is encouraging development of alternatives to opioid pain treatment regimens. This new reimbursement option for Medicare beneficiaries is an incremental change in policy that is part of this larger effort to address the crisis.
CMS believes that sufficient clinical research shows the functional benefits of acupuncture in the alleviation of pain and the restoration of function for those suffering with cLBP. Medicare beneficiaries who meet the qualifications will be able to receive 12 acupuncture sessions within a given 90-day period. An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.
Trend Toward Alternative Therapies
We've noticed an increase in the number and types of holistic and wellness centered clinics that feature alternative products such as CBD, chiropractic, stem cell therapies, and acupuncture services. These clinics often provide other services such as nutritional counseling, personal training, and meditation - all focused on improving general health and assisting with everything from pain to weigh loss. Most of these clinics have maintained a cash only, or non-insurance, business model largely because of the lack of reimbursement options at the federal and state levels. While acupuncture has been covered under some private insurance programs for a few years now, the shift in CMS payment policy gives more individuals options to choose non-pharmaceutical products to help manage and treat their chronic conditions. This shift also indicates a change in public perception about the role that non-pharmaceutical interventions play in the prevention and treatment of diseases and conditions that cause or contribute to chronic pain.
We see this type of healthcare innovation popping up in other sectors such as digital therapeutics, medical devices, and consumer products. However, it is still unclear how many of these technologies will find reimbursement pathways under Medicare and Medicaid and who will be able to bill for certain procedures and devices. For now, clinicians that serve back pain patients (Osteopathic Physicians, Orthopedists, Physiatrists, Chiropractors, Neurologists, Physical Therapists) should take the opportunity to re-examine their business models to determine whether they would like to take advantage of this new payment opportunity for acupuncture services. Qualifying providers will need to meet all state licensing regulations and ancillary support staff must meet supervision requirements for providers to bill for acupuncture services.
Compliance Considerations
Practices “New” to Medicare
Participating in Medicare can open revenue streams but it can also open up additional liabilities as new-to-Medicare providers adapt their clinics to meet heightened regulatory scrutiny. This includes state and federal surveys, HIPAA and patient privacy regulations, and billing and coding issues that may create liability under federal fraud and abuse laws. Providers entering into this new market should also remember to review their referral arrangements to ensure that they are compliant with applicable anti-kickback statutes.
Hybrid Practices
Healthcare practices that generally provide acupuncture services on a cash basis (as opposed to billing their customers’ insurance company), but that also contract with commercial payers and Medicare will need to modify their protocols for their acupuncture patients. Medicare and many commercial insurers only permit their contracted providers to charge their beneficiaries on a cash basis for “non-covered services”—that is, services for which their contracted payers do not reimburse. Until now, that has included things like acupuncture services. Practices will need to determine whether they are permitted to continue to charge patients on a cash basis, whether the amount they’re charging is permissible (in the case of Medicare beneficiaries), and whether they need additional authorizations from patients to do so.
Please contact us if you have questions about what it takes to enroll you and your practice to become a provider in the Medicare program, or if you have any questions on reimbursements for CPT code 97810, CPT code 97811, CPT code 97813, or CPT code 97814.
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