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Well, good day, everyone. This is Sam Collins, your coding and billing expert for acupuncture, the American Acupuncture Council and the American acupuncture council network. Welcome you to another program. We’re going to give you always some updates on coding, billing, documentation, things to help enhance your practice. Remember, our goal is the American Acupuncture Council is to always enhance you. We’re symbiotic. We obviously offer malpractice insurance, which I’m sure many of you have, but we also offer our network service, which gives you some up-to-date information. And this is partly what we do here is to make sure that your practice does well. So let’s get to the point. Let’s start to understand what’s happening in currently going on with modifiers. Let’s go to the slides. If they’re not up. Those modifiers that we run into often are very confusing for many acupuncturists. And there’s been some recent changes that you may not be aware of, that you probably have gotten some denials.
So let’s talk today about what is necessary for modifiers on an acupuncture claim. What do we really need? And believe me, I think there’s a lot of misinformation, unfortunately, and does not get you paid without the right information. So what are modifiers? What modifiers of course are referred to as what we say, a level one modifier and it’s to supplement information about the claim itself. There are usually two digits or two characters in line, and they tell us something specific about the service. By example, modifier 25 to indicate it’s a separate, distinct service things of that nature. So the modifier is there to tell us something more about it. In many ways, the lack of a modifier will cause a denial. In fact, I bet many of you didn’t learn about using a modifier 25 until you got up in practice and you were like, why do I never get paid for an exam is because we’re not using the right modifier.
Remember a modifier does not alter payment. It just indicates a specific specificity about the code so that it can be paid. And so where do modifiers go? This is a portion of a course of a 1500 claim form. You’d put the data service and notice here. There’s a section that says modifier and notice there’s four spaces, 1, 2, 3, 4. So is it possible that you might have to use more than one modifier? It certainly could be. It would be unusual in an acupuncture setting, but possible just bear in mind that you can always add up to four now, what is the most common modifier for acupuncturists? And this is the one I will say. Every acupuncture is going to use at some point and it’s modifier 25. And what modifier 25 indicates it says modifier 25 is defined as a significant separately, identifiable evaluation management service by the same physician or other healthcare, other qualified healthcare professional on the same date of service of another procedure.
So all that gobbly goop means that the modifier is required when you’re doing an ENM evaluation management or exam code the same day as acupuncture or any treatment to indicate that the exam was separate or above and beyond what we note as the pre and post service evaluation. So by example, when you see someone on a first visit, you’ve never seen them before. It is clear, you’re going to do a significant examination. You can’t just say, Hey, I don’t care. What’s wrong with you. Put them on a table and hit them with needles. But what you’re going to do is take their history, do a full evaluation. So that is clearly an exam above and beyond normally what you do. So that’s why on a first visit, when you build an exam, you always will put a 25 modifier. However, let me make a clarification.
Some acupuncturists have the misinformation that they’re going to do an evaluation management or an office visit on every single visit. And that is actually incorrect. And here’s why the acupuncture code includes a pre-service and post-service evaluation. So by example, I just noted the first visit. The first visit. Clearly you have the history of the injury. When did it happen? What did you do? All those things, but on a follow-up visit, yes, you are going to do a small evaluation. What are you going to do on a follow-up visit? Like if I were your patient on the second visit, you would say, Hey Sam, how are you feeling today? Is that better? Last time when you left, the pain was much less. So in other words, it’s going to do a review of the chief complaint that is called the pre-service. So the reason you can’t bill an exam every day is because the acupuncture code or actually any treatment code includes a small evaluation.
So the reason you’re putting a 25 modifier on the first exam is your notification to the insurance that this exam is above and beyond the exam associated with treatment beyond the normal day to day, how are you feeling better, worse tongue pulse and so forth. So again, an exam can’t be done every day, but there is an evaluation every day. That’s part of it. So for billing purposes, take a look how it goes. The modifier goes right next to the code and the mid-level exam, 9 9 2 0 3 and a 25. If you forget to put the 25, it is an automatic denial, just a hundred percent will not be paid. The 25 is there to indicate that it’s a separate and distinct service and payable. Doesn’t alter the price, but does indicate that it is a payable exam because it’s above and beyond the one you do day to day.
Now this, I will say every acupuncturist does no question, the first visit. And re-exams probably about every 30 days. Be careful do not build one each and every visit and also be mindful. Some carriers that you belong to, and that can include some of the blues as well as, um, some of the, uh, uh, United health care policies. Depending if you have a membership through like Ash, they may pay only one exam a year. So it’s not an issue that you didn’t use the right code or modifier check your contract. But assuming non contracted one should be paid. One done so long as you include the 25. Now you’ll notice I did put here a new patient exam, but it could be an established patient 9 9 2 1 3. So that again, most common one. Now here’s one you may not be familiar with, obviously, regardless of that, COVID seems to be tailing off.
Might there still be a use for telemedicine visits for an acupuncturist, particularly for a patient on their first visit. Maybe they don’t have the time to come in for an hour visit. So maybe you do the first half of the visit telemedicine meaning the non-treatment part. So how do you identify telemedicine? Well, there’s a unique modifier for telemedicine. It’s modifier 95. Now you’ll notice I have it right next to an ENM code because a telemedicine visit is an evaluation it’s counseling. So you would use an ENM code, but to identify it as telemedicine put a 95. Now, remember telemedicine does mean audio, video and live. It cannot be recorded as not a phone call. It must be live interactive, audio video. Now the one of a unique difference for this one is not just the modifier. You’ll notice. The place of service says zero to the zero to places.
Service indicates also a telemedicine setting. So it not only needs the 95 modifier, but the zero two, if it’s a telemedicine visit, now remember telemedicine. Obviously we can’t treat, but could there be places where there’s counseling for a patient where they can’t come in or let’s face it? What if they can’t come in timely or don’t have the time to spend an hour an hour and a half, which may be the history, might it be more convenient? Would it make more sense to maybe do a telemedicine, at least that part, and then follow up with a half hour visit where you actually do treatment. So a viable one they’re 25 on exams with treatment, but telemedicine 95. Now there’s another modifier. And this is the one I’m sure many of you have missed out on it’s modifier GP. I’m sure if you’ve billed the VA, you’re aware of it.
But what this modifier is called is called an always therapy modifier. It’s what’s called a HICPAC modifier, HCPCS healthcare, common procedure coding system. And it’s a letter one, and it’s always therapy because every time you build a therapy to some payers, they need to identify who’s providing it, meaning a therapy provider. So for acupuncture purposes, you’re going to use modifier GP. Now you’re going to think, well, GP indicates physical therapy. That’s true, but that’s within your scope. So you’re going to put a GP, not a geo or a GM, just understand geo means services by an occupational therapist, G N by a speech therapist. So for our purposes under scope of practice, it would be a GP. Now, what does this add on to literally every physical medicine rehabilitation code? So when you think of what is that, that’s going to be every therapy code, right?
We all the way from hot packs all the way through the unlisted service. So common services, massage, gosh, manual therapy, infrared heat exercise. In fact, what I will say is any therapy code that begins with the nine seven, not including acupuncture will require the GP and who requires it well United healthcare as of April last year, that includes Optum health. It also includes anyone going to the VA, which you’re probably already aware of, but here’s the newest beginning April 1st of this year. And I’m sure you’ve noticed it on a lot of claims going to Anthem. And this includes blue cross blue shield of Michigan notice blue cross of California. Now let me be clarified here for anyone from California in California, blue cross and blue shield are separate companies. So it includes blue cross in California, but not blue shield. So do be aware of that nuance and most other states they’re combined.
And that includes all of these states, including Indiana, Kentucky, Missouri, New Jersey, New York, Ohio, Vermont, and Wisconsin. And I think others as well. So check your EOB is if it comes back and it says this service is missing a modifier and it’s a therapy, chances are it’s the GP. Now that means all physical medicine codes. The question you may have though, is any other payers? Well, Medicare is one of them, but remember Medicare, we’re not billing directly, but technically if you’re looking for a denial for Medicare, you would put that on there, but again, not common. And so how does the code look like? Well, take a look here. You’ll notice I did an exam, same thing, but notice 9 7 0 2 6 GP. The GP does not change the price. It’s just a requirement for payment. So you may think, well, Hey Sam, can I add the GP to every client?
Why not just add it to everything? Well, that could be partially problematic. And I wouldn’t blanket it because there are carriers that may not recognize it and may deny it. So for now, I’m going to say Anthem policies, United healthcare and their affiliates and the VA a hundred percent. And if you ever get a dial back that says this claim for physical medicine services or physical therapy is missing a modifier, it’s likely a GP, but again, don’t Blake. It, it, because here’s what I’ve also found. If you put a modifier on something, they’re assuming you’re trying to tell them something unique and chances are, they may deny it. So for now stick with just those payers, if you’re wondering, well, how would I know this? One of the things you can do, the American acupuncture council is your partner and our website for our education division.
The network has a new section go to AAC info network, click on the new section, and you’ll see all these updates. It’s one of the ways we try to keep you up to date. So if you’ve never gone to the network website, please take a look, AAC info, network.com, click on news. And in fact, just sign up for our email subscription. And what we’ll do is send you once something has changed, because here’s the difficult part I come to you probably once a month or every other month, but what happens in between us, something has changed. So it’s our way of updating. So again, GP on all physical medicine codes, and we want to give you a portal where you can start to use it. Now here’s an area that I think is often very confusing and a lot of acupuncturists have bad information. They will say, Sam, do I need to use modifier 59?
Well, what does a 59? It says a distinct procedural service. And it says under certain circumstances, it may be necessary to indicate that a procedure service was distinct or independent from other services, not including an ENM. So a lot of acupuncturists have made this assumption that, oh, I put that on my second set. You absolutely do not. A second set is already distinct. There’s also another other modifier. That’s common. It’s more or less the same. And it says a separate structure. And it’s excess. Now I’m bringing this up to make sure you understand what these modifiers are and why you wouldn’t use them, because you do not have to indicate that the acupuncture is to a separate area. We don’t have that type of rule or protocol where I think this comes from is people not understanding chiropractic claims. And part of the unfortunate thing is often people who teach you are not teaching you specific things about acupuncture, but that’s something that may be related to what a physical therapist does or what a chiropractor does.
So let’s talk about specifically a chiropractic claim versus an acupuncture claim. Chiropractors have to use modifier 59 when they’re using massage or manual therapy. And it’s because the rule is a chiropractor is not separately reimbursed for massage or manual therapy. If it’s done in the same area as manipulation, hence why that modifier is there to show, oh, it’s distinct. It’s a separate area. Now this edit doesn’t apply to acupuncture. There’s nothing about acupuncture and manual therapy that will require a 59. So if you’re putting a 59 with it, there’s no absolute necessity for it. In fact, it may cause the claim to be denied. So as a general rule, the modifiers you’re going to use as an acupuncturist are going to be 25 on exam codes in GP. For those, those companies that I mentioned now, would you ever use a 59 will never for acupuncture, but I’ll give a scenario.
Some of you, you may be doing a little bit more of a rehab style with a patient. Maybe they have back pain and you’re doing some exercises and therapeutic activities. Particularly this could apply with a VA patient. If you were combining exercise 9 7 1 1 0 with therapeutic activities and 9, 7, 5, 3 0, you would put a 59 or one or the other codes to distinguish them as separate. And the reason why is those two services are very, very similar in fact, to be the exact same thing, but the outcome being different. So you want to distinguish that part of the service was, you know, exercise and part was a therapeutic activity. So that would be about the only place I would ever see the use of 59. So don’t get caught up that, oh, I have to use it. Trust me, it’s innocuous information and just incorrect. So again, 25 in GP, but not a 59.
And the reason I’m bringing up news, I’ve done a program with you before where I talked about Cigna at American specialty health, I’m going to let you know no, this doesn’t apply to California, Oregon, Washington, but to other states, if you’ve not seen it, they’ve delayed the change to September and they’ve upped the ante to 89, a visit from 55. So that’s a nice change. You should have received some information on it, but if you have not, how do you find out go to AAC info, network.com, click on the news tab. And you’ll see, I’ve written an article piece on that. Our job at the American Acupuncture Council, keeping you up to date, keeping you paid keeping to make sure your practice survives. So if you’ve not been to our site, this is the site. Notice here, the new section, click on that. You’re right in.
But let’s talk about what are you doing to really make your office do well. Have you ever thought of where do I get my answers? Who do I get them from? Hire an expert. We offer a service called the network where for a small fee per year, you get complete access to me where I become part of your staff. You can ask me questions on coding, billing, documentation, medical necessity. Hey, Sam, a claim got denied. Get to a place where we’re making sure your claims getting paid. Here’s what I guarantee you. Join our network. I’ll get your money back within a month because all I have to do is answer one or two questions and it’s always related to money. You’ve gotten paid back and it’s going to be triple fold because guess who gets notified? First people who are in the network, we send out an email chain to everyone.
That’s a network member when something’s changing. Anytime there’s an update. You’re notified first. So let’s help you get your claims paid, go to our site. Here’s a QR code you can go to, but simply go to our site. AACinfonetwork.com. We’re here to help as always the American Acupuncture Council is your policy holder or your policy holders, but we’re also your advocates. Now next week’s program will be Virginia Doran. I look forward to seeing you all next time. Take a look at the site. Let’s get you paid and best wishes to everyone. Thank you very much.
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