Repeatedly using the wrong code for billing an acupuncture service? Use CPT code 97813 for an acupuncture with electrical stimulation! With only four specific codes, acupuncture billing should be very easy, right? However, it is quite the opposite. Many licensed acupuncturists often misreport their services due to a lack of coding expertise and knowledge.
The end result? Continuous denials! For a smooth billing process, you must understand that each code has distinct rules and requirements. Today, we will simplify one of the primary acupuncture codes (97813). So, without further ado, let’s start with its description.
CPT Code 97813 – Description
As we mentioned earlier, CPT code 97813 refers to a one-on-one electroacupuncture session. But what does this mean in simple terms? Simply put, this code reports a combination of traditional acupuncture with electrical stimulation.
During this service, a healthcare provider, most likely a licensed acupuncturist, inserts one or more solid, metallic, and fine single-use needles into specific points on the patient’s body. He then attaches a small electrode to the needles, stimulating the nerve endings via electrical pulses to enhance the treatment’s effect.
Like all the other codes in this specialty, the 97813 CPT code is also timed. It means it covers an initial 15-minute treatment for pain, asthma, stroke, or chemotherapy nausea and vomiting.
Scenarios Where CPT Code 97813 is Applicable
To master any code, you must know when to use it. However, it is not as simple as it seems. To help you with CPT code 97813’s application, here are three detailed, applicable scenarios:
Treating Chemotherapy-Induced Nausea or Vomiting (CINV)
Nausea and vomiting are one of the most common and distressing side-effects of chemotherapy, affecting up to 80% of cancer patients. Acupuncture is usually recommended as a complementary therapy for CINV. Let’s use this information to develop a scenario for the 97813 CPT code.
Suppose a 49-year-old breast cancer patient experiences severe nausea 24 hours after chemotherapy. This nausea lasts up to 5 days after every session with frequent rounds of vomiting. To reduce the severity of CINV, an acupuncturist specially trained in oncology performs electroacupuncture 30 minutes before the patient’s third chemotherapy session. He then bills the initial 15 minutes of this one-on-one treatment with CPT code 97813.
Reducing the Intensity of Medicine-Resistant Chronic Migraine
Did you know that over 37 million people, including men, women, and children, in the U.S. suffer from migraines? The numbers are staggering, but the most shocking part is that only a small percentage (5%) of patients receive appropriate care. Several studies suggest that electroacupuncture is the most effective treatment.
So, for our second example, let’s envision a 37-year-old woman with episodic migraines. She endures 3 to 5 migraine days per month by relying on painkillers. However, she finally gives in and visits an acupuncturist after experiencing more frequent headaches with time. Her common symptoms? Throbbing pain on the left side of her head, neck stiffness, and dizziness.
The healthcare provider places several needles at specific pressure points, including the patient’s head, face, and back, and uses electrical pulses to stimulate the nerves. His billing team then uses CPT code 97813 to bill for the first 15 minutes.
Easing Chronic Obstructive Pulmonary Disease (COPD) Symptoms
Electroacupuncture also effectively improves respiratory disorders, especially COPD symptoms. This condition impacts 11.7 million adults in the U.S. and is the leading cause of hundreds of thousands of ER visits each year.
So, for the final example of the 97813 CPT code, consider a 41-year-old man with COPD. He opts for acupuncture along with conventional treatment to improve his shortness of breath and chronic cough.
Therefore, the patient visits an acupuncture clinic. After a thorough evaluation, an acupuncturist inserts several thin needles into specific points in the patient’s body and performs electroacupuncture. He then uses CPT code 97813 to bill the first 15 minutes of the session.
Applicable Modifiers for CPT Code 97813
While modifiers are typically not required with CPT code 97813, you can use the following depending on the situation or special circumstances.
Modifier GA
Medicare offers limited acupuncture coverage for chronic lower back pain (12 sessions in 90 days and an additional 8 sessions if required in a year). Therefore, if you think that it will deny your claim for exceeding 12 sessions within 90 days, apply modifier GA to CPT code 97813.
This code will help you inform Medicare that you have issued an Advance Beneficiary Notice (ABN) to the patient, informing them about coverage limitations.
Modifier GP
Was the electroacupuncture you performed part of a physical therapy treatment plan? In that case, append modifier GP to CPT code 97813. This two-character code notifies a payer that a service was either:
- Personally delivered by a physical therapist, or
- It was performed under an outpatient physical therapy plan of care
Modifier GY
Did you perform electroacupuncture on a Medicare beneficiary for an uncovered condition? For example, performing acupuncture with electrical stimulation to treat chemotherapy-induced nausea.
In this case, use modifier GY with CPT code 97813 to indicate that the service is statutorily excluded.
CPT Code 97813 – Billing & Reimbursement Guidelines
From coverage limitations to changing regulations and coding inaccuracies, acupuncture billing can give you a headache. To improve your overall billing process and accuracy, follow these billing and reimbursement tips for CPT code 97813.
Use CPT Code 97813 for Electroacupuncture
The major difference between CPT code 97813 and 97810 is the use of electrical pulses to improve the benefits of traditional acupuncture. Therefore, only use this code if you have performed electroacupuncture. Otherwise, use CPT code 97810.
Use this Code to Bill the First 15 Minutes
The 97813 is a primary CPT code. Hence, it covers only the first 15 minutes of an electroacupuncture session. For a longer session, use the add-on CPT code 97814 to report each additional 15 minutes you spent treating the patient.
Document the Medical Necessity of Electroacupuncture
As always, complete documentation is necessary for avoiding denials. Therefore, document the electroacupuncture session thoroughly, including:
- Duration (start and end time)
- Reason for performing the service (patient’s symptoms and diagnosis)
- Number of needles and their placement location
- Use of electrical stimulation
- Patient’s response to treatment
Verify Payer-Specific Rules
Before filing a claim for any code, make it a habit to verify payer-specific requirements. This step will save you from a lot of billing headaches. Each insurance payer has different coverage rules for CPT code 97813. For example, Medicare covers up to 12 acupuncture sessions in 90 days for only one condition: chronic lower back pain.
It covers 8 more sessions (a total of 20 acupuncture treatments a year). If your patient isn’t showing any improvement, Medicare won’t cover further acupuncture treatments. Moreover, it only pays if a qualified healthcare provider (physician or nurse practitioner) performs the service.
This is just one example. Commercial payers may have completely different requirements. Therefore, confirm their coverage rules before billing for electroacupuncture.
Summary
Do you feel more confident about the time requirements, documentation rules, and payer policies for CPT code 97813? To summarize, this code is quite similar to another primary acupuncture code, CPT code 97810. However, as you might have already gathered from our blog, there is a slight difference. The 97813 CPT code covers acupuncture with electrical stimulation. Hence, use it appropriately.
We have covered this code comprehensively, including three detailed examples, applicable modifiers, and billing tips, because we truly want you to master it. But if you are still wary of ever-changing payer rules, consider a professional to handle your billing.
Many companies, including MediBillMD, offer cost-effective acupuncture billing services. So, partner with a reliable option to improve your billing accuracy.
