The Centers for Medicare and Medicaid Services (CMS) recently released a Medically Unlikely Edit (MUE) designating acupuncture billing codes 97810 through 97814 non-payable, effective July 1, 2018. However, these codes remain reimbursable under California’s Official Medical Fee Schedule (OMFS) for workers’ comp services.

While National Correct Coding Initiative (NCCI) edits, including MUEs, are incorporated into the OMFS automatically “by reference,” specific OMFS rules designating 97810-97814 reimbursable take precedence.

Coding Conflicts

The July 2018 update to the Physician and Non-Physician Services portion of the OMFS was the first to apply an MUE value of zero to acupuncture.

However, while the OMFS is aligned with Medicare, specific mandates for certain services (including acupuncture) overrule Medicare MUEs in such cases. California Code of Regulations (CCR) Section 9789.12.13 states (emphasis ours):

§ 9789.12.13 Correct Coding Initiative (a) The National Correct Coding Initiative Edits (“NCCI”) adopted by the CMS shall apply to payments for medical services under the Physician Fee Schedule. Except where payment ground rules differ from the Medicare ground rules, claims administrators shall apply the NCCI physician coding edits and medically unlikely edits to bills to determine appropriate payment.

In this case, the California “ground rules” that exempt acupuncture services from Medicare’s MUE may be found in CCR Section 9789.15.4.

CCR §9789.15.4(a)(1) states (emphasis ours):

The Medicare Multiple Procedure Payment Reduction (“MPPR”) for “Always Therapy” Codes shall be applied when more than one of the following codes is billed on the same day: codes on the Medicare “Always Therapy” list, acupuncture codes, chiropractic manipulation codes.

In addition, CCR §9789.15.4(b)(2) states (emphasis ours):

When billing for physical medicine modality, procedure, or acupuncture codes, no more than 60 minutes on the same visit.

Billing codes 97810 - 97814 carry the status code “N,” which mandates payment according to Medicare Relative Value Units (RVUs) for the service in question (or payment “By Report” if no RVUs exist). The RVU for 97810, for example, lists payment as $49.92 — a payment that remains applicable.

DaisyBill contacted the California Division of Workers’ Compensation (DWC) for clarification. A DWC representative confirmed that acupuncture billing codes remain payable. The DWC plans to issue a Newsline in the near future affirming this position.

As always, we’ll keep our readers informed of further developments.

Meanwhile, in the event that a claims administrator incorrectly denies payment for acupuncture billing codes on the grounds of the MUE in question, providers should request a second review appeal within 90 days. Include with your appeal the following language:

The MUE included in the July 2018 OMFS Update for the Physician and Non-Physician Practitioner Services section of the OMFS designating an MUE value of zero to billing codes for acupuncture is inapplicable.

California Code of Regulations Section 9789.12.13 states that “The National Correct Coding Initiative Edits (“NCCI”) adopted by the CMS shall apply to payments for medical services under the Physician Fee Schedule. Except where payment ground rules differ from the Medicare ground rule.” CCR §9789.15.4(a)(1) states, “The Medicare Multiple Procedure Payment Reduction (“MPPR”) for “Always Therapy” Codes shall be applied when more than one of the following codes is billed on the same day: codes on the Medicare “Always Therapy” list, acupuncture codes, chiropractic manipulation codes,” while CCR §9789.15.4(b)(2) states “When billing for physical medicine modality, procedure, or acupuncture codes, no more than 60 minutes on the same visit.”

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