b'2020 SPRINGINSURANCE Update INSURANCE UpdateInsurance UpdateBy Matt Minnella ANJC Director of Insurance & Regulatory AffairsMedicare-Acupuncture included in this coverage. They advise that CMS does intend to establish a National Coverage Determination (NCD) for CMS has announced that Medicare will cover acupuncture forQ&AMedicare UpdateMedicarechronic low back pain for dates of service on or after Jan. 21,these services but has not provided a timeline for this. 2020. In this case, chronic low back pain is defined as backYou can view the press release and Decision Memo at www. pain that is: anjc.info under Insurance Medicare/Medicaid MedicareLasting 12 weeks or longer; Acupuncture Update.Nonspecific, in that it has no identifiable systemic cause We will continue to monitor this situation and report to (i.e., not associated with metastatic, inflammatory, members as soon as any additional information is confirmed.infectious, etc. disease); United Claims to Require GP Modifier as of April 1, 2020:Not associated with surgery; and After several delays, beginning April 1, 2020, United Health-Not associated with pregnancy care will require the GP modifier to be appended to any codesUp to 12 visits will be covered within 90 days and up to anthat are deemed Always Therapy codes according to CMS. additional eight visits will be covered for patients demon- These codes will include: 97012, 97016, 97018, 97022, strating improvement. No more than 20 acupuncture visits 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, will be allowed annually. 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, To date, Medicare has provided only a press release and a97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, Decision Memo regarding the new acupuncture coverage.97760, 97761, 97762*, 97799, G0281, G0283. This has left many questions regarding who can perform theThis policy change was announced in the United Network services, what diagnosis codes will be considered chronicBulletin January 2020 (page 39). A link to the newsletter low back pain and allowed, what the reimbursement ratesand a copy of the letter sent to United network providers will be, documentation requirements, etc.explaining the policy can be found on the ANJC website We have thoroughly reviewed the available documents,www.anjc.info under Insurance Health Insurance Carriers & spoken with the ACA, reached out to industry expertsMCOs United-Optum. throughout the country and inquired with our local MedicareThis change should not affect coverage or reimbursement. Administrative Contractor (MAC) Novitas in our attempts toIf you receive any denials or reductions in reimbursement answer these questions and continue to follow up with thesefollowing this implementation, or if you have any other sources.questions regarding this policy, please contact me atThe Decision Memo gives direction on who can perform email@example.com. services. It states that physicians (as defined by Sec.1861(r) Horizon NJ Health (Medicaid) New Diagnosis (1) of the Social Security Act) can perform the services ifCoding Rulesthey meet all applicable state requirements. The memo also states that physician assistants, nurse practitioners/clinicalEffective Oct. 14, Horizon NJ Health, Horizons Medicaid nurse specialists (as defined by Sec.1861(aa)(5) of the SocialManaged Care subsidiary, requires diagnosis coding reflec-Security Act) and auxiliary personnel can perform the servicestive of Medicares Local Coverage Determination rules. if they have a masters or doctor level degree in acupunctureThe policy details can be found on the Horizon NJ Health or Oriental Medicine from a school accredited by thewebpage at this address: https://www.horizonnjhealth.ACAOM and are actively licensed to practice acupuncture com/for-providers/resources/policies/reimbursement-poli-in their state.cies-guidelines/chiropractic-manipulation. Per the definitions of physician referenced, only doctors ofThis means that in order for CMT codes (98940-98942) medicine or osteopathy are included. Also, while a PA, NPto be considered for reimbursement, the claim must have or CNS can perform the services if they are also licenseda subluxation code as the primary diagnosis code, listed as an acupuncturist, by the definitions given for auxiliaryfirst in Box 21 of the CMS1500 form. These codes would personnel it is not clear if a licensed acupuncturist who is include M99.00-M99.05. Then you would need to use a not a PA/NP/CNS can perform these services, even under supporting secondary diagnosis code in the next diagnosis the supervision of an MD or DO.code space in box 21. These are the same secondary Our local MAC, Novitas, has advised that CMS has notdiagnosis codes used for Medicare currently. A list of these yet provided any information beyond the Decision Memocodes is found at the bottom of the policy page under the with regards to what diagnosis codes or CPT codes will beReferences section Local Coverage Article: Billing and 14 I Spring 2020 www.anjc.info'