Clear Up Acupuncture Coverage and Coding Misconceptions (2025)

Enlisting the services of a medical biller can improve your ability to get these claims paid.

Licensed acupuncturists face many challenges when it comes to coding and billing. For starters, acupuncturists cannot enroll in Medicare and, therefore, do not get explanations of benefits (EOBs). To add insult to injury, payers seldom understand the techniques performed by acupuncturists, and CPT^® codes do not always accurately reflect the services. Further confusion is created as more provider types are given the green light to perform dry needling, while acupuncture coverage is still somewhat limited. Although most acupuncturists do their own billing, many are turning to billing companies to deal with coordination of benefit (COB) denials and other discrepancies. Let’s look closer at the problems acupuncturists are having and how using a dedicated biller can help get claims paid.

Medicare Exclusion

In 2020, the Centers for Medicare & Medicaid Services (CMS) finalized a decision to include acupuncture in Part B benefits. Coverage only applies to services rendered by certain practitioners like physicians, nurse practitioners, and physician assistants who have a master’s or doctoral-level degree in acupuncture or Oriental medicine. Most acupuncture treatments in the United States are administered by licensed acupuncturists — one of the 22 provider types ineligible to enroll in Medicare as of 2024.

The inability to obtain EOBs from Medicare has created a lot of confusion for patients, providers, and payers. Patients have accused acupuncturists of scamming them when they’re told that Medicare won’t cover the cost of treatment, and secondary payers have now started insisting on receiving EOBs from Medicare before they will process claims. In response to these issues, Medicare finally added a disclosure on their website; however, it has not changed payers’ requirement for EOBs.

Before CMS included acupuncture as a Medicare benefit, claims from licensed acupuncturists were sent directly to secondary payers. Some payers required modifier GY Service provided is statutorily excluded from the Medicare program to indicate that the claim was bypassing Medicare. Now, providers must send a letter signed by someone from the Medicare Integrity Program to the secondary payer with the claim that explains that services provided by acupuncturists “are not payable by the Medicare Program.”

Patients also have the option of filling out the Patient’s Request for Medical Payment form (CMS-1490S). In some cases, Medicare will reimburse the patient for part of the treatment. More likely, the request is denied the first time and must be refiled with more information, and most patients do not want the hassle.

The Acupuncture for Our Seniors Act was first introduced in 2021 and has been reintroduced multiple times. This act would include acupuncturists in Medicare enrollment; however, it has very little support, even among acupuncturists, who are unsure about what Medicare enrollment would look like.

CPT® Code Discrepancies

There are only four CPT^® acupuncture codes: 97810, 97813, and the add-on codes +97811 and +97814. The code definitions for +97811 and +97814 include the phrase “reinsertion of needles,” and many payers require “evidence of reinsertion” in medical notes. However, reinsertion of needles is not something acupuncturists ever do; in fact, it violates the Clean Needle Technique. A licensed acupuncturist would never take a needle out of a patient and then “reinsert” that used, dirty needle. In practice, it’s also unnecessary. Collectively, acupuncturists have decided that reinsertion in this context refers to the addition of new needles or the manipulation of needles previously placed. Payers still require the word “reinsertion” in the medical notes, however, and will deny claims simply because they don’t see this word.

Another pain point is that, upon adding acupuncture as a Part B benefit, the number of reimbursable units has dropped to three. There are few, if any, payers who will pay for more than 45 minutes of acupuncture, and some will not pay for an evaluation and management (E/M) service done on the same date of service, even with modifier 25 Significant, separately identifiable E/M service … appended.

Cupping therapy is a technique used by acupuncturists for which there is no specific CPT^® code. Cupping therapy uses small cups with a slight suction to adhere to the skin and pull blood and healing factors into an area. There are two main types of cupping: static and sliding. For static cupping, the cups are applied and left. For sliding cupping, the cups are pulled along the skin like a vacuum. Because sliding cupping requires constant manual intervention by the provider, 97140 for manual therapy technique is an appropriate code, but there is no appropriate code for static cupping — practitioners must use 97039 for an unlisted modality. Most payers will pay 97140, but most will not pay 97039.

Moxibustion, the technique of burning moxa, a dried herb, on acupoints or attached to needles, is another therapeutic technique that trips up billing. Again, there is no code for moxibustion. Most providers consider it to be part of acupuncture and do not separately bill for the service. Other practitioners bill separately using 97039, but it is not generally reimbursable separately.

Dry needling is often confused with acupuncture. CPT^® codes for dry needling include the number of muscles in which needles are placed rather than the face-to-face time indicated in the acupuncture codes. CPT^® guidelines state not to code both dry needling and acupuncture in one session. Remember though that only licensed acupuncturists or healthcare providers with a master’s or doctoral degree in acupuncture or Oriental medicine are allowed to bill the higher-paying acupuncture codes.

The practice of using acupuncture in place of anesthesia is common in China but not performed in the United States. Most plans will not cover acupuncture when it is performed “in lieu of anesthesia.”

Coverage Limitations

In addition to the usual coverage limitations for number of visits or payout amounts, some plans have some unusual exclusions. In the early 1970s, some hospitals in the U.S. experimented with using acupuncture anesthesia; however, the practice did not catch on. Despite numerous publications on its effectiveness, acupuncture anesthesia is not performed in the United States today, but some plans still have a coverage exclusion where they will only pay for acupuncture when it is performed “in lieu of anesthesia.” It’s been requested that this outdated language be removed, but it seems more plans are adopting this exclusion.

“Same day as surgery” is another phrase found in some benefits packages that payers use to deny acupuncture coverage. Very few people would go to their acupuncturist’s office for treatment on the same day they are scheduled for surgery.

How Billers Help

An increasing number of acupuncturists are turning to individual billers and billing companies to help navigate denials and billing questions. Acupuncture billing requires constant intervention on the part of the biller. Billers who take on acupuncturist clients will spend a lot of time educating payer representatives on acupuncture practice and Medicare ineligibility and educating acupuncturists on code descriptions and how to improve documentation.