Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Part B Acupuncture billed on dates of service from January 21, 2021, through (October 2, 2023). Below are the review results:

Background

Acupuncture is the selection and manipulation of specific areas of skin or tissues (referred to as “acupuncture points”) by a variety of needling and non-needling techniques. Per National Coverage Determination 100-03, Chapter (Ch) 1, Part 1, § 30.3.3, Acupuncture for Chronic Lower Back Pain (cLBP) Medicare limits coverage for acupuncture services under Medicare Part B. Coverage is available under certain circumstances for select indications, effective for services performed on or after January 21, 2020.

Medicare reimbursement for acupuncture, as an anesthetic, or as an analgesic or for other therapeutic purposes, may not be made unless the specific indication is excepted. All indications for acupuncture outside of National Coverage Determination (NCD)100-03, Chapter (Ch) 1, Part 1, § 30.3.3, Acupuncture for cLBP, remain non-covered.

In October 2020, the SMRC performed research and data analysis on this topic and noted an increase in paid amounts for the first half of 2020. The SMRC also identified claims with a noncovered diagnosis, and claims billed more than the covered quantity or frequency as outlined in the NCD. Medical review was recommended.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record reviews on claims with CPT codes billed for acupuncture to include DOS January 21, 2021, through October 2, 2023.

The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Services Not Rendered as Billed
  • The documentation submitted does not support services were rendered as billed. Internet Only Manual (IOM) Publication (Pub.) 100-08, Medicare Program Integrity Manual (PIM), Chapter 3, Section 3.6.2.5, A. The documentation submitted did not contain a detailed acupuncture procedure note including acupuncture points, needle insertion, and duration of the acupuncture service with each set billed.
• Non-Response to the ADR
  • The requested records were not received. 42 CFR 424.5(a)(6), Social Security Act 1862(a)(1)(A), Social Security Act 1833(e). The PIM Pub.100-08, Chapter 3, Section 3.2.3.8 requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request for the dates of service under review. The documentation was not submitted from the provider to support the claim as requested by the additional documentation request (ADR).
• Medical Necessity
  • The documentation submitted does not support medical necessity as listed in coverage requirements in the National Coverage Determination (NCD)or Local Coverage Determination. Social Security Act 1862, IOM, NCD, Pub. 100-03, Chapter 1, Part 1, §30.3.3 Acupuncture for Chronic Lower Back Pain (cLBP), and IOM Pub. 100-08, PIM, Chapter 3, Section 3.6.2.2. The documentation submitted did not support cLBP lasting 12 weeks or longer as required by the NCD.

References

Social Security Act (SSA), Title XI

• § 1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• § 1815(a) Payment to Providers of Services
• § 1833(e) Payment of Benefits
• § 1842(p)(4) Provisions Relating to the Administration of Part B
• § 1861(aa)(5)(A) Physician assistants (PAs), Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs)
• §1861(r)(1) Physician
• § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• § 1877(g) Blanket Waivers of Section 1877(G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
• § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• § 1893(f)(7)(A)(B) (i-iv), (h)(4)(B) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• § 410.26 Services and Supplies Incident to a Physician’s Professional Services: Conditions
• § 410.27 Therapeutic Outpatient Hospital or Critical Access Hospital (CAH) Services and Supplies Incident to a Physician’s or Nonphysician Practitioner’s Service: Conditions
• § 410.3 Scope of Benefits
• § 411.15(k)(1) Particular Services Excluded from Coverage
• § 424.5(a)(6) Basic Conditions

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). Effective March 1, 2020. Retrieved from CMS-1744-IFC.

Public Law

• Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments. May 2021. Retrieved from Stafford Act, as Amended – FEMA P-592 vol. 1 May 2021 .

Internet Only Manual (IOM), Medicare National Coverage Determination Manual (NCD), Publication (Pub). 100-03

• Chapter (Ch). 1, Part 1, §30.3.3 Acupuncture for Chronic Lower Back Pain (cLBP)

IOM, Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Ch. 16, § 20 General Exclusions from Coverage

IOM, Medicare Claims Processing Manual (MCPM), Publication 100-04

• Ch. 23, § 20.9 National Correct Coding Initiative (NCCI)
• Ch. 30, § 30.2 Healthcare Provider or Supplier Knowledge and Liability
• Ch. 30, § 50 Advance Beneficiary Notice of Non-coverage (ABN)
• Ch. 32, § 410 Acupuncture for Chronic Low Back Pain (cLBP)

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3, § 3.2.3.2 Time Frames for Submission
• Ch. 3, § 3.2.3.3 Third-Party Additional Documentation Request
• Ch. 3, § 3.2.3.4 Additional Documentation Request Required and Optional Elements
• Ch. 3, § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3, § 3.3.2.1 Documents on which to Base a Determination
• Ch. 3, § 3.3.2.4 Signature Requirements
• Ch. 3, § 3.4.1.3 Diagnosis Code Requirements
• Ch. 3, § 3.6.2 Verifying Errors
• Ch. 13, § 13.5.4 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. §§ January 1, 2021, and January 1, 2022

Local Coverage Determination (LCD)

• L33622 Pain Management

Local Coverage Article (LCA)

• A52863 Billing and Coding: Pain Management

Other

• Medicare Learning Network, MLN Matters MM6563. Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs). Effective April 1, 2010
• Medicare Learning Network, MLN Matters MM11755. National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP). Effective January 21, 2020, with a date of change October 20, 2021.
• Medicare Learning Network, MLN Matters 905364. Complying with Medicare Signature Requirements. April 2022

Last Updated Jul 31, 2024