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To Bill Or Not To Bill
Is No Longer The Question
During my 14 years with the American Academy of Medical Acupuncture (AAMA), including my term as President, one of the most frequently asked questions was whether a physician acupuncturist could "legally" bill Medicare for an office visit (evaluation and management [E&M]) during the same visit that acupuncture was performed. The AAMA expended significant resources attempting to secure a definitive response from Medicare on this issue without success. Finally, we have an answer!
"Medicare will pay for the evaluation and management (E&M) portion of an office visit even if acupuncture, a non-covered service, is performed during the same visit, if certain specific conditions are met."
This conclusion was reinforced in the Medicare hearing decision resulting from a complaint by one of my new Medicare patients. The facts of the case are as follows: per my usual routine, I meticulously detailed Medicare billing rules and office payment policies to the new patient. I had him sign a statement clearly explaining the same. The Medicare patient personally paid for his acupuncture treatment and Medicare was billed for the E&M services performed. To my surprise and annoyance, the patient demanded a refund, challenging the fact that I received payment from Medicare for E&M services performed prior to providing him acupuncture.
After reviewing my office progress notes, Medicare requested reimbursement of the monies paid to me for E&M services. Their stated position, at the time, was that any services performed with acupuncture during the same office visit were non-compensable.
My requested hearing on the matter was held before a Medicare hearing officer. I received a "FULLY FAVORABLE Hearing Decision."
The following is the legal rationale presented and accepted...The Medicare hearing officer and I agreed that the controlling regulation on the subject of Medicare payment for an E&M conducted during an office visit where acupuncture, a non-covered service, is performed, was the following paragraph from the Medicare Report dated March 1997:
"Additionally, any other services billed on the same date of service as acupuncture services, e.g., evaluation and management services, are not covered when they are related to the acupuncture services. The other services must be medically reasonable and necessary for the patient's medical condition and not related solely to the acupuncture services. In such a case, it would be expected that the separately billed service would be distinctly recorded and documented in the patient's medical record and available to the carrier for review."
Our contention was that this paragraph is precisely on point and confirms the propriety of compensation. Addressing the paragraph in sequence, it states that other services, for example E&M, are not covered when they are related to the acupuncture. This statement then subsequently is refined to say that the other services must be "medically reasonable," "necessary," and "not related solely" to the acupuncture if they are to be covered.
The questions then arise as to whether an E&M (history, physical examination, and medical decision making) service, provided during the same visit as acupuncture is performed, is indeed "medically reasonable," "necessary," and "not related solely" to the acupuncture.
- That the service is "medically reasonable" asks whether it is rational to expect a licensed physician to obtain information (history) as to why a patient is seeking medical advice/treatment. Additionally, it may be asked if it is logical to expect a licensed physician to examine the patient (physical examination) and to decide on the management options and treatment alternatives (medical decision making) before actually providing treatment. It is always acceptable according to common sense and, therefore, medically reasonable for a physician to perform an E&M service on a patient before instituting medical treatment. Additionally, there are obvious moral, ethical, and legal obligations supporting this requirement.
- Obviously, it is essential and the accepted convention for a physician to obtain the information gleaned from an E&M service prior to deciding upon and undertaking the proper course of treatment for the particular patient in question. Clearly, therefore, it is "necessary" for a physician to perform an E&M service on a patient before instituting medical treatment.
- An E&M service, especially with the initial visit, is never "related solely" to any acupuncture treatment because the primary goal of a physician in providing said service is to obtain information that will lead to management and treatment decisions of which acupuncture may or may not be included. A licensed Western physician is required to consider all of his/her medical training, knowledge, and skills when deciding on a course of therapy, and to use the appropriate treatment. Appropriate treatment decisions can be made only after E&M services are performed. The treatments selected as appropriate are the result of the E&M – not the reverse. In this case, the decision to use acupuncture was made as a result of the E&M. The sequence of events in an office visit, especially with the initial visit, makes it impossible for the E&M to relate solely to the acupuncture. To say that the E&M related solely to the acupuncture is to put the proverbial horse before the cart. Therefore, the E&M service is the first step and one that must take place before any treatment can be considered and, therefore, is independent and not related to any other service subsequently performed.
In other circumstances, however, the conclusion might be different and payment for the E&M could be correctly denied. An example would be a 4th patient visit following the performance of only E&M and acupuncture services during the previous visit #3. In this situation, the E&M of the 4th visit may relate solely to the non-covered acupuncture treatment of the 3rd visit and would, therefore, not be a covered service. In this case, it is arguable that the E&M follow-up for the 4th visit was solely for the purpose of determining whether to continue with acupuncture treatment and, therefore, ineligible for reimbursement.
The same or similar arguments can be made with respect to services other than E&M, such as physical therapy modalities, osteopathic manipulation, etc.
Referring back to the above-quoted paragraph from the Medicare report dated March 1997, the final sentence begins with the phrase, "In such a case..." These words indicate that there are such cases where payment for an E&M and other covered services are proper when acupuncture is performed. If payment were to be denied without exception, this sentence would read, "In no such case..." Therefore, "in such a case" indicates that if all the prerequisites of the paragraph are met, payment is appropriate.
The final prerequisite of the Medicare report paragraph is the requirement that the "separately billed service [is] distinctly recorded and documented in the patient's medical record and available to the carrier for review." Proper documentation of progress notes verifying the items and issues discussed above is essential for compliance.
When all the criteria of the Medicare report are met, Medicare should compensate the treating physician for the properly performed and documented E&M services.
— Marshall H. Sager, DO, DABMA, FAAMA
Guest Editor
GUEST EDITOR INFORMATION
Dr Marshall Sager is in Medical Acupuncture private practice, is a Founding Chair of American Board of Medical Acupuncture, and is the Immediate Past President of American Academy of Medical Acupuncture (AAMA).
Marshall H. Sager, DO, DABMA, FAAMA*
191 Presidential Blvd, Ste C-130
Bala Cynwyd, PA 19004
Phone: 610-668-2400 • E-mail: dr.mhs@verizon.net
*Correspondence and reprint requests
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