Dry needling, a popular physical therapy technique, has been gaining attention for its potential benefits in pain management and muscle function improvement. However, many patients and healthcare providers are left wondering: is dry needling covered by Medicare? This question has sparked confusion among physical therapists, especially since Medicare made a significant ruling on the matter in 2020.
In this article, we'll dive into the complexities of Medicare coverage for dry needling and explore how it affects both patients and practitioners. We'll look at the current Medicare stance, billing procedures, and CPT codes related to dry needling. Additionally, we'll discuss how private insurance handles this treatment and what physical therapists need to know about documentation and reimbursement. By the end, you'll have a clearer understanding of the dry needling landscape in terms of coverage and billing practices.
Medicare Coverage
2020 Final Rule - CMS Will Not Cover Dry Needling
In 2020, the Centers for Medicare & Medicaid Services (CMS) made a significant ruling regarding dry needling coverage. The 2020 final rule stated that CMS would not cover dry needling billing codes, as they do not cover acupuncture [1]. This decision has left many physical therapists confused about how to bill Medicare patients for dry needling services.
Covered Conditions
Effective January 21, 2020, Medicare will cover all types of acupuncture including dry needling for chronic low back pain within specific guidelines in accordance with NCD 30.3.3 [2]. Chronic low back pain is defined as pain lasting 12 weeks or longer, with no identifiable systemic cause, and not associated with surgery or pregnancy [3].
Medicare Part B covers up to 12 dry needling treatments in 90 days for cLBP. If the patient shows improvement, an additional 8 sessions may be covered, with a maximum of 20 treatments in a 12-month period [3].
Documentation Needed
The patient's medical record should include documentation that fully supports the medical necessity for services mentioned in the LCD. This documentation should encompass relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
A procedure note should be clear and provide enough information to reconstruct the procedure. The note must include a description of the techniques used, the site(s) of needling, and pre- and post-procedural pain assessments.
How to bill a medicare patient for dry needling
Billing Medicare patients for dry needling can be tricky, as it's not a covered service. However, there are ways to provide this treatment while staying compliant with Medicare regulations.
Advance Beneficiary Notice (ABN)
To bill Medicare patients for dry needling, physical therapists must use an Advance Beneficiary Notice (ABN). This form informs the patient that Medicare may not cover the service, and they might be responsible for payment [1]. The ABN should be issued to original Medicare beneficiaries before providing therapy that may be denied as not medically reasonable and necessary [5].
When using an ABN, therapists can collect payment from the patient at the time of service [1]. It's important to note that even with an ABN, Medicare Administrative Contractors (MACs) can still deny that the patient should be paying for the service [4].
GX modifier
After completing the ABN, the treatment should be billed with the GX modifier [1]. This modifier indicates that an ABN has been issued as required by payer policy [5].
It's crucial to provide CMS with the correct codes and information, at the right time, and in the right order to avoid issues [4]. Remember, the -KX and -GA modifiers cannot be used on the same claim line (charge), as they convey opposing payer policies [5].
By following these guidelines, physical therapists can navigate the complexities of billing Medicare patients for dry needling while maintaining compliance with regulations.
Is dry needling covered by commercial insurance?
Coverage for dry needling varies among private insurance providers. Many insurers followed Medicare's lead after the 2020 final rule, deciding not to cover or reimburse for dry needling codes [1]. However, some plans may cover the service if it's deemed medically necessary to treat a specific condition or injury [6].
Coverage Limitations
Coverage will vary depending on insurance company, state and plan. Insurance companies often have strict guidelines for covering dry needling. For instance, some payers consider it medically necessary only in specific clinical scenarios, such as myofascial trigger point-related pain or temporomandibular joint disorders, and typically limit coverage to up to three sessions [7].
Non-covered service
If an insurer classifies dry needling as a non-covered service, patients may need to pay out of pocket. In such cases, physical therapists should clearly document that the patient paid for the dry needling separately and that it wasn't billed to the insurer as part of another service [1].
Not medically necessary service
Some insurers may categorize dry needling as "not medically necessary." For in-network providers, this classification often means they can't balance bill patients for the service [1]. In fact, some insurance companies, like ASH/Cigna, require therapists to inform patients in writing that the evidence for dry needling's effectiveness is inconclusive and that it's an unproven, non-covered service [7].
To navigate these complexities, physical therapists should be well-versed in their contracted insurers' policies and prepared to offer self-pay options for patients whose insurance doesn't cover dry needling [6].
Can I charge a cash rate for dry needling?
With commercial payers that do not consider dry needling to be medically necessary or a covered service, a therapist can charge a cash rate for dry needling. Physical therapists should clearly document that the patient paid for the dry needling separately.
CPT Codes For Dry Needling
Current Procedural Terminology (CPT) codes are essential for healthcare providers to accurately bill for their services. These 5-character numeric codes, maintained by the American Medical Association (AMA), are used to identify medical services and procedures performed by healthcare professionals [8].
For dry needling, specific CPT codes have been established:
Both codes 20560 and 20561 are untimed for billing purposes and include the cost of needles and other supplies required for blood-borne pathogen needle insertion procedures [1]. It's important to note that these trigger point dry needling (TDPN) codes are listed in the CPT Manual alongside muscle injection codes. This accounts for the description of the service as "insertion without injection" [1].
When submitting claims to insurance for reimbursement, providers must ensure that the CPT codes align correctly with the corresponding ICD-10 diagnosis codes. Misalignment between these codes may result in claim denials [8]. Therefore, accurate coding is crucial for proper reimbursement and compliance with insurance requirements.
State Regulations and Medicare
Varying state laws
When it comes to acupuncture and dry needling as a treatment, state regulations play a crucial role. Not all healthcare providers can offer acupuncture services under Medicare, and the rules vary from state to state [3].
In the United States, dry needling is a technique that is permitted in 38 states and the District of Columbia, albeit with specific requirements. This means that approximately 76% of U.S. states allow physical therapists to use this technique. However, it is important to note that in some locations, physical therapists may be required to undergo additional training, continuing education, or certification in order to perform dry needling.
Conclusion
The landscape of dry needling coverage in Medicare and private insurance remains complex and often confusing for physical therapists. Medicare's 2020 ruling that dry needling is not a covered service has had a ripple effect, influencing many private insurers to follow suit. This has led to a need for clear billing practices and patient communication. Physical therapists must be well-versed in using Advance Beneficiary Notices and appropriate modifiers when billing Medicare patients for dry needling.
For private payers, the situation varies widely. Some insurers may cover dry needling under specific conditions, while others consider it a non-covered or not medically necessary service. This patchwork of policies underscores the importance of thorough documentation and transparent communication with patients about potential out-of-pocket costs. As the field evolves, staying informed about CPT codes, state regulations, and individual insurer policies is crucial for physical therapists to provide this treatment option while maintaining compliance and financial stability.
FAQs
Why is dry needling not included in Original Medicare benefits? Currently, Original Medicare does not cover dry needling treatments primarily due to insufficient research supporting the practice and inadequate regulation of its practitioners.
Is dry needling billable to insurance? As of January 1, 2020, dry needling can be reported using CPT codes 20560 and/or 20561. Medicare has extended coverage to include all forms of acupuncture, including dry needling for chronic low back pain, following specific guidelines outlined in NCD 30.3, effective January 21, 2020.
What are the Medicare codes for dry needling? The Centers for Medicare & Medicaid Services (CMS) have designated two specific CPT codes for dry needling: 20560 and 20561. CPT code 20560 is used for needle insertion without injection for 1 or 2 muscles.