Medicare Acupuncture Coverage Requirements for Chiropractic Physicians in Illinois
As chiropractic physicians in Illinois, it is crucial to stay informed about Medicare coverage changes and understand how they may affect our practices. In 2021, Medicare significantly changed its coverage of acupuncture. However, the requirements are considerable, and most chiropractic physicians are not eligible for reimbursement.
Understanding Medicare Acupuncture Coverage
Medicare created two considerations to determine acupuncture coverage eligibility, and coverage only applies when criteria are met in these two areas:
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- Treatment for chronic low back pain lasting 12 weeks or longer, without a specific systemic cause, and not linked to surgery or pregnancy.
- Acupuncture services when performed by limited, eligible practitioners that meet stringent requirements. However, a review of the rules governing “eligible practitioners” as detailed below, makes it clear that reimbursement for chiropractic physicians will likely only be feasible in rare cases.
Who Can Bill Acupuncture to Medicare?
- Physicians: Medicare allows physicians to perform acupuncture without additional restrictions. However, the term “physician” is defined differently under federal law than under state law. In the context of Medicare, a physician refers to a chiropractor only when performing manual manipulation of the spine to correct a subluxation. Unfortunately, this means chiropractic physicians are not physicians under federal law when providing acupuncture services.
- Physician Assistants (PAs) and Nurse Practitioners (APNs): PAs and APNs can provide acupuncture services under Medicare but must meet specific requirements. They must hold a master’s or doctorate degree in acupuncture or Oriental medicine from an ACA OM-accredited school and possess a current, full, active, and unrestricted license to practice acupuncture in their respective states.
- Auxiliary Personnel: Chiropractic physicians who perform acupuncture services on Medicare patients in Illinois fall under the category of auxiliary personnel under federal Medicare law. To bill acupuncture to Medicare, chiropractic physicians must meet the following criteria:
- Hold a master’s or doctorate degree in acupuncture from an Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM) accredited school;
- Hold an active chiropractic license in Illinois;
- Be fully educated, trained, and skilled to perform acupuncture (standard of care); and
- Work under the appropriate level of supervision provided by an APN, PA, MD, or DO, all of whom must also meet the same requirements above (a-c).
The Challenge for Chiropractic Physicians
For chiropractic physicians in Illinois seeking to bill acupuncture services to Medicare, there are significant hurdles to overcome. While you may have the necessary license and acupuncture degrees (you must have both), the critical barrier lies in finding a qualified supervisor who meets the stringent requirements outlined by Medicare. The supervisor must be an APN, PA, MD, or DO with extensive training and experience in acupuncture and also meets the requirements above.
Additionally, the limitations are not specific to Illinois. In fact, Illinois has favorable acupuncture laws for chiropractic physicians. However, the above requirements apply to providers in all 50 states.
How to Handle Non-Reimbursable Cases
Given the challenging reimbursement landscape for chiropractic physicians, it’s essential to approach non-reimbursable cases appropriately. When a Medicare patient requests acupuncture services, chiropractic physicians should use the GY modifier to inform Medicare that the service is not statutorily covered. Additionally, the ICS recommends obtaining an Advanced Beneficiary Notice (ABN) signed by the patient and appending the GA modifier to provide an extra layer of protection.
