The American Association of Chinese Medicine and Acupuncture (AACMA) from California is submitting this comment on the proposed changes in the 2021 CMS Fee Schedule foracupuncture series CPT codes 97810, 97811, 97813 and 97814. AACMA is the largest professional organization of Chinese medicine and acupuncture in the United States.
The CY 2021 Payment Policies under the Physician Fee Schedule (the Policies) is proposing to reduce the Relative Value Units (RVUs) for the above acupuncture codes from 0.6 to 0.48, a 20% cut, while decreasing the PFS conversion factor at the same time. The reduction is based on “a crosswalk” to CPT code 20560 and 20561 which is for “Needle insertion(s) without injection(s)” or in other term “dry needling (DN)/trigger point procedures”.
The Policies on page 50168 continues to state that “CPT codes 20560 and 20561 are clinically similar services associated with DN……we believe that, since the two components of work are time and intensity, clinically related services with similar intensities and work times should, generally speaking, be valued similarly. Due to the similar clinical nature of these services and their nearly identical work times, we believe that it is more accurate to propose crosswalking CPT codes 97810 through 97814 to the work RVUs of the Dry Needling codes, which were finalized last year, as opposed to proposing work RVUs from 2004, which were never reviewed by CMS. ”
It looks like the two sets of codes (acupuncture codes 97810-97814 and DN codes 20560, 20561) have some similarities by both inserting needles into skin or muscles. However, the similarities end there. Although somehow they are related, the two services are not only clinically different in work time and intensity, but also in their natures. They are essentially two different types of services based on their theories, practice scopes, therapeutic methods and results, and educational requirements.
First of all, acupuncture’s theories involve holistic view and energy flows (systematic view and blood, body fluids and nutrients etc. in modern words). Although DN originated from acupuncture, it rather emphasizes localized muscle and tendons, hence differences exist in their assessments, practice scopes, therapeutic methods and results. Acupuncture can be very beneficial on a broad range of disorders, e.g. fibromyalgia, general pain management, headache and migraine–, abdominal pain,, low back pain,, general well-being or depression, nausea/vomiting–, fever,, asthma– and immunity related diseases– and many more. DN rather focuses on treating muscular and myofascial or localized disorders. Acupuncture has also demonstrated promising effects on reducing the number of prescriptions for opioids, muscle relaxants and non-steroidal anti-inflammatory medications and can improve the health of our general public–. Therefore, keeping this great potential benefit in the CMS coding system available and accessible to needed patients is not only crucial to the patients’ health, but also favorable in reducing the burden on our society created by the opioid dependence.
Secondly, the educational requirement for becoming a Licensed Acupuncturist (LAc) involves extensive and thousands of hours acupuncture training, relative science and medical classes in accredited programs, and passing national examinations or state board exams. California Acupuncture Board requires a minimum of 3,798 hours of theoretical and clinical training. The independent certification agency National Certification Commission for Acupuncture and Oriental Medicine requires a minimum of 3-year master degree with at least1905 hours training. On the other hand, there are no standardized and nationally recognized agency-accredited training programs for teaching the DN and examining the competence of the participants. A typical DN training course could be only 20-30 hours, or just over a weekend course and the participants may receive a dry needling certificate without any national or state board examination being required. No one would doubt that medical doctors (MD) are definitely more trained than physical therapists to perform invasive procedures such as DN. But ironically even MDs who wish to practice acupuncture must have satisfactorily completed a minimum of 300 hours of systematic acupuncture education acceptable to the American Board of Medical Acupuncture and meet the standards of World Federation of Acupuncture and Moxibustion Societies. Therefore, compared with acupuncture, the lack of educational requirements and level of DN is so obvious.
Clinically, in DN practice, the needles usually don’t stay inserted in the skin for long. After palpating for the knots/trigger points underneath the skin localized around the affected area, needles are inserted to prick the knots with single or multiple strokes, and then removed in a very short time. In contrast, a LAc takes a full review of history and symptoms, performs physical examination, makes a diagnosis and point prescription, then locates and inserts needles with clean needle techniques and other manipulation techniques in multiple body regions which could be distal or remote to the affected area. The needles stay in for about 25 to 45 minutes depending on the patient’s condition. Repeated or continuous manipulation of needles, additional and reinsertion of acupuncture needles, and connecting the needles to some electrical devices are often needed and done during the treatment. Although the acupuncture codes and the DN codes 20560 share some similar description of numbers such as 1 or more needle(s) versus 1 or 2 muscle(s), or the 15 minutes of one-on-one contact time, in a real clinical setting, the difference is so apparent that LAcs very often use more than 10 to 30 needles to rebalance the patient’s holistic wellbeing, and the treatment easily lasts for about an hour, while DNs usually finish their treatments with one or a few needles in a much shorter time. There are even more differences between acupuncture and DN in the complexity of decision/diagnosis making and skills involved.
In fact, the clinical differences in real work time and intensity of the two services are so undeniable that American Medical Association has to create two unmistakable sets of CPT codes with different RVUs to truly reflect the real natures of the two different services. Therefore, the base of cross walking the two different sets of codes seriously needs to be thoroughly reconsidered.
LAcs have already been facing challenges of reduced appointment due to the COVID-19, low and often rejected reimbursement from insurance companies, lack of hospital facilities resources, and lengthy treatment with scarce reimbursement. LAcs have already been earning a disproportionate low income for their high level and lengthy educational requirement and their remarkable contribution to the society. The proposed 20% cut in RVUs of acupuncture CPT codes in addition to the already insufficient reimbursement could really make LAc an unsustainable career, hence inhibit the availability and accessibility of such an effective, drug–free and safe care to the needed patients performed by the truly thoroughly trained, board exam
qualified and competent professionals.
The work value component of RVU should accurately reflect the actual training effort, the real work time and intensity of acupuncture. Therefore, if CMS hasn’t review the work RVUs of acupuncture codes recently as stated in the proposal, then please does so thoroughly and accurately instead of crosswalking a set of reviewed but inappropriate RVUs from a related but essentially different service to the acupuncture codes of 97810 through 97814. “Never reviewed by CMS” should not be a good and sound reason to lower the RVUs of acupuncture codes. We sincerely suggest a reconsideration of the proposal.
Dr. Jun Hu, president of AACMA
777 Stockton St. Suite 105, San Francisco, CA 94108 tel. (415) 981 8384 www.aacmaonline.com
 A Proposed Rule by the Centers for Medicare & Medicaid Services on 08/17/2020, Document Citation:85 FR 50074, Federal Register The Daily Journal of the United States Government, National Archives.
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