Dry Needling Codes: Compliance Implications

By Nancy J. Beckley, MS, MBA, CHC

The 2020 Medicare Physician Fee Schedule Final Rule contains a lot of information for physical therapists in private practice, as well as outpatient physical therapy services in other outpatient venues including rehab agencies, Comprehensive Outpatient Rehabilitation Facilities (CORFs), and hospital outpatient therapy departments.

There is a new payment conversion factor, an updated therapy threshold of $2,080, updates on CPT codes for 2020, rules for documenting and coding therapy services provided by physical therapist assistants (PTAs), and the impending doom of a projected 8 percent cut for therapy codes in 2021 in order to update evaluation and management (E&M) codes while maintaining budget neutrality. Total hip replacements have joined total knee replacements in being removed from the Medicare inpatient only list, and CMS has approved total knee replacements for Ambulatory Surgery Center (ASC) payment. And don’t forget merit-based incentive payment systems (MIPS).

One potential area of good news is that there are now codes to report trigger point dry needling procedures! The industry remained cautiously optimistic following the release of the 2020 Medicare Physician Fee Schedule Proposed Rule that CMS would approve payment for the new CPT codes¹:

• CPT 20560: Needle insertion(s) without injection(s), 1 or 2 muscle(s)
• CPT 20561: Needle insertion(s) without injection(s), 3 or more muscle(s)

The Final Rule indicated that the new dry needling codes would not be payable by CMS in 2020, unless otherwise indicated in a National Coverage Determination. Maybe hopes were too high? Of interest, CMS noted that the codes should be considered as “sometimes therapy” procedures rather than “always therapy” procedures.

What does this mean for dry needling in your practice, and more importantly what are the compliance implications for documentation, coding and billing in your practice when integrating dry needling as part of your clinical services?

The Way We Were

Physical therapists performing dry needling in their practice in prior years often “reported,” debated, or perhaps argued, a number of different methodologies to justify coding and billing. Some providers billed for an unlisted procedure, or unlisted modality, likely guaranteeing that a denial was forthcoming. Other providers justified the use of another CPT® code, such as manual therapy, or neuromuscular reeducation, despite dry needling not being identified as part of those codes. Others provided dry needling, and reported that the minutes associated with needle insertion were not calculated in the tally for timed-code treatment minutes. Alternatively, providers may have issued a voluntary Advance Notice of Beneficiary Non-coverage (ABN), and collected payment from the patient at the time of service. Therapists may have hoped to get billing and coding advice from instructors and colleagues at a dry needling course. Many therapists express confusion over practice versus payment. “If the practice act allows dry needling, why are there coding and payment issues?”

For providers seeking and providing coding advice on social media platforms, the question remains: Have you just admitted to submitting a false claim or a practice in violation of Medicare policy, federal laws, or other payer policies?

Some recent Facebook posts that are cause for concern:

1. “…dry needling is not a covered service under Medicare, we bundle it with manual therapy and use that code, we have no trouble getting reimbursed by Medicare.”
2. “We were told at my course to bill it as manual if for trigger point release and neuromuscular re-ed if for muscle recruitment. And Medicare is the only one I know of that specifically doesn’t cover, so we just don’t bill Medicare patients.”
3. “I…will use cups or other instruments, but I leave that part out and just document myofascial release without mention of whatever I was using.”

In looking at these sample posts (no one really believes that social media groups are private, do they?), what potential risks should be assessed?²

Medicare has likely paid this claim because the notes have not been reviewed. Therapy providers report that under the Medicare Targeted Probe and Educate Program (TPE) that if they billed for manual therapy and documented dry needling, that payment was denied payment, and counted as an “error” for audit scoring.

Not billing Medicare patients for services may constitute a violation of the beneficiary-inducement statute, which prohibits providing free or discounted items or services to a Medicare or Medicaid beneficiary that are likely to influence the beneficiary to seek these reimbursable services from a particular provider.

Not documenting the method of myofascial release for the purpose of preventing a coding error, and/or denial of non-covered services may constitute the submission of a false claim.

Days of Future Passed

For 2020 the facts tell the story: There are now two new dry needling codes, and they will not be payable by Medicare. All thoughts of using another CPT to bill for dry needling should be banished, as with anecdotal advice posted in social media groups. Providers should be reminded of Iontophoresis, which is a covered code by Medicare, but subject to payment by Local Coverage Determination (LCD). In instances where a provider’s Medicare Administrative Contractor (MAC) does not cover Ionto, or only covers Ionto by specific diagnosis, a provider would issue an ABN (voluntary) to indicate to the beneficiary that the service is not covered by policy, and that they are financially responsible if they elect to have the service. Another example of a non-covered service, albeit previously covered by Medicare, where a provider should issue an ABN is Anodyne Therapy.

The Rest of the Story

Physical therapy practices should establish policies and procedures for dry needling coding and billing. Communicate these policies and procedures with all staff. Develop a specific policy statement for patients. Given that, it is wise to identify dry needling coding and billing under your Compliance Program’s Annual Auditing and Monitoring Work Plan. If routine audit activities uncover payment to which you are not entitled, understand payback obligations including refunds and self-disclosures. Also keep in mind that an effective pre-billing monitoring program focused on dry needling is likely to prevent the submission of a claim in error. This activity is an effective tool in the compliance lifecycle of detecting, preventing, and correcting errors.

Providers should also identify payer policies for everyone with whom they contract. Are the dry needling codes on their list of payable codes? Are there specific requirements to use the codes? Do they require specific documentation to support dry needling procedures? These two new dry needling codes, although not payable by Medicare, allow a therapy practice to develop and implement policies and procedures consistent with the parameters of the codes and payer policy. No more guessing, no more social media debates. A compliance blessing in disguise?

References:

¹CPT® is a registered trademark of the American Medical Association.

²Examples do not, nor are they intended to, provide legal advice, but rather to give considerations to an underlying risk assessment.

Nancy J. Beckley, MS, MBA, CHC, is certified in Healthcare Compliance and provides consulting services to therapy practices on developing and implementing compliance programs, responding to audits and investigations, and due diligence support for mergers and acquisitions. She is located in Milwaukee, Wisconsin. She can be reached at nancy@nancybeckley.com.