Houston, TX (WorkersCompensation.com) – Medical coding guidelines and rules change on a continual basis, requiring providers and billing staff to jump through numerous hoops in order to know the rules and stay compliant, all while trying to stay in business. These constant changes are a huge contributor to the ever-rising cost of healthcare.
Rules for medical necessity are tricky to navigate, especially when it comes to newer treatments that were previously unrecognized by mainstream insurance, such as electrical stimulation and acupuncture. While healthcare has seen an increase in acupuncture techniques to avoid opioid use in pain management, the Centers for Medicare and Medicaid Services, which steers the rules on medical necessity, has taken quite a bit longer to recognize alternative pain management strategies. As a result, some providers have made attempts at circumventing payer rules in order to get paid.
Pain management specialist Dr. Syed Nasir of Houston is one such provider, according to allegations from the U.S. Department of Justice in the southern district. Earlier this week the department issued a press release stating that from March to October of last year, Nasir had billed Medicare for surgical implantations of neurostimulator electrodes, when in fact he was performing electrical acupuncture therapy on his patients. To resolve the allegations, Nasir agreed to pay out $530,000.
In 2019, Medicare did not publish a rate for electrical acupuncture (CPT codes 97813, 97814) as they considered it non-covered, even though the codes were recognized by the American Medical Association years before. In 2019, CMS did, however, publish a rate for the surgical implant code (CPT code 63650) and considered it a covered code. The 2019 national Medicare rate for a 63650 was $1,357.08.
In 2020, however, CMS did recognize and published a rate for the electrical acupuncture codes. The rate for 97813 is $42.22 in the office, $34.29 in a facility. The rate for 97814 is $34.65 in the office, and $29.23 in a facility. Code 97813 is billed for the first 15 minutes of treatment, and 97814 is for the subsequent 15 minutes of treatment.
Two months prior, another Texas pain management physician agreed to pay out $100,000 to resolve allegations for the exact same scenario. Dr. Jaime Robledo from Katy, Texas allegedly billed Medicare for surgical implantation of neurostimulator electrodes when in fact he was actually providing electrical acupuncture from November 2018 through March 2019.