Dry Needling – Competency and Coding

The Academy has had numerous requests in recent months regarding the use of “dry needling” for trigger point therapy and if the service is permitted to be performed by Physical therapists and/or other non-physicians who are not permitted to do invasive procedures or are certified in acupuncture.

Dry needling has been around for quite a while and involves the use of either solid filiform needles or hollow-core hypodermic needles for alleviation of muscle pain due to the hyper-irritative foci we call “trigger points”, that may occur in any skeletal muscle in response to strain produced by acute or chronic overload.  We know that these trigger points produce a referred pain pattern characteristic for that individual muscle that helps differentiate myofascial pain syndrome from tender points and fibromyalgia. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS); and each of these single muscle syndromes is responsive to appropriate treatment, which includes injection therapy where injection is achieved with needle insertion through the dermal layer.

Depending on who is trying to classify the procedure, it may be referred to as; dry needling, acupuncture or a new term, intramuscular stimulation (IMS).  About the only “consensus” you will get is that the  needle insertion procedure can NOT be billed under a trigger point injection code (20553-20553) that requires administration of agents such as local anesthetics.

Acupuncture, dry needling and/or IMS techniques are similar but not necessarily the same. The clinician may perform dry needling with either a   filiform needle (aka “acupuncture” needle) or a standard gauge hypodermic needle.  Many healthcare practitioners use 22,25 or 27-gauge, 1.5 inch hypodermic needles for fear of deflection issues, those concerns have since proven unfounded and many now feel that the solid filiform needles not only provides better tactile feedback but also better penetration with less discomfort to patients. Both the use of hypodermic needles and the use of solid filiform needles are now accepted dry needling practice.

It is true that the solid filiform needles used in dry needling are regulated by the FDA as a Class II medical device “intended to pierce the skin in the practice of acupuncture”, however the FDA definition applies to how the needles can be marketed and does not mean that acupuncture is the only medical procedure where they can be used.

That being said, no one profession actually owns a skill or activity in and of itself nor does any single activity within the practice make any particular service professionally unique. Simply because a skill or activity is within one profession’s skill set does not mean another profession cannot and should not include it in its own scope of practice.

The practice of acupuncture by acupuncturists and the performance of dry needling by physical therapists appear to differ in terms of historical, philosophical, indicative, and practical context. The debated distinction between dry needling and acupuncture has become a controversy because it relates to an issue of scope of practice of various professions.  It is my understanding from the APTA that Physical therapists that perform dry needling do not use traditional acupuncture theories or acupuncture terminology.  Similarities do however exist in terms of dermal penetration with a solid filament needle (a tool) to varying depths within the body for therapeutic indications. Many States have already approve dry needling by PTs who are specifically trained while others, such as the Superior Court in Washington State[1] have ruled that dry needling is practicing medicine and prohibited absent a physician’s license.   The American Physical Therapy Association has posted many of the opinions issued by State Attorney Generals on their web site at  http://www.apta.org/StateIssues/DryNeedling/

It is unlikely that our Academy or the AMA will be “solve” the turf battle in the near future.

This however has nothing to do with how the service is billed……  The CPT™ [2]  specifically states the most basic use is to select the procedure or service that accurately identifies the service performed and prohibits using a CPT code that merely approximates the service provided. The “standard” is; if no specific code exists in either the CPT™ or HCPCS , then you report the service using the appropriate unlisted physical medicine/rehabilitation service or procedure code.

The code selection then is simple for an actual “acupuncture” procedure.  Code 97810; Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient would be our correct coding unless electrical stimulation was also used. (see 97813)  If you are using “a solid core acupuncture needles” it is illogical to assume you are doing some form of “injection” as is required by codes 2055x.  Use of acupuncture needles is not a covered service, whether an acupuncturist or any other provider renders the service. 42 U.S.C. § 1395y(a)(1

For those however that want to view the procedure as “dry needling, intramuscular manual therapy, intramuscular stimulation (IMS) or as a silver-crested winged aviate waterfowl, we will still consider it a “duck” without a standardized name or assigned code. In our opinion, billing under Current Procedural Terminology (CPT) codes 2055x TPI or therapy codes 97112 (neuromuscular reeducation) or 97140 (manual therapy techniques) is a misrepresentation of the actual service rendered and could be considered fraud by Medicare. 31 U.S.C. §§ 3729–3733.

Therefore, in the opinion of this Academy, the proper “coding” will depend on the actual “intent” of your procedure.  IF you wish to consider the procedure a dry needling under the trigger point injection area of the CPT, you should report it as 20999 with the specific description of dry needling.  If you are a PT/OT and you feel this is under your therapy POC, it should be reported as a PT/OT procedure under 97999 with the same description.

By the way ……….IN THE REAL WORLD…   most carriers have dry needling addressed as a “one liner” in their TPI policies as being “not covered” and very few cover “acupuncture”.

[1] South Sound Acupuncture Association vs. Kinetacore, et al.

[2] CPT is a registered trademark of the American Medical Association – © all rights reserved. Used with permission.


Q&A with Dr R.

Our doctor uses electo-acupuncture to break up trigger points.  Can I bill this under the TPI code 20552-20553 to Medicare or others.

NO. Acupuncture is not a covered service for Medicare, even if provided for the treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not covered regardless of who is doing it.   For your major medical carriers, acupuncture with electrical stimulation is a stand-alone service billed under 97813-97814 based on the “time component” of 15 minute increments.  The actual “focus” of the procedure does NOT affect the billing code.

CodingCoding Alert for P-Stim™ AGAIN!

Writing for the Academy:  R.L. Ramsdell PhD, FACFEI, CFC, DABFE, LFMAAMA. Executive Director.

March 21, 2014

We are once again receiving coding questions and issues regarding the P-Stim™.

We originally published a special alert for this product on September 15, 2013 when members reported the sales representatives were recommending CPT 64553 “implant” code for the procedure and a billing of L8680 for the electrodes.

In our original alert to our members, we stated;

The Academy has received many recent inquires on the proper coding for electrical stimulation of auricular acupuncture points using the P-Stim™ device.  Various coding scenarios were submitted from concerned members, including “stealth” coding using implant codes, as offered by some sales representatives as well as their claims of “coverage” by “Medicare and Most Major Medical Plans”.

Our investigations have shown these claims for the most part, are false and may be designed to create an unrealistic anticipation of payment and/or offer various “stealth coding” scenarios that could qualify the procedure for payment based solely on submission of inaccurate codes BUT would put the practitioner “at significant risk” for allegations of fraud or abuse on audit.

According to recent member reports, the sales people have now “altered” their coding suggestion to use CPT implant code 64555 for the procedure and E1399 for the electrodes.

First, let’s look at the FDA approval for the unit.  You can view it for yourself at:  http://www.accessdata.fda.gov/cdrh_docs/pdf5/K050123.pdf

  • Trade or Proprietary Name: P-Stim
  • Common Name: Electro-acupuncture device
  • Classification Name: Electro-acupuncture stimulator
  • Classification: Unclassified

Predicate Device: The legally marketed predicate device to which the P-Stim is substantially equivalent is the Acu-Stim (KO14273).

Intended Use:The P-Stim is intended for use as an electro-acupuncture device to stimulate appropriate auricular acupuncture points.

Device Description: The P-Stim is a miniaturized, battery-powered, transcutaneous electrical nerve stimulator that has a pre-programmed frequency, pulse, and duration for the stimulation of auricular acupuncture points.

The device connectsvia three stainless steel wires to acupuncture needles that have been applied to the appropriate auricular acupuncture points. The device is powered by three zinc air batteries, each with a voltage of 1.4 V. The device is on for 180 minutes, then off for 180 minutes, for a maximum period of up to 96 hours.

Based on the unit’s approval and accepted indications, we must again stress the most “basic instructions” on code selection contained in the CPT manual that prohibits misrepresentation through “stealth” coding.

Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.

Medicare entertained a request from P-Stim in their May 29, 2013 HCPCS Meeting.  Agenda item #6 Stated; Topic/Issue:Request to establish a new Level II HCPCS code to identify a miniaturized device designed to administer auricular point stimulation treatment over several days. Trade name: PSTIM. Applicant’s suggested language: “P-STIM: percutaneous auricular neurostimulator with 3 needles; used for before and after measurements of sympathovagal balance”. According to the requester, the P-STIM is a miniaturized device designed to administer auricular point stimulation treatment over several days. Point stimulation by the P-STIM is mainly used to treat pain. The P-STIM is a wearable device this is designed to administer continuous pulses of a low-level electrical current at the ear over several days. Electrical pulses are emitted though three selectively positioned acupunctures needles. The P-STIM is worn for four days on and three days off and is removed by the patient on the fourth day. The average patient usually requires 1-12 weeks of treatment. According to the requester, the patient population for which the device is clinically indicated is patients who suffer from diagnosis as: migraine, chronic pain (lower back or otherwise), shingles, fibromyalgia, refractory neuropathy, central sensitization disorders and PTSD.  The decision was; A national program operating need was NOT identified by Medicare, Medicaid, or the private insurance sector to establish a code to identify this device. Based preliminary benefit category analysis, we believe that there would be NO Medicare payment for these items.

Major Medical Coverage:

Non-coverage of the services may be found in their Acupuncture policies, complementary and alternative medicine or, if specifically addressed, like with the “Blues”, in a policy for “CRANIAL ELECTROTHERAPY STIMULATION (CES) AND AURICULAR ELECTROSTIMULATION”. Others, like Health Net, for example, just include the service under their non-payable “investigational procedures” listing.


Opinion on the use of CPT implant code 64555 for the procedure and E1399 for the electrodes. 

 In reviewing the literature and rationale from the company, we see that they are making a “leap” to now declare the unit to be a “percutaneous electronic nerve stimulator” (PENS) and applicable to the coverage provisions and coding applicable to those units INCLUDING the implant procedure code 64555  Percutaneous implantation of neurostimulator electrodes; peripheral nerve.

We must again take exception with the rationale, based both on the coding and on the “off label” use that exceeds the FDA approval of the unit as an electro-acupuncture device to stimulate appropriate auricular acupuncture points.

We must also take exception that the electrodes are “implanted” when the FDA 510(k) approval specifically states “The P-Stim™ device connects to 3 inserted acupuncture needles with caps and wires.”

Typically carriers interpret “implant” as being a surgical procedure way beyond an “insertion” of needles.

Last, we must object to assuming that the implant is to the “nerve(s)” since the approval also specifies that the use of the “stylus” is to identify the appropriate auricular acupuncture points.

Academy Conclusion On Proper Coding:  Based on the available evidence, the Academy finds that the representative claims that “P-stim is reimbursed by Medicare and Most Major Medical Plans” and should be billed under the 64555 code are inaccurate.

The Academy therefore suggests the following as “applicable” to the P-Stim™


  • 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
  • 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)

HCPCS:  Is the Most specific.

  • S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient.
    • (Developed and became effective April 1, 2012.)

There is no specific supply code for the unit(s) and therefore you would use E1399 with a description of “P-Stim electro-acupuncture device”.

In our opinion, billing for application of the unit under 64555 is NOT appropriate and such reporting should be restricted to 64999 with an accurate description of the procedure to avoid any misrepresentation to the carrier.  We remind everyone that the fact you billed using an approximate fit code which was paid, does NOT mean you billed it correctly.   For example, Medicare will pay the codes you billed because they are valid codes and they are assuming those are the procedures you performed. Your PAIN will come with audit when your notes do NOT support a surgical implant.

We also feel proper billing for the supplies (unit kits) should be reported under the E1399 NOS supply code or CPT general supply code 99070, with an accurate description of “electro-acupuncture device” including the unit name.   Most carriers will expect you to submit an invoice with the claim.   

We feel any other coding scenarios would be a misrepresentation of the service performed, subject to recovery upon carrier audit and possible allegations of fraud or abuse.  

Again, our opinion here is on the “Coding” ONLY and not the quality or efficacy of the actual equipment, technology or potential therapeutic benefit to the patient.

Members should consider the potential benefit to the patient within the reality of a “non-covered service” and provide the patient with applicable notice of personal liability.

CMS lookNational CERT data showed projected rises in improper payments for outpatient E&M services for 2013 with CPT codes 99205 and 99215 being in the top 15 codes identified for improper payment. Previous review of high level outpatient E&M services resulted in high error rates because services were frequently billed at a higher level than could be supported for medical necessity by the medical record.

Audit Results: The overall percentage of services recoded or denied for CPT 99205 was 78.66%. The overall percentage of services recoded or denied for CPT 99215 was 78.50%. The key reasons services were denied are as follows:

  • Failure to respond to the request for documentation
  • Documentation was missing a provider signature
  • Insufficient or missing documentation
  • The medical record did not support the coverage requirements forservices of nonphysician personnel furnished incident to physician’s services billing
  • Documentation did not support a separately identifiable E&M service performed in addition to procedure billed for the same date of service (inappropriate use of modifier 25)

The key reasons services were recoded to a lower level E&M service are as follows:

  • The medical record failed to support the medical necessity of the highest level of outpatient E&M service
  • For new patient E&M service CPT 99205, all 3 key components (comprehensive history, comprehensive examination, and high complexity medical decision making) were not supported at the level billed
  • The provider selected the level of E&M using time as the controlling factor, but the medical record failed to differentiate physician time devoted to face-to-face counseling with the beneficiary from the time dedicated to history and physical examination; or the record failed to provide sufficient detail about the coordination of care or counseling provided to justify the level of E&M billed

The majority of the services billed as CPT 99205 were recoded one or two levels, and the majority of the services for CPT 99215 were recoded one level. Based on the results of this widespread audit, prepayment review of CPT 99205 and CPT 99215 will resume for Part B claims in Illinois, Minnesota and Wisconsin beginning June 2014.

This article becomes effective on Coding and is being used by MA plans as well at this time.

The following directions are provided for billing the drug codes for Hyalgan products. 

  1. HCPCS code J7322 has been deleted and replaced with HCPCS code J7325 (hyaluronan or derivative, Synvisc or Synvisc-ONE for intra-articular injection, 1 mg) effective for dates of service on or after 01/01/2010.
  2. If an aspiration and an injection procedure are performed at the same session, bill only one unit for CPT code 20610.
  3. The appropriate site modifier (RT or LT) must be appended to CPT code 20610 to indicate if the service was performed unilaterally and modifier (50) must be appended to indicate if the service was performed bilaterally.
  4. The appropriate site modifier (RT or LT) must be appended to the drug code to indicate if the service was performed unilaterally or bilaterally. The drug must be reported on a separate claim line for each knee or shoulder treated using the appropriate site modifier, RT or LT. Claims without a modifier will be returned to the provider unprocessed.
  5. Use “EJ” modifier on drug codes to indicate subsequent injections of a series. Do not use this modifier for the first injection of each series. A series is defined as the set of injections for each joint and each treatment. Injection of the left knee or shoulder is a separate series from injection of the right knee or shoulder.