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.