Dual-licensed Billing: A Guide for ND-LAcs

The WANP receives many requests each year from dual licensed practitioners for training on the nuances of dual licensed insurance billing. In this article, I will explain how to set up your insurance contracts to create more ease in the billing process as well as explain how to bill for both ND and LAc/EAMP services in your practice.

First, it is important to explain how insurance companies view dual licensed providers. Essentially, insurance companies that we contract with see each license we hold as a separate entity. For this reason, most insurers will give you two separate provider numbers – one for each license. These provider numbers are for in-office insurance company use only and are not related to your state license numbers or NPI number. These numbers help the insurance company keep track of your dual status and it is important you use them appropriately.

Many dual licensed practitioners are under the impression that you cannot see someone for a naturopathic medical visit and acupuncture treatment on the same day. This is not true, but there is a right and a wrong way to do this.

When you become contracted with a health insurance plan, it is very important to set your ND license as your primary specialty with each insurance company and your acupuncture license as your secondary specialty. This is important because you want to have your license with the largest scope of practice listed as primary in insurer’s computer system. The insurance company will then process all claims through your ND contract first then through your LAc/EAMP contract. This will greatly reduce the number of denials you receive for services rendered as most codes are covered under your ND license compared to a much smaller set covered by your LAc/EAMP license. Note: many insurers are not familiar with our EAMP (East Asian Medical Practitioner) status in Washington, so they may refer to you as an Acupuncturist or LAc instead of an EAMP.

The correct way is to create separate visits and chart notes for each service as if it will be rendered under a different license. This means your naturopathic notes should be completely separate from your acupuncture notes for that day. You will also need to create two separate charges or super bills for each service that you will bill to the insurance company. Yes, this is more work, but entirely necessary for proper billing. Under no circumstances should you combine your ND and LAc/EAMP notes or bill these as combined services on one super bill when billing insurance.

I also recommend that you create two distinct visits in your scheduling software, EMR or schedule book in case these records are ever requested by the insurance company during an audit. This also helps your patients to understand that they are receiving two separate services that day, which may result in two co-pays or coinsurance payments. Some insurers will waive the acupuncture co-pay if ND services are rendered on the same day, but this is specific to each health plan and not a hard and fast rule. Collect separate co-pays at time of service, and, if needed, refund the waived co-pay once you receive the EOB from the insurer.

Self Referrals: Dual-licensed providers often refer their patients to themselves for treatment. This means we see someone for an ND visit for and refer to ourselves for acupuncture treatment as well. Many dual-licensed providers make the mistake of billing a new patient E&M (evaluation and management) code for the ND visit and a new patient E&M code plus acupuncture code for the LAc/EAMP visit. Using new patient E&M codes (99201, 99202, 99203, 99204, 99205) are tax ID specific, not license specific. If you have seen a particular patient, or anyone else in your practice has seen that patient under the same tax ID number in the past 3 years, you cannot bill a new patient E&M code. Here is an example: You see a new patient in your office for a headache. You take a history, do the appropriate exam, order labs, and recommend treatment. Part of this treatment plan is a referral to yourself for acupuncture treatment of the headache. You would then bill the appropriate new patient E/M code under your ND license for that initial visit.

If you see the same patient later that same day for acupuncture, you will not bill for another new patient E&M code, but rather only for the acupuncture treatment since the exam has already been performed that day for the headache. You will simply bill for the acupuncture treatment under your LAc/EAMP license. An alternate scenario is that the patient follows up in two weeks for their first acupuncture treatment. You take a history, do a brief exam and administer acupuncture treatment. You would then bill the appropriate established patient E&M (99211, 99212, 99213, 99214, 99215) code and acupuncture treatment under your LAc/EAMP license. Be careful to include the modifier “-25” on the E&M code. Remember that you have already seen this patient and that she is not a new patient. The same explanation stands if another doctor in your practice (under the same tax ID) refers to you for acupuncture. Bill the appropriate E&M code plus your acupuncture treatment codes under your LAc/EAMP license.

Which license to bill under: Generally you want to bill E&M codes under your ND license whenever you can since the ND specialty has a larger scope of practice and usually better reimbursement. This can be a challenge since it can be very difficult to separate your naturopathic medical mind from your East Asian medical mind. The exception to this is when you are thinking purely as an LAc/EAMP. This comes into play in my office when addressing many issues solely with East Asian Medicine or if I have already provided naturopathic treatment for the patient. Clearly, my diagnosis of liver blood and kidney yin deficiency is not part of a naturopathic diagnosis. In these instances, I will bill the E/M under my LAc/EAMP license. This is really an issue of ethics more than rules, but I feel it is important to mention.

If you refer a patient to yourself for acupuncture treatment you should not bill an E&M code with every treatment. Set a certain number of treatments, such as once a week for 6 weeks, and then schedule an office visit for reevaluation. This would mean that after the sixth visit the patient will be examined to determine the need for further treatment. At this examination you will bill the appropriate established patient E&M code. During each acupuncture visit of the treatment series, the time you take for a brief check in about how they felt after last treatment, current symptoms, tongue and pulse diagnosis are accounted for within the acupuncture treatment codes and do not warrant the billing of an E&M code.

Charting and treatment plans: Make sure that you are charting your acupuncture treatments appropriately when billing insurance. Always include tongue and pulse evaluation in each chart note as well as your Traditional Asian Medicine diagnosis. Some insurers require these for payment of acupuncture claims and if you are ever audited, they may fine you if these are not included in each note. If you see patients for 30 minutes of acupuncture treatment, be sure to list your treatment plan as follows:

• Acupuncture treatment first 15 minutes: (list points used).
• Acupuncture treatment additional 15 minutes: (list points used)
• Total of 30 minutes face to face with patient.

Acupuncture is a time based treatment, so you must document time spent for the visit in order to be eligible for reimbursement by the health plan.

I hope that this information has helped demystify dual-licensed billing for many of you. Proper billing of medical and acupuncture claims should help you to be more profitable and feel more comfortable billing insurance in your practice. I am happy to address any more of your questions on dual-licensed insurance billing further in future issues of the newsletter, so please send us your feedback and questions.

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