Question: I have heard there are changes coming to the Veterans Administration acupuncture benefits available through the Community Care Network (CCN) and Patient-Centered Community Care (PC3). Is there information you can share?
The most recent updates relate to Optum Health and its contract to manage VA patients under the program. Optum Health is taking over the management for regions 1, 2 and 3. Region 1 includes Connecticut, Delaware, the District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, Vermont, Virginia, and West Virginia.
Region 2 includes Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. Region 3 includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, Puerto Rico, South Carolina, Tennessee, and the U.S. Virgin Islands.
Information for this network can be found at www.vacommunitycare.com, and you can join the network via Optum at www.myoptumhealthphysicalhealth.com. The provider line numbers are Region 1: 888-901-7407; Region 2: 844-839-6108; and Region 3: 888-901-6613. (Note that access for services with Optum Health includes providers of tai chi and massage therapy, not just acupuncture.)
TriWest will continue to manage all other states except Alaska. The link for more information online is www.triwest.com and the phone number for the TriWest contact center is 855-PCCCVET (722-2838).
Program Access Details: Practitioners & Veterans
It is mandatory that the acupuncture provider is registered with either plan to gain access to these VA patients. This VA program facilitates health care for veterans from providers in the community outside of the VA. Veterans may be eligible to receive care from a community provider when the VA cannot provide the care needed. This care is provided on behalf of and paid for by the VA. However, there are certain requirements for a veteran to gain access to the community care network:
- A service is needed that is not available at a VA medical facility.
- Full-service VA medical facility is not available in the area where the veteran lives.
- A veteran qualifies under the "grandfather" provision related to distance eligibility for the Veterans Choice Program.
- Care cannot be delivered at a VA medical facility that is within a 30-minute drive for primary care or a 60-minute drive for specialty care.
- The wait time at a VA facility is more than 20 days for primary and mental health care or 28 days for specialty care.
- It is in the veteran's best medical interest, as determined by the VA provider.
- A VA medical service line does not meet certain quality standards.
Acupuncture is seen as reasonable and necessary complementary care to deal with the management of pain. Considering the crowding of patients with respect to the available providers and services at VA facilities, not to mention the copious use of opioids for pain management, acupuncture is seen as a viable alternative.
How the VA Program Works
For a veteran to access services through the program, there must be direct authorization and referral for acupuncture. However, it is patient (veteran) driven. The simple version of the protocol is as follows:
- The veteran seeks care from the VA.
- The VA determines, based on eligibility criteria, that the veteran should receive care from a community provider. The veteran agrees.
- The VA engages a community provider to accept referral and method of delivery (referral packet to include medical record).
- The VA schedules an initial appointment with community provider and sends referral packet.
- The veteran self-schedules an appointment following community provider acceptance of referral.
- The veteran receives care from the community provider.
- The provider sends the medical record to the VA.
- The provider bills TriWest or Optum for the care provided.
The veteran may and should specifically request acupuncture to deal with their "pain" issue and state that they no longer wish to use medication and likely have attempted other methods such as physical therapy, etc. It is also important (and assuming you are in the network) that they request you as their provider.
Treatment and Billing
Authorizations for VA generally are for 12 visits and 90 days, but often can be for many more visits and longer periods. The standard services authorized include acupuncture 97810 to 97814, but often indicate a limit of two sets of acupuncture per visit. Also included are evaluation and management services 99201-99215, therapeutic exercise 97110, neuromuscular re-education 97112, massage 97124, manual therapy 97140, therapeutic activities 97530 and cupping 97016/97139. If you want to provide additional services, they will have to be specifically requested.
Billing for acupuncture codes requires no specific modifiers; however, any physical medicine codes do require modifier GP "always therapy." If there is no GP modifier on the physical medicine codes, the code will be denied with this explanation: "missing or incomplete modifier." If you ask the insurer what the modifier is, often they will indicate that they cannot inform you what it is, so please bookmark and remember the use of GP with physical medicine codes.
Documentation and Authorization Specifics
TriWest also recently published some specific requirements of documentation for acupuncture, as it has requirements that must be met as evidence the care was effective and/or that the patient needs additional visits. Two factors to always include daily are 1) the patient's level of pain on a numeric scale and how it is changing; 2) but more importantly, how this changing pain is resulting in functional improvement.
Here are the eight items the VA needs to ensure your medical documentation is complete and thorough, so that it may provide effective information for secondary requests for authorization:
- Date of treatment
- Specific treatment
- Total treatment time
- Response to treatment
- Reassessment of progress
- Progress toward goals
- Barriers to reaching goals
- Name and credentials
Of these eight criteria, the most common that are missing from documentation are reassessment of progress, progress toward goals and barriers to improvement. One simple way of satisfying the first two is the use of validated outcome assessment tools such as the Patient-Specific Functional Scale (PSFS) or similar instrument. These speak heavily to the need for additional care and if the VA cannot identify the clinical need, it is unlikely to approve additional care.
A Few Words of Caution
One final interesting note published by the VA in relation to acupuncture providers: "TriWest reminds our network acupuncturists to please remember to remove all needles from patients after completing a session. Through TriWest's Clinical Quality Management, Complaints, and Grievances processes, several Veterans have reported leaving a treatment site and later finding one or more needles that were not removed by the practitioner."
Remember, payments for VA services are paid 100 percent by the VA and the patient should have no co-pays, co-insurance, deductibles, etc. The fee allowance for acupuncture is based on Medicare or the prevailing usual, customary and reasonable rate for your region. Providers may bill your regular rate; however, the payment by the VA is final and you cannot balance bill the patient for amounts not allowed.
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