The chiropractor rate is all that an acupuncurist is entitled to

Understanding Acupuncture Fee Schedules in New York Personal Injury Cases

In the complex world of New York’s no-fault insurance system, acupuncture practitioners and their patients often face confusion about proper reimbursement rates. For healthcare providers serving accident victims across New York City and Long Island, understanding how courts determine acupuncture fee schedules is essential for successful practice and fair compensation. The legal landscape surrounding acupuncture billing has evolved significantly, with recent court decisions providing clear guidance on reimbursement standards.

Acupuncture has become an increasingly important treatment modality for personal injury victims throughout the New York metropolitan area. From Manhattan’s bustling medical centers to suburban practices in Nassau and Suffolk Counties, acupuncture providers play a vital role in helping accident victims recover from their injuries. However, the intersection of traditional Eastern medicine and New York’s regulatory framework has created unique challenges for both practitioners and patients.

The Legal Standard for Acupuncture Reimbursement

The Appellate Term is starting to sound like a broken record. Yet, each time they play the record it seems that the message is more emphatic.

In New Wave Acupuncture v. Geico, 2009 NY Slip Op 52211(u)(App. Term 2d Dept. 2009), the Court stated the following: “For the reasons stated in Great Wall Acupuncture v GEICO Gen. Ins. Co. (16 Misc 3d 23 ), it was proper for defendant to use the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which plaintiff was entitled to receive.”

Note: The court as of this case and Ava Acupuncture v. Geico does not require the carrier to provide evidence as to why it chose to pay chiropractor fee schedule rate as opposed to another rate. The chiropractor fee schedule amount is acceptable as a matter of law. Period, the end.

Now, let’s assume that you are in a stipped in trial and the sole issue is whether or not the billing was in accordance with the “fee schedule”. Based on New Wave Acupuncture v. Geico and Ava Acupuncture v. Geico, this is what the defendant’s portion of the trial should look like:

Exhibit “A”

(1) Denial of claim form with explanation of benefits

Exhibit “B” .

(2) Fee schedule with CPT 97810, 97811, 97813, 97814;

Exhibit “C” .

(3) Chiropractor conversion factor ;

Exhibit “D” for identification:

(4) Shiny Sharpe brand Calculator

Exhibit “E” for reference: New Wave Acupuncture v. Geico and Ava Acupuncture v. Geico

(5) Give copies to the Judge and Plaintiff’s counsel.

(6) Tell Plaintiff and judge: “No, I do not need to bring a claim rep. This is why…”

(7) With calculator, take the relative value, multiply by the Region IV conversion factor of 5.78 and announce the result to the court. If you want, read the portion of the fee schedule that tells the court that this is how you arrive at the compensable amount. You will find this in the introduction section of the fee schedule.

Now, do this for each billed for code. Does the amount you calculated match the amount paid on the denial of claim form? If yes, go to next step.

(7) Motion for directed verdict.

(8a) If win smile

(8b) If lose APPEAL and do not forget to enter a judgment for costs and disbursements including the prospective marshal fee after the judgment is reversed without costs. The without costs only refers to appellate costs.

(8c) Tell the marshal you want to enforce the $105 judgment you just entered. See what the marshal says. I know first hand what you will be told. But, insist that the marshal collects the judgment. He is duty-bound to do this. I guarantee you will have a check in the mail in no time. One warning however: the next time you call that marshal, you will be told that you have the wrong number. Don’t worry – there are plenty of marshals out there.

Impact on NYC and Long Island Acupuncture Practitioners

The ruling in New Wave Acupuncture has significant implications for acupuncture providers throughout the New York metropolitan area. Practitioners in Manhattan, Brooklyn, Queens, the Bronx, Staten Island, Nassau County, and Suffolk County must understand that their reimbursement rates are legally tied to chiropractic fee schedules, regardless of the specialized nature of acupuncture services or the unique training required for licensure.

This standardization affects thousands of acupuncture providers across the region who treat motor vehicle accident victims. Many practitioners initially assumed that acupuncture services would be reimbursed at rates comparable to other specialized medical treatments, but the court’s clear directive eliminates any ambiguity about billing standards.

Understanding the Fee Schedule Framework

The workers’ compensation fee schedule structure that governs acupuncture reimbursement in no-fault cases uses a complex system of relative value units (RVUs) and conversion factors. For Region IV, which includes the New York metropolitan area, the conversion factor of 5.78 multiplied by the relative value for specific CPT codes determines the maximum allowable reimbursement.

Common acupuncture CPT codes affected by these rulings include:

• 97810: Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes
• 97811: Acupuncture, without electrical stimulation, each additional 15 minutes
• 97813: Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes
• 97814: Acupuncture, with electrical stimulation, each additional 15 minutes

Each of these codes has a specific relative value that, when multiplied by the 5.78 conversion factor, establishes the legally mandated reimbursement rate for acupuncture services in personal injury cases.

Practical Implications for Patients and Providers

For accident victims seeking acupuncture treatment in New York City and Long Island, understanding these billing limitations is crucial for making informed healthcare decisions. Patients should be aware that their insurance coverage through no-fault benefits will be calculated using chiropractic rates, which may be lower than standard acupuncture fees charged for non-insurance patients.

Healthcare providers must also adjust their billing practices and patient communications accordingly. Many acupuncture practices across the five boroughs and Long Island have had to modify their business models to accommodate these reimbursement limitations while still providing quality care to accident victims.

Frequently Asked Questions About Acupuncture Fee Schedules

Why are acupuncture services reimbursed at chiropractic rates in no-fault cases?

The New York courts determined that the workers’ compensation fee schedule for chiropractic services provides an appropriate framework for acupuncture reimbursement. This decision was based on legal precedent and the need for standardized billing practices within the no-fault system, rather than the specific nature of acupuncture treatment.

Can acupuncturists charge patients the difference between their regular fees and insurance reimbursement?

The ability to balance bill patients (charge them for amounts above insurance reimbursement) depends on specific contractual arrangements and state regulations. Providers should consult with legal counsel about their particular circumstances and ensure compliance with New York no-fault insurance laws.

How do I calculate the correct reimbursement amount for acupuncture services?

To calculate proper reimbursement, multiply the relative value unit (RVU) for the specific CPT code by the Region IV conversion factor of 5.78. This calculation provides the maximum allowable reimbursement under New York’s no-fault system for acupuncture services.

What should acupuncture providers do if insurance companies underpay claims?

Providers should first verify that their billing accurately reflects the proper CPT codes and that their calculations align with the fee schedule requirements. If underpayment persists despite correct billing, they may need to pursue formal dispute resolution through the appropriate legal channels.

Are there any exceptions to the chiropractic fee schedule requirement for acupuncture?

Based on current court precedents, including New Wave Acupuncture v. Geico, the chiropractic fee schedule rates are mandatory for acupuncture services in no-fault cases. The courts have made clear that insurance carriers are not required to justify this rate structure, as it is established as a matter of law.

If you’re an acupuncture provider or patient dealing with no-fault insurance billing disputes, or if you’ve been injured in an accident and need guidance on your treatment options and insurance coverage, don’t address these complex waters alone. Call 516-750-0595 to speak with an experienced attorney who understands both the medical and legal aspects of personal injury cases in New York. Our team can help ensure you receive the compensation and care you deserve while complying with all applicable legal requirements.

Related Articles

• NY Acupuncture Prima Facie Defense: Chiropractor Rate Limitations Upheld
• NY Acupuncture Fee Schedules: Licensed Practitioners Limited to Chiropractor Rates
• Understanding Medical Billing and Down-Coding in New York No-Fault Insurance Claims
• Fee Schedule Defense Requirements in No-Fault Insurance Cases
• New York No-Fault Insurance Law

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Legal Update (February 2026): The fee schedules and reimbursement rates referenced in this 2009 post have been subject to multiple regulatory amendments and updates over the past 17 years. Practitioners should verify current fee schedule provisions, as the Department of Financial Services has implemented various adjustments to no-fault reimbursement rates and billing procedures since this decision. Additionally, subsequent court decisions and regulatory changes may have modified the standards for acupuncture reimbursement discussed in this analysis.