CPT Code 97813 and 97814

Understanding the proper reimbursement rates for acupuncture services under New York’s no-fault insurance system requires careful attention to specific CPT codes and applicable fee schedules. CPT codes 97813 and 97814 represent different acupuncture treatment modalities, and their reimbursement has been subject to ongoing litigation between healthcare providers and insurance carriers.

CPT code 97813 designates acupuncture services involving one or more needles with re-insertion, while CPT code 97814 covers acupuncture with electrical stimulation. These codes represent additional acupuncture services beyond the initial procedure coded under 97810 or 97811. Healthcare providers have historically billed these services at physician rates, arguing that acupuncture requires specialized training and clinical expertise warranting higher reimbursement. Insurance carriers, conversely, have contended that the workers’ compensation fee schedule mandates lower reimbursement rates similar to those paid for chiropractic services.

The workers’ compensation fee schedule plays a crucial role in determining payment rates for these services, particularly for treatments rendered after April 1, 2013. This regulatory framework establishes maximum allowable fees that insurers must pay for covered medical services, creating standardized billing practices across the New York No-Fault Insurance Law system. Regulation 11 NYCRR 65-3.8 incorporates the workers’ compensation fee schedule by reference for certain categories of no-fault services, creating a crossover between the two distinct insurance systems that has generated significant litigation.

Recent appellate court decisions have provided important clarity on how these codes should be processed and reimbursed, affecting both acupuncture providers and insurance companies operating within the state’s no-fault framework. The emergence of consistent precedent resolving the applicable fee schedule for acupuncture services has reduced uncertainty in billing practices, though providers continue to advocate for higher reimbursement rates through regulatory channels.

Case Background: Live In Grace Acupuncture

In Live In Grace Acupuncture, P.C. v GEICO General Insurance Co., the plaintiff acupuncture provider sought reimbursement for services billed under CPT codes 97813 and 97814 for treatments provided after April 1, 2013. The provider apparently billed these services at rates exceeding those permitted under the workers’ compensation fee schedule, prompting GEICO to reduce the payments to the fee schedule amounts. The provider then filed suit seeking the difference between its billed charges and the amounts paid.

Both parties filed cross-motions for summary judgment. The provider argued it was entitled to higher reimbursement rates based on the complexity and specialized nature of acupuncture services. GEICO cross-moved for summary judgment dismissing the complaint, arguing that it had fully satisfied its payment obligations by reimbursing the services at the workers’ compensation fee schedule rates mandated by regulation 11 NYCRR 65-3.8. The Civil Court granted the provider’s motion and denied the insurer’s cross-motion. GEICO appealed to the Appellate Term.

Jason Tenenbaum’s Analysis:

Live In Grace Acupuncture, P.C. v GEICO Gen. Ins. Co., 2020 NY Slip Op 51360(U)(App. Term 2d Dept. 2020)

“The branch of defendant’s cross motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims using CPT codes 97813 and 97814 was based upon the defense that it had fully paid plaintiff for the services at issue in accordance with the workers’ compensation fee schedule. The record establishes that defendant demonstrated that it had fully paid plaintiff in accordance with the workers’ compensation fee schedule for the services billed under CPT codes 97813 and 97814 for acupuncture services that plaintiff had rendered after April 1, 2013. As a result, the branch of defendant’s cross motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims using CPT codes 97813 and 97814 should have been granted (see 11 NYCRR 65-3.8 ; ; Jing Luo Acupuncture, P.C. v NY City Tr.Auth., 60 Misc 3d 136, 2018 NY Slip Op 51083 ; Oleg’s Acupuncture, P.C. v Hereford Ins. Co., 58 Misc 3d 151, 2018 NY Slip Op 50095 ).”

CHIRO rate.

Legal Significance: Fee Schedule Application to Acupuncture Services

The Appellate Term’s reversal in Live In Grace Acupuncture resolves lingering uncertainty about the applicable reimbursement rates for acupuncture services coded under CPT 97813 and 97814. The court’s citation to Jing Luo Acupuncture, P.C. v NY City Transit Authority and Oleg’s Acupuncture, P.C. v Hereford Insurance Co. demonstrates consistency across multiple appellate panels in applying the workers’ compensation fee schedule to these specific acupuncture codes.

The decision reflects the regulatory structure established under 11 NYCRR 65-3.8, which incorporates the workers’ compensation fee schedule for certain medical services in the no-fault context. This cross-referencing between two distinct insurance systems creates administrative efficiency by preventing providers from billing different rates for identical services depending on whether the underlying claim arises from workplace injury or automobile accident. The regulatory framework promotes uniformity in reimbursement while constraining healthcare costs across both systems.

From a statutory interpretation perspective, the court’s analysis turns on the plain language of the regulation designating the workers’ compensation fee schedule as the controlling payment standard for acupuncture services after April 1, 2013. When regulations specify maximum reimbursement rates, courts lack authority to permit higher payments absent constitutional infirmity or regulatory invalidity. The Live In Grace decision reinforces that providers cannot circumvent fee schedule limitations through creative billing arguments or claims that their services warrant premium reimbursement.

The April 1, 2013 effective date creates a temporal dividing line with significant practical implications. Services rendered before this date may be subject to different fee schedules or reimbursement methodologies, while post-April 2013 services fall conclusively under the workers’ compensation fee schedule. Providers pursuing claims for services spanning this transition date must carefully segregate pre- and post-April 2013 services to ensure proper application of the governing fee schedules.

Practical Implications: Acupuncture Provider Billing Practices

For acupuncture providers, Live In Grace Acupuncture establishes clear boundaries on permissible billing rates for services coded under CPT 97813 and 97814. Providers cannot bill these services at physician rates or other enhanced rates; instead, reimbursement is capped at the amounts specified in the workers’ compensation fee schedule. Billing in excess of these amounts will result in automatic reductions by insurers, and subsequent litigation challenging those reductions will fail as a matter of law.

Acupuncture practices should audit their billing systems to ensure that CPT codes 97813 and 97814 are configured to bill at workers’ compensation fee schedule rates for services rendered after April 1, 2013. Continuing to bill at higher rates creates administrative inefficiency, as insurers will reduce payments to the fee schedule amounts, requiring providers to write off the difference. Accurate billing from the outset avoids the false appearance of accounts receivable that will never be collected.

Insurance carriers defending against acupuncture provider claims for CPT codes 97813 and 97814 have strong precedent for summary judgment dismissal when they can demonstrate full payment in accordance with the workers’ compensation fee schedule. The Live In Grace decision, combined with the earlier Jing Luo and Oleg’s Acupuncture precedents, creates a robust line of authority establishing the applicable fee schedule. Defense counsel should cite these cases prominently in summary judgment motions to demonstrate that the legal question has been conclusively resolved against provider claims for enhanced reimbursement.

Key Takeaway

This ruling confirms that acupuncture services billed under CPT codes 97813 and 97814 are properly reimbursed at the workers’ compensation fee schedule rates, not higher rates that providers might seek. Insurance carriers who pay according to these established rates have fulfilled their obligation under the 120-day rule and Fee Schedule, protecting them from additional liability for these specific acupuncture treatments.

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