Key Takeaway
New York court ruling clarifies CPT codes 97813 and 97814 acupuncture billing rates under workers' compensation fee schedule for no-fault insurance claims.
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.
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.
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.
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.
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.
