97810 CPT Code: The Complete Billing, Insurance, and Reimbursement Guide

Introduction to CPT Code 97810

CPT Code 97810 is a critical billing code used in acupuncture treatments. It falls under acupuncture CPT codes and is essential for insurance reimbursement and medical billing. If you’re a healthcare provider, acupuncturist, or medical biller, understanding the correct 97810 CPT code billing guidelines can help you maximize reimbursements and avoid claim denials.

In this guide, we will cover everything you need to know about CPT code 97810, including billing procedures, insurance coverage, reimbursement rates, and best practices.

What is CPT Code 97810?

CPT code 97810 is the Current Procedural Terminology (CPT) code used for acupuncture treatment without electrical stimulation, including the initial 15 minutes of personal one-on-one contact with a patient.

7810 CPT Code description

• Procedure: Acupuncture treatment (without electrical stimulation)
• Duration: Initial 15 minutes with direct patient contact
• Category: Acupuncture billing codes
• Medicare & Insurance: Covered under specific conditions

CPT 97810 vs. Other Acupuncture Codes

CPT Code	Description
97810	Initial acupuncture session (15 min, no electrical stimulation)
97811	Additional 15-minute acupuncture session (no electrical stimulation)
97813	Initial acupuncture session with electrical stimulation
97814	Additional 15-minute acupuncture session with electrical stimulation

How to Bill CPT Code 97810 Correctly

Billing 97810 acupuncture code correctly is crucial for ensuring proper insurance reimbursements and avoiding claim denials.

Step-by-Step Billing Guide for CPT 97810

1. Verify Patient’s Insurance Coverage
   • Why it’s Important: Not all insurance plans cover acupuncture. Verifying coverage beforehand prevents claim denials.
   • Medicare Consideration: Medicare only covers acupuncture for chronic low back pain under specific conditions (e.g., up to 12 sessions in 90 days).
   • Private Insurance: Different insurers have different policies, so checking pre-authorization requirements is key.
2. Assign the Correct CPT Code
   • CPT 97810: Used for the initial acupuncture treatment session (15 minutes, no electrical stimulation).
   • CPT 97811: Used when the acupuncture session extends beyond 15 minutes.
   • Why it’s Important: Using the wrong CPT code can result in delayed or rejected claims.
3. Use Correct CPT Modifiers
   • Modifier 25: Used when acupuncture is performed on the same day as another service (e.g., chiropractic adjustment).
   • Modifier GP: Required by some insurers to indicate physical therapy-related services.
   • Why it’s Important: Modifiers prevent coding conflicts and help in insurance approval.
4. Document the Session Properly,
   • Required Information:
     • Treatment duration (start and end times)
     • Diagnosis codes (ICD-10) matching the patient’s condition
     • SOAP notes (Subjective, Objective, Assessment, Plan)
   • Why it’s Important: Incomplete or missing documentation can lead to insurance audits and claim denials.
5. Submit the Claim Correctly
   • ICD-10 Codes: Must match the diagnosis for which acupuncture is provided.
   • Claim Submission Best Practices:
     • Use clearly documented progress notes.
     • Double-check coding and modifiers.
     • Submit claims electronically for faster processing.
   • Why it’s Important: Correct claims increase reimbursement rates and reduce the likelihood of claim rejection\

To ensure accurate billing and maximize reimbursements, it’s essential to understand CPT codes in medical billing and their role in insurance claims.

Insurance & Medicare Coverage for 97810

Does Medicare Cover Acupuncture (CPT 97810)?

Yes, Medicare covers acupuncture but only for chronic low back pain and under specific provider requirements.

Medicare Guidelines	Coverage Details
Condition	Chronic low back pain
Sessions Covered	Up to 12 treatments over 90 days
Additional Coverage	8 more sessions if showing improvement
Maximum Limit	20 treatments per year

Private Insurance Coverage

Many private insurers cover CPT code 97810, but policies vary. It’s recommended to check individual insurance policies.

97810 acupuncture Code Reimbursement Rates & Best Practices

Latest Reimbursement Rates (2024)

Reimbursement rates vary by location, insurer, and Medicare guidelines.

• Medicare Rate: ~$30 – $40 per session
• Private Insurance: ~$40 – $70 per session (depends on provider)
• Cash-Pay Clinics: Often charge $75 – $150 per session

How to Maximize Reimbursement

• Ensure correct documentation: Incomplete records lead to claim denials.
• Use proper coding combinations: CPT 97810 and 97811 together for extended sessions.
• Stay updated with payer policies: Medicare & private insurers update guidelines annually.

Common Billing Mistakes and How to Avoid Them

• Incorrect Use of CPT Modifiers
  • Fix: Apply Modifier 25 when billing acupuncture alongside other treatments.
• Insufficient Documentation:
  • Fix: Maintain SOAP notes and detailed treatment logs.
• Billing 97810 Without Meeting Insurance Criteria:
  • Fix: Check insurance policies before submitting claims.

Applying the right common billing modifiers ensures proper coding and improves reimbursement rates.

Documentation Requirements for CPT 97810

To avoid audits and ensure compliance, follow these best documentation practices:

1. ✔ Patient History & Diagnosis – Must match ICD-10 codes for acupuncture conditions.
2. ✔ Session Duration & Techniques Used – Required for Medicare and insurance approval.
3. ✔ Treatment Progress Notes – Document improvements or continued symptoms.
4. ✔ Patient Consent Forms – Especially for insurance-covered treatments.

For official Medicare guidelines on acupuncture coverage, refer to the CMS National Coverage Determination for Acupuncture.

Future of CPT 97810 & Acupuncture Billing Trends

With the increasing recognition of acupuncture, billing policies and reimbursement rates are evolving. Upcoming changes in 2025 may include:

• Expanded Medicare Coverage for conditions beyond low back pain.
• Higher reimbursement rates with proper documentation.
• AI-powered billing systems for faster claim approvals.

For better financial outcomes, explore strategies for maximizing insurance reimbursements in medical billing.

Final Thoughts

Mastering CPT code 97810 billing and insurance reimbursement can significantly increase revenue and reduce claim denials for acupuncture providers. By following correct coding procedures, verifying insurance coverage, and optimizing documentation, practitioners can ensure maximum reimbursement success.

FAQs – 97810 CPT Code