Public Comment on CY 2021 Payment Policies under the Physician Fee Schedule

Below you will find the ASA’s comment on CY 2021. Please feel free to use it as a guide to submit your own comment. The deadline is 5:00 PM, October 5, 2020

Public Comment on CY 2021 Payment Policies under the Physician Fee Schedule

To Whom it May Concern:

The American Society of Acupuncturists (ASA) is submitting this response to proposed changes in the 2021 CMS Fee schedule for CPT codes 97810-97814. The ASA represents over 34-member state organizations in 33 states.

The proposed changes to the 2021 Physician Fee Schedule (PFS) will reduce the Relative Value Units (RVUs) for acupuncture codes (97810-97814) and decrease the PFS conversion factor by 10%. The proposed changes devalue acupuncture treatments to the point where it may not be financially feasible for Licensed Acupuncturists to serve Medicare beneficiaries and other insurance patients. For example, when the VACCN program recently adopted Medicare reimbursement rates, many Licensed Acupuncturists stopped accepting VACCN patients because the Medicare rates did not provide a sustainable fee structure. We are concerned that this fee reduction will decrease patients’ ability to access care.

Page 286 of the Federal Register lists the proposed rule changes, stating:

…that the RVUs for the acupuncture codes were based on a pair of crosswalks to two recently reviewed codes in the Dry Needling family…Due to the similar clinical nature of these services and their nearly identical work times, we believe that it is more accurate to propose cross walking CPT codes 97810 through 97814 to the work RVUs of the Dry Needling codes, which were finalized last year, as opposed to proposing work RVUs from 2004, which were never reviewed by CMS.

We disagree that these codes are clinically similar. The expertise, skill and intensity required for codes 97810- 97814 is distinct from codes 20560-20561 and they should not be cross walked. Furthermore, the procedures themselves are nowhere similar. The precision and decision making involved in acupuncture is far beyond that of dry needling. This is why the AMA established two distinct CPT codes for acupuncture and dry needling/trigger point acupuncture procedures. One significant difference is that the acupuncture codes include pre- and post-service work up (as per the AMA CPT instructions) whereas the dry needling/trigger point acupuncture codes do not. Another difference is the intensity of diagnostics. Acupuncture point selection typically requires at least 5 to 10 points placed bilaterally in multiple body regions, and is considerably more involved than straightforward dry needling/trigger point acupuncture. These differences distinguish the skill and intensity of Acupuncture versus dry needling/trigger point acupuncture.

The vignettes used to create the AMA CPT dry needling/trigger point acupuncture codes describe that the practitioner locates the trigger point, inserts, manipulates, then removes the needle. In contrast, acupuncture procedures require a review of symptoms, physical examination, diagnosis, point prescription, location of and insertion of points in multiple body regions, repeated and/or continuous manipulation of needles, additional and/or reinsertion of acupuncture needles. Acupuncture licensure requirements include set didactic standards with at least 660 hours of supervised Acupuncture procedure training, examination by an

independent Certification body [National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)] in most states, and 60 hours of continuing education every four years in most states. Medical Acupuncturist requirements include 300 hours of systematic acupuncture training, Certification through the American Board of Medical Acupuncture, and 150 hours of continuing education every 10 years.

In contrast, to practice dry needling/trigger point acupuncture, there are no independent, agency-accredited training programs, no standardized curriculum, no means of assessing the competence of instructors in the field, and no independently administered competency examinations. There are no set requirements for

supervised acupuncture procedure training, which may range from 25 to 75 hours of unaccredited coursework, and no requirement for continuing education. A physical therapist could perform dry needling/trigger point acupuncture immediately after a weekend course. Comparing acupuncture to dry needling/trigger point acupuncture is like comparing apples to kumquats.

Improved patient outcomes with acupuncture are reflective of the additional skill and intensity of the acupuncture procedures. The strength of acupuncture is the ability to treat symptoms beyond pain AND the ability to treat multiple symptoms simultaneously. There is a strong and growing body of evidence to support acupuncture as an effective treatment for several non-musculoskeletal conditions.(*See Appendix A) For example, acupuncture is an effective adjunct treatment for the mental health conditions of anxiety, depression and insomnia.(*See Appendix B) These mental health conditions can be both a cause and a result of musculoskeletal injuries and pain. Acupuncture can simultaneously reduce musculoskeletal pain and symptoms of anxiety, depression, insomnia. This is just one example of the added value of acupuncture. So much of our population, particularly Medicare beneficiaries, have multiple chronic conditions that can be addressed alongside musculoskeletal pain within the same acupuncture procedure. Acupuncture has also demonstrated the ability to reduce the number of prescriptions for opioids, muscle relaxants, benzodiazepines, and non-steroidal anti-inflammatory medications which creates significant cost savings for insurers.(*See Appendix C) Acupuncture is able to achieve these enhanced outcomes when fully trained providers apply multiple acupuncture approaches simultaneously. One of the simplest subsets of acupuncture approaches is dry needling/trigger point acupuncture, which has only a limited application for musculoskeletal pain. Only acupuncture by fully trained providers can accomplish improved outcomes in multiple symptoms simultaneously and add value to the system.

We respectfully recommend that the RVUs for acupuncture codes are NOT reduced from their current values.

ASA’s Insurance Committee Chair, Mori West, is available at [email protected] if you have any questions or concerns. You can also reach Amy Mager, VC Public Policy at [email protected] or Jennifer Broadwell, ASA Advocacy Chair at [email protected].

Respectfully,

Mori West, ASA Insurance Committee Chair


Appendix A: References Supporting Acupuncture for Other Select Non-Musculoskeletal Conditions:

Bae K, Yoo HS, Lamoury G, Boyle F, Rosenthal DS, Oh B. Acupuncture for Aromatase Inhibitor-Induced Arthralgia: A Systematic Review. Integr Cancer Ther. 2015 Nov;14(6):496-502.

Chang SC, Hsu CH, Hsu CK, Yang SS, Chang SJ. The efficacy of acupuncture in managing patients with chronic prostatitis/chronic pelvic pain syndrome: A systemic review and meta-analysis. Neurourol Urodyn. 2016 Jan 6.

Chao GQ, Zhang S. Effectiveness of acupuncture to treat irritable bowel syndrome: A meta-analysis. World J Gastroenterol. 2014 Feb 21;20(7):1871-7.

Chiu HY, Hsieh YJ, Tsai PS. Systematic review and meta-analysis of acupuncture to reduce cancer-related pain. Eur J Cancer Care (Engl). 2017 Mar;26(2). doi: 10.1111/ecc.12457. Epub 2016 Feb 7.

Feng S, Han M, Fan Y, Yang G, Liao Z, Liao W, et al. Acupuncture for the treatment of allergic rhinitis: a systematic review and meta-analysis. Am J Rhinol Allergy. 2015 Jan-Feb;29(1):57-62.

Franco JVA, Turk T, Jung JH, Xiao YT, Iakhno S, Garrote V, Vietto V. Non‐pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database of Systematic Reviews 2018, Issue 1. Art. No.: CD012551. DOI: 10.1002/14651858.CD012551.pub2.

Fu Q, Zhang L, Liu Y, et al. Effectiveness of Acupuncturing at the Sphenopalatine Ganglion Acupoint Alone for Treatment of Allergic Rhinitis: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2019;2019:6478102. Published 2019 Mar 12. doi:10.1155/2019/6478102

Liu AJ, Li JH, Li HQ, Fu DL, Lu L, Bian ZX, et al. Electroacupuncture for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials. Am J Chin Med. 2015;43(8):1541-66.

Liu BP, Wang YT, Chen SD. Effect of acupuncture on clinical symptoms and laboratory indicators for chronic prostatitis/chronic pelvic pain syndrome: a systematic review and meta-analysis. Int Urol Nephrol. 2016 Dec;48(12):1977- 1991.

Manheimer E, Wieland LS, Cheng K, Li SM, Shen X, Berman BM, et al. Acupuncture for irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol. 2012 Jun;107(6):835-47; quiz 48.

McDonald J, Janz S. The Acupuncture Evidence Project: A Comparative Literature Review (Revised Edition). Brisbane: Australian Acupuncture and Chinese Medicine Association Ltd; 2017.

Qin Z, Wu J, Tian J, Zhou J, Liu Y, Liu Z. Network Meta-Analysis of the Efficacy of Acupuncture, Alpha-blockers and Antibiotics on Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Sci Rep. 2016 Oct 19;6:35737.

Wang L, Xu M, Zheng Q, Zhang W, Li Y. The Effectiveness of Acupuncture in Management of Functional Constipation: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2020;2020:6137450. Published 2020 Jun 17. doi:10.1155/2020/6137450

Wang XP, Zhang DJ, Wei XD, Wang JP, Zhang DZ. Acupuncture for the relief of hot flashes in breast cancer patients: A systematic review and meta-analysis of randomized controlled trials and observational studies. J Cancer Res Ther. 2018;14(Supplement):S600-S608. doi:10.4103/0973-1482.183174

Yang GS, Kim HJ, Griffith KA, Zhu S, Dorsey SG, Renn CL. Interventions for the Treatment of Aromatase Inhibitor- Associated Arthralgia in Breast Cancer Survivors: A Systematic Review and Meta-analysis. Cancer Nurs. 2017 Jul/Aug;40(4):E26-E41. doi:10.1097/NCC.0000000000000409.

Zhang JH, Wang D, Liu M. Overview of systematic reviews and meta-analyses of acupuncture for stroke. Neuroepidemiology. 2014;42(1):50-8.

Zheng H, Chen Q, Chen M, Wu X, She TW, Li J, Huang DQ, Yue L, Fang JQ. Nonpharmacological conservative treatments for chronic functional constipation: A systematic review and network meta-analysis. Neurogastroenterol Motil. 2019 Jan;31(1):e13441. doi: 10.1111/nmo.13441. Epub 2018 Aug 20.

Zheng H, Chen R, Zhao X, et al. Comparison between the Effects of Acupuncture Relative to Other Controls on Irritable Bowel Syndrome: A Meta-Analysis. Pain Res Manag. 2019;2019:2871505. Published 2019 Nov 11. doi:10.1155/2019/2871505

Appendix B: References Supporting Acupuncture for Anxiety, Depression, and Insomnia:

Amorim D, Amado J, Brito I, et al. Acupuncture and electroacupuncture for anxiety disorders: A systematic review of the clinical research. Complement Ther Clin Pract. 2018;31:31-37. doi:10.1016/j.ctcp.2018.01.008

Chan YY, Lo WY, Yang SN, Chen YH, Lin JG. The benefit of combined acupuncture and antidepressant medication for depression: A systematic review and meta-analysis. J Affect Disord. 2015 May 1;176:106-17.

Chen C, Shan W. Pharmacological and non-pharmacological treatments for major depressive disorder in adults: A systematic review and network meta-analysis. Psychiatry Res. 2019;281:112595. doi:10.1016/j.psychres.2019.112595

Di YM, Yang L, Shergis JL, et al. Clinical evidence of Chinese medicine therapies for depression in women during perimenopause and menopause. Complement Ther Med. 2019;47:102071. doi:10.1016/j.ctim.2019.03.019

Dong B, Chen Z, Yin X, Li D, Ma J, Yin P, Cao Y, Lao L, Xu S. The Efficacy of Acupuncture for Treating Depression- Related Insomnia Compared with a Control Group: A Systematic Review and Meta-Analysis. Biomed Res Int. 2017;2017:9614810. doi:10.1155/2017/9614810.

Goyata SL, Avelino CC, Santos SV, Souza Junior DI, Gurgel MD, Terra FS. Effects from acupuncture in treating anxiety: integrative review. Rev Bras Enferm. 2016 Jun;69(3):602-9.

Hollenbach D, Broker R, Herlehy S, Stuber K. Non-pharmacological interventions for sleep quality and insomnia during pregnancy: A systematic review. Can Chiropr Assoc. 2013 Sep;57(3):260-70.

Kim SH, Jeong JH, Lim JH, Kim BK. Acupuncture using pattern-identification for the treatment of insomnia disorder: a systematic review and meta-analysis of randomized controlled trials [published correction appears in Integr Med Res. 2020 Jun;9(2):100420]. Integr Med Res. 2019;8(3):216-226. doi:10.1016/j.imr.2019.08.002

Lan et al. Auricular acupuncture with seed or pellet attachments for primary insomnia: a systematic review and meta- analysis. BMC Complement Altern Med. 2015 Apr 2;15:103.

Lee SH, Lim SM. Acupuncture for insomnia after stroke: a systematic review and meta-analysis. BMC Complement Altern Med. 2016 Jul 19;16:228.

Liu C, Xi H, Wu W, et al. Placebo effect of acupuncture on insomnia: a systematic review and meta-analysis. Ann Palliat Med. 2020;9(1):19-29. doi:10.21037/apm.2019.11.15

MacPherson H, Richmond S, Bland M, Brealey S, Gabe R, Hopton A, Keding A, Lansdown H, Perren S, Sculpher M, Spackman E, Torgerson D, Watt I. Acupuncture and counselling for depression in primary care: a randomised controlled trial. PLoS Med. 2013 Sep;10(9):e1001518. doi: 10.1371/journal.pmed.1001518.

Shergis JL, Ni X, Jackson ML, Zhang AL, Guo X, Li Y, et al. A systematic review of acupuncture for sleep quality in people with insomnia. Complement Ther Med. 2016 Jun;26:11-20.

Tan HJ, Lan Y, Wu FS, Zhang HD, Wu L, Wu X, Liang FR. [Auricular acupuncture for primary insomnia: a systematic review based on GRADE system]. Zhongguo Zhen Jiu. 2014 Jul;34(7):726-30.

van Ravesteyn LM, Lambregtse-van den Berg MP, Hoogendijk WJ, Kamperman AM. Interventions to treat mental disorders during pregnancy: A systematic review and multiple treatment meta-analysis. PLoS One. 2017 Mar 30;12(3):e0173397. doi:10.1371/journal.pone.0173397.

Yan B, Zhu S, Wang Y, Da G, Tian G. Effect of Acupuncture on Chronic Pain with Depression: A Systematic Review. Evid Based Complement Alternat Med. 2020;2020:7479459. Published 2020 Jun 25. doi:10.1155/2020/7479459

Appendix C: References Supporting Acupuncture for Pain Management

Crawford, MD, Paul; Donald B. Penzien, MD; and Remy Coeytaux, MD. “Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population.” Medical Acupuncture 29:4 (2017): 229-231.

Fan AY, Miller DW, Bolash B, Bauer M, McDonald J, Faggert S, He H, Li YM, Matecki A, Camardella L, Koppelman MH, Stone JAM, Meade L, Pang J. Acupuncture’s Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management-White Paper 2017. J Integr Med. 2017 Nov;15(6):411-425. doi: 10.1016/S2095-4964(17)60378-9. PMID: 29103410.

Gong CZ, Liu W. Acupuncture and the Opioid Epidemic in America. Chin J Integr Med. 2018 May;24(5):323-327. doi: 10.1007/s11655-018-2989-z. Epub 2018 May 11. PMID: 29752610.

MacPherson H, Vertosick EA, Foster NE, Lewith G, Linde K, Sherman KJ, Witt CM, Vickers AJ. The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain. Pain. 2017 May;158(5):784-793. doi: 10.1097/j.pain.0000000000000747. PMID: 27764035; PMCID: PMC5393924.

Tedesco D, Gori D, Desai KR, Asch S, Carroll IR, Curtin C, McDonald KM, Fantini MP, Hernandez-Boussard T. Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta- analysis. JAMA Surg. 2017 Oct 18;152(10):e172872. doi: 10.1001/jamasurg.2017.2872. Epub 2017 Oct 18. Erratum in: JAMA Surg. 2018 Apr 1;153(4):396. PMID: 28813550; PMCID: PMC5831469.

Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon RL, Wayne P, Zador V; Pain Task Force of the Academic Consortium for Integrative Medicine and Health. Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY). 2018 May-Jun;14(3):177-211. doi: 10.1016/j.explore.2018.02.001. Epub 2018 Mar 1. PMID: 29735382.

Wu MS, Chen KH, Chen IF, Huang SK, Tzeng PC, Yeh ML, Lee FP, Lin JG, Chen C. The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLoS One. 2016 Mar 9;11(3):e0150367. doi: 10.1371/journal.pone.0150367. PMID: 26959661; PMCID: PMC4784927.

Yin C, Buchheit TE, Park JJ. Acupuncture for chronic pain: an update and critical overview. Curr Opin Anaesthesiol. 2017 Oct;30(5):583-592. doi: 10.1097/ACO.0000000000000501. PMID: 28719458.