Good afternoon. Good afternoon. Thank you for your late afternoon attendance. I know sometimes long academy days, the afternoon attendance begins to dwindle. Welcome to Get to the Point, adding acupuncture to your physiatric practice. I have the privilege of leading this session. My name is Mike Salino. I am a physiatrist at Cooper University Hospital in Camden, New Jersey, right across the river from Philadelphia. I have three friends and colleagues joining me in today's presentation, talking about the clinical aspects of acupuncture practice, as well as the administrative components. We're going to talk for about 15 to 20 minutes each, leaving some time for questions at the end. The only exception to that is our second presenter, Dr. Dung, has a plane to catch, so she's going to take questions right after her presentation. The rest of us will take it at the end. So, our first presenter today is my partner and colleague at Cooper, Dr. Jerry Friedman. Thank you for joining us. This is Otzi the Iceman. He's a mummy that was actually found in the Alps, near the Italian Alps. He used stone tools, had a copper axe, and 61 tattoos on his body. These corresponded to different acupuncture meridians. So that's from around 3000 BC. Sorry. So the picture on the left, this is a picture of a book. It's called the Neijing. This is the classic Chinese medicine textbook. Dates to around 300 forces, the rise and fall of different opposing forces and how they interact. So yin and yang, the five elements, the natural laws, and our role in the natural environment. Acupuncture is one part of Chinese medicine. As far as the balance, we have health and illness, external and internal forces, excess and deficiency, acute and chronic. The paradigms are a little bit different than allopathic medicine. So for example, skin we usually think of as the outside of the body. Lungs are inside. In Chinese medicine, inside the lungs we have the external environment again. So skin and lungs are actually the same system. And if you think of your eczema patients or allergy patients or asthma, you'll know it's actually true. As acupuncture spreads throughout the world, it was changed and modified. The statue in the middle is from the Mayo Clinic. There's the meridians on there. If you cover it in wax, you can actually needle them, and when the needles are put in the right spot, the water actually comes out. On the far right, this is how most people in the United States learned about acupuncture. This is the front page article, 1971, James Retson. Let me tell you about my appendectomy in Peking, and acupuncture was used to treat his post-op ileus. Now medical profession, we actually have records going back to the 1800s for acupuncture. Benjamin Franklin Bach published in Philadelphia, Experiments on Prisoners Using Acupuncture, and that was the first volume. In the second volume, there's a case report of neuralgia being cured with acupuncture, as well as the electrical effects of the acupuncture needles. And then if we look at one of our classic textbooks, Principles and Practice of Medicine, Sir William Osler, this is also 1800s. Acupuncture can be used to treat droopsy, lumbago, and sciatica. At the time, acupuncture was considered the key treatment, the most effective method to treat lumbago. They describe taking three to four inch needles and inserting it at the seat of the pain. Sterilize them first. Not recommending using... Another rehab doc, Dr. Richard. He developed it using ear tacks. Thank you, Jerry. Next, that's not the correct one. Why don't you go ahead and just point out the right presentations. So next up on our list is Dr. Dong who comes to us from State University upstate in New York. She's going to be talking about the utility of acupuncture in the musculoskeletal pain management patient. All right. Thank you. Good afternoon, everyone. So okay, great. So I'm going to talk a little bit about incorporating acupuncture into musculoskeletal pain management. Chances and barriers, et cetera. History. So acupuncture has been, just like Jerry mentioned, has a long history used for the treatment for chronic pain and continues to be a frequently sought treatment for chronic pain relief. How many times when you were in the office, you were asked by some patients, okay, can I have some acupuncture treatment? Actually, that was the driving force to get me to pick up acupuncture. Yes, I did not learn acupuncture when I was in China. I picked up 100% here in the U.S. So traditional acupuncture, like Jerry mentioned, more individualized in conjunction with herbal medicine, copying, lifestyle counseling, like Jerry mentioned. And the most adverse events have been associated with needle use. And in 1997, there's a NIH consensus on acupuncture. So they listed this grade A evidence, grade B evidence. So most are still associated with chronic pain issues. So well, chances right now, as you all know, the current U.S. opioid crisis has been really a primary driver for the efforts to find some non-pharmacologic solutions for pain control. And the graph is actually from CDC website that show the three waves of opioid overdose death, which is scary and very intimidating to think about the numbers we encounter as U.S. history to so many deaths because opioid overdose. And in 2018, there's a white paper published to see the evidence-based non-pharmacologic strategies for comprehensive pain care. So in this white paper, acupuncture is actually recommended as one of the non-pharmacologic therapies for pain control. And as a matter of fact, it's the number one recommended as a non-pharmacologic therapies for pain control. That's a 2018 published paper. And barriers. So of course, there are chances, there are driving forces, there are barriers to incorporate this acupuncture into medical practice. I guess we all know we have a busy practice. And also, as Jerry mentioned in the previous presentation, there are so many styles. Okay. There is an individualized treatment plan usually was used in traditional Chinese medicine or Asian medicine. Well, here in the U.S., we are more used to this protocolized treatment strategies, right? So there are different styles right over there. And also, non-standard styles. So as Jerry mentioned, we have Japanese style, Korean style, Chinese style, French style. So just to name a few. So there's not such a standardized protocol over there. And also, we have this coverage barrier. We'll talk more about that in the next few slides. And also, research barrier. License and coverage. You could get a license through two organizations, NCCAOM or ABMA. That's actually the certification, board certification. So for us, if you are a medical provider, medical physician, you could get your board certification through ABMA, American Board of Medical Acupuncture. You don't have to hold the board certification to practice. Different state has different requirements for you to practice acupuncture. So you have to check with different state requirements. And Medicare and Medicaid, they actually do cover limited acupuncture for chronic low back pain only. We'll talk about that in the next few slides. Commercial insurance usually have some form of coverage depending on the plan. Research barrier. Difficulty in designing the control group or sham treatment. Think about that. If I receive acupuncture, I know it. And if I don't, I know it too, right? And also, that's why it's difficult to perform a double blind study. So you get a needle into my body, of course I know I'm the treatment group. And if I did not get that, I'm not non-treatment group. So it's very hard to design a double blind study. However, there is a smart trial in 2009 published. They have this total more than 300 patients. And they were randomized to individual acupuncture, standardized acupuncture, and also simulated acupuncture or urocare. The smartness is when they design the sham treatment, they kind of use a toothpick in the acupuncture needle guide tube against the skin. So make people feel like they got the treatment. All right? And eight weeks, back dysfunction scores improved by similar amounts in the individualized, standardized, or sham acupuncture groups. And all of them more than in the urocare group. Now about knee pain. So similar, actually, conclusion get to the knee pain. So both are better than the conservative therapy group that we usually use, like physical therapy and non-steroid anti-inflammatory. So the 53%, 51% versus 29%, which is significant. So here's a dilemma, right? Needle or non-needle, right? And also, similarly, several well-designed European trial also show that sham acupuncture, so-called sham acupuncture with a tip, some toothpick tip kind of touch the skin, also receive similar good response. Well, it's controversial. In fact, the use of blunt needles that did not penetrate the skin was described about 2,000 years ago in the classic book, Acupuncture Needling. So it's not something new. And another controversy, people also think about this controversy with sham acupuncture is that, you know, once you stimulate the skin at any position, you will have some biological response, whether penetrate the skin or not penetrate the skin, right? So therefore, it's very hard to interpret the data about this sham acupuncture. So that's a dilemma. That's a confusion. So I don't think we have a lot of clear conclusion on that right now. But nevertheless, it's pretty useful, and it's significant beneficial for the patient. Progress. In 2015, the Joint Commission revised the guidelines for the management of pain to include non-pharmacologic strategies, including acupuncture. In 2016, the American Society of Clinical Oncology included acupuncture for chronic pain management as part of their cancer survivor care recommendations for grown-up. And in 2017, American College of Physicians recommend that acupuncture should be among the first-line non-pharmacologic options for patients with chronic low back pain. In 2017, acupuncture was included in the 2017 Clinical Practice Guidelines for VA system. And then, finally, in 2020, the Centers for Medicare and Medicaid Services approved the use of acupuncture for chronic low back pain, which is monumental. However, that news did not stir a lot of media coverage. Why? Because at that moment, which is early 2020, we were busy preparing for the COVID pandemic. So that monumental decision did not even stir too much interest at all. But it's very new. And also, like Jerry mentioned, the military use in the battlefield acupuncture. So it's increased use in military, developed by this Dr. Niemanzo. And he really kind of have been advancing this technique almost into the whole military, active military system. And this is just like Jerry showed. It's a battlefield acupuncture protocol. Because it's battlefield acupuncture, they need a quick access. That's why they pick up the ear. So quick access. And the needle will stay in for about a couple of days, two, three, four days sometimes. And that's my quick presentation. Any questions? I would say chronic back pain and also knee pain. These are the major ones. Really do well, especially for the elderly patients. They really do well. What about migraines? Migraines, so go back to there's certain evidence over there. Okay. We have four presenters Yeah, so that's also, you know, any stimulation of the skin will elicit some biological response. So that's just kind of similar to when you press on something, you will have some response from it, and the body will respond to it. All right, well, thank you so much. Have a nice day. For our next presenter, we're going to bring in some local talent. My former colleague at Moss Rehab and current Johns Hopkins physiatrist, Dr. Ning Cao, is going to talk about the use of acupuncture in neurologic disease. Hey, good afternoon. This is Ning. So I'm gonna switch gear to talk about more the acupuncture application, the neurological disease. So I'm gonna skip this slide because Jerry and Dr. Deng already went over the overview regarding the serratic theory behind the acupuncture in oriental medicine. So I'm gonna focus on the acupuncture application in the treatment of a variety of neurological disorders in clinical practice, and not only in the oriental countries and also in the United States. Believe it or not, although there's still a lot of mystery and evidence debatable, the usage of the acupuncture however, there's a commonly neurological condition has been treated by acupuncture currently, which are including ischemic stroke, post-stroke spasticity, spinal cord injury, migraine. So I'm gonna go over some preclinical studies for mechanism of acupuncture for these conditions and also get some updated evidence regarding systematic review and meta-analysis from our current understanding. So there are accumulated evidence demonstrated that acupuncture actually can induce neuroplasticity. And interestingly, if we can see the RADM model is both to the cerebral ischemic condition, the cortical surface somehow is more sensitive to the manual acupuncture treatment and subventricular hippocampus and striatum is more sensitive to the electroacupuncture based on our current understanding. And on the RADM model, you can see based on the landmark and neuroanatomy, we do have those meridian acupoints used for the studies. And the graph showed most commonly used acupoints to treat cerebral ischemic condition. So there's a group of researcher from Korean published this study, which is quite interesting. And they generate the middle cerebral artery occlusion mouse model, then they applied electroacupuncture treatment from day five to day 14 after the occlusion to the two points laterally, governing 20 and governing 14. Then they look at behavioral assessment and in addition to the neuromotor and behavioral assessment, they also look at RT-PCR, Vastan blot analysis, immunostaining to understand the basic science behind the neurogenesis from the acupuncture treatment. So what they found based on the neuromotor cognitive test and the mouse who received electroacupuncture, we can see performed using less time to perform those tasks. That means there's a beneficial effects for the neuromotor and cognitive test. And subsequently, they look at the screening a series of genes to understand which pathway involved this neurogenesis recovery. So among all the factors, they found brain derived neurotrophic factor and the vascular endothelial growth factors are significantly increased in the ipsilateral hemisphere after 14 days of occlusion in the mouse model, but not other factors. To determine whether these two growth factors are the pathway leading to the endogenous neurogenesis, they also look at PI3K pathway. All the results from the immunostaining Vastan blot suggest that electroacupuncture stimulation improve the proliferation of neuronal stem cells against ischemic induction through activation, BDNF and VEGF mediated downstream PI3K pathway. So another group of researchers from China also investigate the anti-apoptotic effect through demodulation of PI3K-AKT signaling pathway using the acupoints, Zhu Sanli and Qu Chi. So they generated internal carotid artery occlusion model as we can see on the group two and the first group is SHAM control group and the third group is electroacupuncture treatment. So the red staining means the healthy brain tissue and the yellowish area are the size of the infarct. As we can see, the electroacupuncture group do have neuroprotection from the event. The last group is the PI3K-AKT antagonist which abolished the neuroprotection from the electroacupuncture treatment. And they also investigate the downstream gene production involved PI3K-AKT signaling pathway which is very busy slides and we just wanna focus on the picture B and C as we can see compared to the SHAM control group and the modulation of the ratio of pro-BAT versus BAT and PCL2 and BAX ratio all received enhancement from the electroacupuncture compared to the second group which is cerebral ischemic model. So the graph E, we can see this is another downstream apoptotic gene product called caspase. So we can see the antagonist can really abolish the protection from the electroacupuncture treatment. So in conclusion, at least from this study, we can see the electroacupuncture treatment at points Zhu Sanli and Qu Chi suppressed neuronal apoptosis via PI3K-AKT pathway. So in my clinical practice, I primarily do the stroke rehabilitation and post-stroke spasticity is really interesting area for the application of the acupuncture. So I'm trying to incorporate the acupuncture treatment in the post-stroke spasticity management and we do see emerging evidence from recent years. They're around for this paper, systematic review meta-analysis, they analyzed 88 studies and there's more than 6,000 individuals involved in the analysis and they do see the favorable results were observed in comparison between acupuncture versus conventional rehabilitation. And from the subgroup analysis also showed the acupuncture treatment itself with a frequency once or twice a day was more favorable or effective than the conventional rehabilitation. So another domain caused attract a lot of research interest is the cognitive impairment, whether the cognitive impairment can be benefiting from the acupuncture treatment. So what they look at it also in the Rauden model, they use a two-vessel occlusion model, then they applied electro-acupuncture on two acupoints, Zhu Sanli and Baihui, which is ST36 and Garmin 20. And what they found, there's a very beneficial or suppressed hippocampal long-term potentiation impairments. As we can see on the graph and second bar is the two-vessel occlusion. The right panel, you can see with the antagonist, we can abolish the electroacupuncture effect. The antagonist just confirmed. Speculated mechanism So I'm going to switch gear. We are talking about a lot of cerebral impairment. Now how about the spinal cord injury? So there is a systematic review and a meta-analysis from the publication in 2015, look at 12 randomized control trials, and they searched seven databases through August 2014. Their four key outcomes were assessed, which included neurological recovery, motor recovery, sensory recovery, and functional recovery. So as we can see over here, all the pooled analysis from this meta-analysis showed acupuncture analyzed the So in summary, from the 12 studies analysis in this review, current understanding acupuncture may have beneficial effect on the neurological recovery and motor function, functional recovery, however not the sensory recovery. And they also, based on the sensitivity analysis, suggested in the acute phase and with the different acupuncture sections and more frequent treatment demonstrated larger magnitude of effect. So in terms of migraine, actually that's not only the systematic review data, the meta-analysis, we do have a golden standard randomized control trial support the long-term effect of acupuncture for migraine prophylaxis, which is published in JAMA Internal Medicine 2017. This study involved 249 participants from 18 to 65 years old. Majority of the patient were included in the intention to treat analysis and majority of patient were women. Baseline characteristic were comparable across the three groups, which including the true acupuncture, sham acupuncture, and patient didn't receive any treatment. So the acupuncture was performed five days a week for four weeks, total 20 sessions, and they follow up in 20 weeks. So they're trying to look at the long-term effect. And the obligated points they used is GB20 and GB8. Then in addition, based on the location of the headache, they pick and choose other acupoints, but they have to include these two points. And what we have seen from the graph, you can see a greater reduction. than the waiting list group. So, this is strong evidence we can use, apply the acupuncture for migraine prophylaxis. So, in summary, there are emerging evidence demonstrated that acupuncture could induce neuroplasticity in Jarden model exposed to cerebral ischemia. And neuroplasticity mediated by acupuncture in other neurological disorders, such as vascular dementia, spinal cord injury, were also investigated. And there are also positive role in these conditions. Mediation of neuroplasticity by acupuncture is likely associated with the modulation of neurotrophins and neurotransmitters. So, the exact mechanism underlying acupuncture effects on neuroplasticity remain to be elucidated. However, there are more evidence support this neurorecovery theory. And we do have strong evidence support the effectness of acupuncture for migraine. spasticity also including neuropathic pain. So my colleagues have done an expert job in presenting to you the clinical aspects and the clinical utility of acupuncture in the physiatry practice. So that's great. Now we've spurred your interest. Now you have to go and make the business argument to your administrator as to why this would be a beneficial addition to your practice. So my talk for the next couple of minutes will try to help guide you through that process. Some of the things that you need to think about, we'll expand a little bit more into the insurance coverage that Dr. Dong brought up. These are my disclosures. My disclosures have nothing to do with acupuncture. Probably the biggest disclosure I should put out is that I am not an acupuncture practitioner. I am more the person who has to think about business models and administrative issues. Off-label discussions, it really isn't anything to discuss from an off-label perspective. I will tell you that acupuncture needles are considered a medical device, which gives us an advantage over non-physician providers. We can order medical devices as part of our training. The only thing that would perhaps skirt about an off-label discussion, we'll discuss a little bit about indications that are not typically covered by insurance payers. So outline for the talk, how do you work up a business model? What are some of the things to think about in terms of licensure and certification, cost, malpractice, insurance coverage, billing and coding concerns, and then lastly, some practical tips. So with all business models, whether you're opening up a coffee shop or adding acupuncture to your physiatry practice or looking to add something, you need to do a needs analysis. Is there a need for this service? And one of the things that we just really scratched the surface in is that there are a bunch of diagnoses that physiatrists crosstalk with in which acupuncture can work. Some of these are very familiar to us, neurologic recovery, spasticity, chronic pain, et cetera. Some of these things are also a little bit far afield of us, digestive disorders, gynecologic disorders, cosmetic indications, weight loss. That's not exactly core physiatric knowledge, and that does have a little bit of implication when we talk about malpractice in a little bit. The other thing to consider when you're working up a business model is, what is the local competition like? So this is a two-edged sword, right? So if you look in, well, there's no phone books anymore, but if you Google acupuncture Baltimore and 700 names come up, well, that's good in one sense that a lot of people are interested in it, but it also means that there's a lot of other people practicing acupuncture in that region. So you'd like to see some, and it actually can give you some competitor analysis, but you don't want to see so much that you're going into a completely saturated market. For those of you who work in hospital settings or other practice settings, probably the next step is to go to your hospital privileging office or your privileging website or medical staff handbook and look at what are the requirements for individual staff requirements. I did a deep dive as best I could, and most hospitals have this somewhere, at least if you're a hospital of reasonably sufficient size. There are some scope of practice concerns that we'll talk about in a little bit. Then after you look at your local hospital, you have to look at state licensure, and I have a nice state breakdown of what each individual state looks at. And then lastly, you look at cost. So this is no different than any other business model. What's the opportunity costs? What are the costs that are ongoing? What are capital investments? What are operating expenses and those sorts of things? So scope of practice. So those places that just say yes, those states just say, if you're a physician, you could practice acupuncture. No additional training is required. No additional licensure is required. If I lived in Alaska, I could open up a practice tomorrow and give acupuncture having never used an acupuncture needle in my life. And you could see that the majority of states actually just consider it within the scope of any generalist practice. There are several states, including the states that Jerry and I practice in, Pennsylvania and New Jersey, say yes, it's a physician skill, but you need additional training. As we'll talk about in just a moment, that additional training is not trivial. Some places just say, no, it's not in your scope of practice and you need a specific license for it. And then there are four states that are just silent on the matter, that don't say if it's in your scope of practice or say it's not. So the good news is the majority of states say, yes, it's just within scope of practice. That has some risks that we'll talk about in just a second. So physicians versus non-physician providers. There are, in the majority of states, allowances for non-physicians to practice acupuncture. These are some of the degrees that you might see from individuals. LAC, licensed acupuncturist, MAOM, DAOM, master's or doctorate in acupuncture and oriental medicine, diplomat in acupuncture. Some of these are relatively strict criteria. Most states require at least a college degree followed by training. Other states are pretty wide open, almost to the degree that you could go take a weekend course and set up an acupuncture practice on your own. This is also represents an area of competition for us. That lots of people who are not physicians, maybe even not medical providers at all, can practice acupuncture and set up a clinic right next door. Where this also gets involved with us is certain states actually define who can put in needles but also who can take them out. And this has a flow of clinic consideration. For example, you could have your medical assistant or your nursing assistant bring the patient in, get the patient in the proper position, get them disrobed if need be. The physician can come in, insert the needles, do any interview techniques that need be. But then that same physician extender can actually remove needles and do checkout. So check your individual licensure about not only who puts the needles in but who could take the needles out. Dr. Dong mentioned this a little bit and this kind of shows what our competition is. So the National Certification Commission for Acupuncture and Oriental Medicine, this is a general organization. You do not have to be a physician provider, has distributed over 20,000 certificates. Yet the medical associations, which is the American Academy of Medical Acupuncture, which is sort of the professional society, as well as the board, the American Board of Medical Acupuncture, and there's a relationship between the two just like we have with AAPMNR and the American Board of PMNR, they've only issued about 1,000 certificates. So for each one of us that have a certificate in acupuncture, there are 20 non-physician individuals who have certificates also. Some states that lump dry needling and acupuncture together will allow physical therapists to do this, occupational therapists, and athletic trainers, again, with a wide spectrum of training being permitted. Some states also allow chiropractors and podiatrists to perform acupuncture, some with additional training and some without. There's also an American chiropractic organization for acupuncture. Costs. So probably the biggest thing that you want to think about after you've figured out what your state will allow and what your hospital will allow is what are the training costs. There are usually two components to training. One is a didactic component and one is a mentorship component. Now if there is one benefit from COVID, a lot of learning is going on now in remote and hybrid settings. It used to be that you needed to physically go to conferences, not that I don't enjoy seeing everyone, but you could see that even the academy is doing a live and a virtual conference this year. So many of the didactic components can be done in at least a partial virtual or hybrid model, but that is often coupled with a direct one-on-one mentorship, oftentimes somewhere between 100 and 200 hours of direct one-on-one mentorship. So if I want to have one of my other physicians learn acupuncture, they have to take 100 to 200 hours out of their clinical day where they're not generating any revenue just to get the mentorship done. So the take-home message to my colleagues, especially my younger colleagues, if you're going to think about this, perhaps the time to do it is earlier in your career so that later on you don't lose the revenue of an active practice of a more mid-to-late career physiatrist. It can be troubling to even find a mentor. Maybe there's no one who does acupuncture in your town, so you have to take every Friday off to travel somewhere to go find that mentor, depending, again, on where you live in this country. The room setup. You know, acupuncture, as mentioned, it does not follow traditional Western medicine techniques. So the room in which you execute acupuncture may not be set up for that. Maybe you even want to set up a dedicated area for this. One of the things that probably makes the business model work a little bit better is to always have two rooms operating at the same time, sort of like a surgical theater that while one room is getting turned over, the other room is active and there isn't any downtime. Well, now you're talking about room occupancy costs, right? You have to go to your administrators, your managers, your vice presidents, and say, I need two rooms all day to occupy this, and you haven't seen one patient yet, and you're asking for room to do that. So you have to consider that when you're building your business plan, that the ramp-up is going to be slow. As mentioned, needles are an FDA-approved device, and they are only approved as medical devices, meaning that only physicians order them. So these non-physician practices have to get some physician to order them for them. Of note, they are all sterile and are indicated for single use only. If you look at some older literature, you'll see literature about reusing acupuncture needles and an infectious risk associated with it. That would be considered an off-label practice right now. Disposal. Most offices have some place to dispose of biohazards, but if you're going to set up your own little clinic in your own little corner of the universe, is there a place to dispose of the needles? We'll talk about malpractice in a little bit to delve into that a little bit deeper. Informed consent. So it was interesting when I was reviewing for this topic, the medical acupuncture societies, the academy and the board, obviously recommending a consent because it's a medical procedure and like all medical procedures, there should be a consent associated with it. Interestingly, that non-physician commission said that a consent was optional. They did not think consent was needed. I think that would be a mistake for us as physicians. Sometimes you just can't snap your fingers and get a consent done. You may have to go to an informed consent committee and have that approved, and that can take some time and effort. Let's talk a little bit about insurance coverage. I know Dr. Dunn touched on this a little bit. So as mentioned, in 2020, Medicare did approve acupuncture as part of a Part B coverage. Patients are still responsible for 20% co-pay, right? So Medicare covers 80% of UCR, usual and customary charges. That means that they are still responsible for 20%. You have to tell that to folks up front. Only indicated for 12 visits for chronic back pain, as mentioned, you can get up to eight additional sessions if improvement is demonstrated. So you just don't want to say, oh, patient here for acupuncture for chronic back pain. This is in our wheelhouse, right? We do functional assessments. We're able to demonstrate functional improvement. We should be able to attain those additional sessions if needed. Of note, Medicare will only pay for acupuncture administered by a physician, a physician assistant, or a nurse practitioner. However, earlier this year, a House bill was introduced looking to expand provider lists to non-physician providers. I don't want to get into anything political because all that we'll do will stir undue passions. But if we get to the November election and this bill hasn't passed, that bill dies and then has to be reintroduced in the next Congress. So with three weeks to the election, I doubt that's going to get through in this Congress and would be reintroduced. Another thing of note is that for Medicare Advantage plans or managed Medicare plans, sometimes those acupuncture sessions count as referrals to specialists. So if a managed Medicare or a Medicare Advantage plan only limits you to a certain number of specialist visits per year, you can exhaust a Medicare beneficiary's coverage for specialist referrals with your acupuncture sessions. Something to keep in mind with. And I just heard in a previous talk earlier today that in 2022 for the first time, there are more managed Medicare beneficiaries than there are traditional Medicare beneficiaries. Is that something that we need to keep an eye on? Medicaid coverage. So Medicare is a federally administered program for elderly and disabled individuals. Medicaid are state-run programs. Now one element of all state-run programs, the federal government does mandate what all Medicades need to cover, and there's a certain number of criteria. For example, if a Medicaid beneficiary gets admitted to a hospital, they have an in-hospital benefit. Acupuncture, even though covered by Medicare is not a Medicaid mandated benefit. Those states in green that you see here have some Medicaid benefit. Those states in red do not. Some people would look to overlay this map with a political map and try to draw some conclusions. The most common indication for Medicaid benefits are chronic pain conditions. There are certain limited coverages for other conditions, but pain is far and away the largest. What do some of the commercial payers look like? Overall, about a third of commercial plans have some degree of coverage. Note that most HMO and PPO plans require a referral from a primary. So someone with a commercial plan, even if they have coverage for it, can't just walk into your office and say, give me my acupuncture doc. Aetna, for example, requires, allows 12 sessions per year, and the conditions are noted there for you. Again, with a variable degree of co-pay. Kaiser Permanente also offers 12 sessions a year, $15 co-pay. Low back pain and migraine are the only indicated ones. United, they have variable coverage, but interestingly, United allows you to buy supplemental policies or rider policies for acupuncture and other complementary and alternative medication or medicine conditions. I think that's a pretty intriguing model that if you feel this is of benefit, you could purchase additional benefit. Cigna, everybody's favorite, right? Only covers pregnancy-related nausea and migraines. Pretty restrictive. Blue Cross and Blue Shield, they are very, very variable. Some plans have very wide coverage. Others have next to none. Malpractice. Most states, again, because it's within scope of practice, it is minimal added cost. You should check with your malpractice provider also. Recognizing the inherent risk of an acupuncture procedure is extraordinarily low. One legal commentary said that you are more likely to be involved in a motor vehicle accident driving to your acupuncturist appointment than to suffer an adverse effect relative to the acupuncture. But there is one little hooker that we need to keep in mind. The vast majority of malpractice suits against physicians relative to acupuncture were not due to the acupuncture themselves, but for us to fail to diagnose or a delay in diagnosis of another problem. So for example, someone comes to us and asks to be treated for dysmenorrhea when in fact they have an ovarian tumor. This is where I think we need to be a little bit careful with scope of practice. We should probably restrict our acupuncture practice to things that we would treat anyway. We don't routinely or most physicians don't do things like digestive disorders or gynecologic problems or weight loss. We could miss something and if a diagnosis gets missed or a diagnosis gets delayed, that's one deficit that we have as physicians compared to our non-physician providers. We do not take our physician hats off when we perform acupuncture. So again, it was really fascinating that the liability concerns for acupuncture have nothing to do with the acupuncture or very, very little to do with the acupuncture and more to do with our approach as just being a physician. Coding. Once Medicare approved something, they have to come with coding guidelines for it. So there are actual codes for the administration of acupuncture with and without electrical stimulation. Note that you can't bill both with and without. So you could not bill a 97810 and a 97813 simultaneously on the same patient during the same visit. Also know on subsequent units that that requires reinsertion of the needles. So even if the patient received acupuncture for an hour, but the needles were left in place in the exact same position without reinsertion, you could only bill a single unit of time. Probably the biggest controversy in acupuncture administration is, can you bill an acupuncture code along with an E&M? This is the so-called 25 modifier that we all experience when giving, when using a procedure and attempting to bill an E&M code with it. Medicare defines the 25 modifier as a significant separately identifiable service above and beyond the service that is provided. I could tell you that there was no bigger controversy in the coding world right now than this 25 modifier. It affects practically all physician. You cannot include work that is inherent to the procedure. So for example, if you're giving acupuncture for knee arthritis, your knee exam doesn't count towards your E&M service. So this becomes a real challenge. You need to show some sort of effort outside of just the procedural norms. Ordering tests, medications, therapies, discussion about home exercise programs, complementary efforts. One way, one of the ways that certain places look at this is they actually have separate notes for procedures and E&M, even though they were contemporaneous. Another way that places try to look at this is to make sure that the procedure note is not deeply embedded in E&M space, so to speak, in an EMR world. One maybe practical tip that I saw in a lot of coding websites, if you put your hand over the procedure piece, would the rest of your note justify the E&M bill? As mentioned, some organizations actually want two chart notes or two encounters. There also is a misrepresentation. You do not need a separate diagnosis to use the 25 modifier, although some payers do act that way. In one sense, it might be better to have a separate diagnosis because it then shows that separate and identifiable concern. Recognize this only counts if you're going to bill both the procedure and the E&M to insurance. And given the fact that lots of things aren't covered, lots of people utilize acupuncture as a cash transaction. So just finishing up with some practical tips. Is this going to be a standalone process or part of a larger complementary and alternative medicine approach in your practice? You got to market your practice extensively initially. The growth is going to be slow. But then once you do grow and your practice is there, how do you handle that growth? Can you get enough new patients in because you're giving out so many repeat sessions? And considering how long it takes to train a physician, you may want to think of yourself a year or two years down the line of how to grow a practice. Recognize that certain places will not allow you to do MOX abduction. There wasn't much discussion about that. Because of fire risks and smoke, recognize there are smokeless and infrared heating devices that can supplement for MOX abduction. How do you, can your practice handle a cash visit and an insurance bill at the same time? Some practices will actually have the same patient having two medical record numbers, one that gets billed to insurance and one is their cash account. Again, this is something you may need to consider as you put this into practice. And lastly, will you allow your providers to get tips? You know, how many people tip their barber, their hairstylist, their massage therapist? Most of us do, probably. People may be thinking about, do I tip my physician for acupuncture? And are you going to allow that? So this is where Jerry and I work. This is what our building looks like and will look like in the future. I want to thank you for your attention late in the afternoon today. Hope you enjoy the rest of the conference. We do have a couple of minutes for questions if you would like. We're actually just at 445, so if you need to leave, I certainly understand that. But if you have some questions, we'd be more than happy to field them. Go ahead. So, that's a great question, and that's going to be state-dependent, you know. Do you want to set up a cash practice kind of separate from your medical practice? Or if you integrate it, you have to ask your administrators how you handle a cash practice for things that are covered. I mean, you know, think of what you would have to answer in a court of law. Did the physician reinsert just by tweaking it? Yeah, I mean, this is, this is right out of the Medicare guidelines.

clinical aspects

administrative components

business considerations

acupuncture

physiatric practice

musculoskeletal pain management

neurologic diseases

needs analysis

local competition

scope of practice

licensure