California State Oriental Medicine Association Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, Oct. 26 -- Nell Smircina, president, and Ra Adcock, executive director, of the California State Oriental Medicine Association, San Francisco, have issued a public comment on the Centers for Medicare and Medicaid Services proposed rule entitled "Medicare Program; CY 2021 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; etc". The comment was posted on Oct. 22, 2020:

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CSOMA, California State Oriental Medicine Association, is submitting this response to proposed changes in the 2021 CMS Fee schedule for CPT codes 97810-97814. CSOMA is a non-profit organization that represents licensed acupuncturists in California and is a member organization of the American Society of Acupuncturists, ASA. CSOMA is focused on ensuring individuals have access to acupuncture services, that these services are integrated into the health care delivery system, and that over 12,000+ acupuncturists in California and their services are a vital part of primary care throughout California's public and private health insurance programs.

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 as an association respectfully 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.

California Acupuncture licensure requirements include at least 3,000 hours of which at least 2,050 hours are didactic and laboratory training, and at least 950 hours are supervised clinical instruction. Clean Needle Technique certification, and an examination by the California Acupuncture Board and 50 hours of continuing education every 2 years. 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.

No other individual shall offer to provide or represent that they are qualified to provide any acupuncture related treatment that they are not qualified to perform by their professional education or advanced post professional study that falls within the Acupuncture Practice Act of California. (NOT SURE IF THIS SHOULD BE INCLUDED)

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.

CSOMA

View attachment at: https://www.regulations.gov/contentStreamer?documentId=CMS-2020-0088-31311&attachmentNumber=1&contentType=pdf

Respectfully,

Nell Smircina, CSOMA, President, [email protected]

Ra Adcock, CSOMA, Executive Director, [email protected]

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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0088-1604

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