Acupuncture Billing Guidelines for 2026: CPT, ICD-10, CMS & Reimbursement Guide
- Sirius solutions global
- 5 hours ago
- 8 min read
Acupuncture billing has gotten more complex over the past few years. Medicare started covering it for chronic back pain. More commercial insurers added it to their plans. But here is the problem: most practices still struggle to get paid consistently.
The rules are specific and honestly a bit confusing. One wrong code means a denied claim. Missing documentation can cost you thousands. And every insurance company seems to have different requirements.
If you run an acupuncture clinic or offer these services as part of your practice, you need to know what has changed for 2026. This guide covers the CPT codes you actually use, which ICD-10 codes get approved, what Medicare will and will not pay for, and the documentation that keeps claims from getting rejected.
The CPT Codes You Need to Know
There are four main codes for acupuncture billing. Getting these right is step one.
97810 covers your first 15 minutes of acupuncture without electrical stimulation. This is your foundation code.
97811 is for each additional 15 minutes beyond that first quarter hour. Treat someone for 30 minutes? Bill 97810 once and 97811 once.
97813 is used when you add electrical stimulation to the needles. Again, this covers the first 15 minutes.
97814 handles additional 15-minute increments when using electrical stimulation.
Here is how it breaks down in real practice:
Important: You cannot round up aggressively. Treat someone for 12 minutes? You cannot bill that first unit. The full 15 minutes matters. Always document your start and stop times clearly. Write "treatment started 2:00 PM, ended 2:30 PM" instead of just saying "30 minutes." This protects you if there is ever an audit.
ICD-10 Codes That Actually Get Paid
Your diagnosis code needs to match what the insurance company covers. This is where a lot of claims fall apart.
Medicare only covers acupuncture for chronic low back pain right now. So M54.5 is your code. Try to bill a migraine code to Medicare and you will get denied instantly.
Commercial insurers are more flexible. Common diagnosis codes they accept include:
M54.5 (low back pain)
M25.511 through M25.519 (shoulder pain)
M79.1 (muscle pain)
G89.29 (chronic pain)
M54.2 (neck pain)
G43.909 (migraines, depending on the payer)
G44.209 (tension headaches)
Before you treat anyone, verify their coverage. Call the insurance company. Ask specifically which diagnoses they cover for acupuncture. Get a reference number. Write it down. Do not assume coverage just because a code exists.
Your documentation needs to show why acupuncture makes sense for this patient. Include what treatments they tried before. Note their pain level using a number scale. Explain how acupuncture fits into the bigger treatment picture. Vague notes like "patient has back pain" will not cut it anymore.
What Medicare Actually Covers in 2026
Medicare coverage is limited but specific. Understanding these rules prevents headaches later.
They cover acupuncture only for chronic lower back pain. The pain must have lasted at least 12 weeks. It cannot be related to surgery, pregnancy, or cancer. And the patient needs to have tried other conservative treatments first without much improvement.
Medicare allows up to 12 sessions over 90 days initially. If the patient shows improvement, you can get approval for 8 more sessions. That is 20 total maximum. After that, coverage stops for this episode of care.
Your documentation has to be thorough. Medicare wants to see a baseline pain assessment with specific numbers. Describe how the pain limits what the patient can do. List what treatments they already tried. Write out your treatment plan with clear goals. Then reassess the pain and function at every single visit.
The improvement piece is critical. If someone does not get better after those first 12 treatments, Medicare will not authorize the additional 8. Document changes in pain scores. Note if they are moving better. Track whether they reduced pain medications. This evidence of progress matters.
Who can provide Medicare-covered acupuncture? Licensed acupuncturists where state law allows it. Physicians. Physician assistants. Nurse practitioners. The provider must work within their state scope of practice requirements.
Billing Commercial Insurance
Commercial payers are all over the map with acupuncture coverage. Some plans cover it broadly. Others exclude it completely. Most fall somewhere in between.
Always verify benefits before starting treatment. Ask these exact questions:
Does this plan cover acupuncture at all?
Which diagnoses are covered?
Do I need prior authorization?
How many visits per year are allowed?
What does the patient pay per visit?
Am I in network for this plan?
Get answers in writing when you can. If you verify by phone, write down the representative's name and the reference number they give you.
Some plans require prior authorization before you can start treatment. You submit a treatment plan showing how many visits you want to do and what diagnosis you are treating. If you treat someone without getting required authorization, the claim gets denied automatically. There is no appealing that.
Being in-network makes a huge difference. Out-of-network acupuncture benefits are often minimal or nonexistent. Patients end up paying most of the cost themselves. If you stay out of network by choice, make sure patients understand what they will owe before their first appointment.
Common Billing Mistakes to Avoid
These errors show up constantly in acupuncture billing. Fixing them improves your revenue immediately.
Billing too many time units. Your notes say 20 minutes but you bill three units (45 minutes worth). Insurance companies check this. Bill what you actually did.
Wrong diagnosis codes. Using a diagnosis the payer does not cover guarantees denial. Keep a list of what each major insurance company covers. Check it before billing.
Weak medical necessity documentation. Insurance wants proof the patient needs acupuncture specifically, not just wants it. Show what else they tried that did not work. Explain their functional limitations. Set clear treatment goals.
Billing E&M and acupuncture together. Most payers will not pay for an office visit and acupuncture on the same day. They consider the evaluation part of the acupuncture service. Some practices try using modifier 25 to get around this. It rarely works. If you truly did a separate significant evaluation, document exactly why it was necessary and distinct from the acupuncture.
Exceeding visit limits. Plans typically allow 12, 20, or 24 visits per year. Going over without authorization means denials. Track where each patient is on their annual limit. Warn them when they are getting close so they can decide whether to continue paying out of pocket.
Documentation That Protects You
Strong notes prevent denials and survive audits. Here is what you need.
Your initial evaluation should be comprehensive. Include the complete history of their condition. What treatments have they tried? What medications do they take? What did your physical exam find? What is your acupuncture treatment plan? Did you discuss risks and get consent? This first note establishes medical necessity for everything that follows.
Each treatment session needs a progress note with these elements:
What the patient reports about their symptoms (subjective)
Your physical findings and their current pain level (objective)
What treatment you provided, including specific points and how long needles were retained (treatment)
How they responded both immediately and overall (response)
What comes next (plan)
Documenting specific acupuncture points adds credibility. Use standard naming like LI4, ST36, GB34. For example: "Needles placed at LI4 bilateral, ST36 bilateral, BL40 bilateral. Retained 20 minutes with electrical stimulation at 2Hz to LI4 and ST36."
This level of detail shows clinical expertise. It makes your services harder to question.
Choosing a Billing Partner
Many acupuncture practices outsource billing because the rules are so specific. Here is how the main companies compare.
Sirius Solutions Global
We specialize in acupuncture and integrative medicine billing. We know which diagnosis codes each payer accepts. We understand the documentation requirements. We work with practices upfront to prevent denials rather than just chasing them after the fact. Our clients report acceptance rates above 95 percent for acupuncture claims. We also provide detailed reports showing denial patterns and revenue opportunities specific to your practice.
MedBillMD
They handle general medical billing including some acupuncture. Their platform does basic claim submission. Results vary because acupuncture is not their main focus.
CareCloud
They offer practice management software with billing features. The technology is decent but needs customization for acupuncture. You need knowledgeable staff to set it up correctly.
AdvancedMD
They provide comprehensive medical software. The system catches basic errors but requires internal expertise to manage acupuncture billing properly. Smaller practices sometimes find it overly complex.
Athenahealth
They use a network model sharing data across clients. Acupuncture is a small part of their volume though, so specialty insights can be limited. Pricing runs high for smaller practices.
Kareo
They target small practices with simple software. It handles straightforward acupuncture billing adequately. Complex situations often need extra support.
For practices where acupuncture represents significant revenue, Sirius Solutions Global delivers the best combination of expertise, technology, and reporting.
Maximizing Your Revenue
Beyond avoiding errors, take these proactive steps to improve collections.
Verify benefits at every visit, not just the first one. Coverage changes. Plans renew. Limits reset. Checking at each appointment prevents surprise denials.
For self-pay patients, consider package pricing. Offer a discount if they prepay for multiple sessions. This improves cash flow and patient commitment.
Track every denial. Look for patterns. File appeals systematically. Many acupuncture denials get overturned when you submit proper documentation. Winning strategies include providing detailed clinical notes, showing evidence of failed prior treatments, citing the specific coverage policy, and including research supporting acupuncture for that condition.
Estimate costs upfront for patients. After verifying benefits, tell them what they will likely pay per visit. Include copays, deductible status, and annual limits. Put it in writing. This prevents confusion and payment problems later.
Staying Compliant
Compliance protects your practice from audits and payment recoveries.
Only bill services within your legal scope of practice. State laws vary on who can perform acupuncture. Make sure your providers have current, valid licenses.
Never unbundle services that should be billed together. Never upcode by billing more time than you actually spent. Bill based on your documentation, period.
Your documentation must accurately reflect what you did. Do not backdate notes. Do not alter records after a denial. If you find an error, make a dated addendum noting the correction. Never just change the original record.
What is Coming Next
Acupuncture coverage will likely expand. Advocacy groups keep pushing Medicare to cover more conditions beyond just back pain. Commercial payers continue adding coverage as evidence grows.
Value-based payment models may become more common. These reward outcomes rather than visit volume. Practices that track patient results and demonstrate effectiveness could benefit.
Prior authorization and utilization review will probably increase. As more plans add acupuncture coverage, they also tighten controls on how much they pay for.
Getting Professional Help
If billing is draining your time or costing you revenue, get expert help. Sirius Solutions Global can assess your current performance, show you where revenue is being lost, and implement systems to fix it. Many practices recover the service fees through increased collections within a few months.
Contact them for a free revenue cycle assessment. They will analyze your data and show you exactly how to improve your acupuncture billing results.
Final Thoughts
Acupuncture billing in 2026 requires specialty knowledge. The right CPT codes matter. Diagnosis coding must match payer coverage. Documentation needs to prove medical necessity. One mistake anywhere in this chain causes denials.
Medicare coverage brought new opportunities but also increased scrutiny. Commercial payers offer broader coverage but every plan is different. Success means understanding these rules and following them consistently.
Whether you handle billing yourself or work with specialists, invest in getting it right. Your practice revenue depends on it. Sirius Solutions Global has the expertise to help you maximize collections while staying compliant. Reach out today to start improving your results.
