With our services, we aim to meet the healthcare administrative needs - of our Facility clients as well as our Community Member clients.

  • From beginning to the end - get Eligibility verification, through Denial/Payment processing.

  • Get assistance with the process of Provider enrollment applications, with:

    Humana, Regence BCBS, MODA Health Plan, Cigna, Saif Corp, Heraya Health & Majoris Health

  • External Audit reviews can be initiated that can meet operational needs.

  • Receive up-to-date, meaningful healthcare guidance, that will meet our community needs.

  • ICD-10 Codes in effect, for higher specificity for the, Musculoskeletal System and Connective Tissue, diagnosis codes, for 2025 - effective as of 10/01/2024 =

    ** M51.36_ (Other Intervertertebral disc degeneration, lumbar region)

    M51.360 (… with discogenic back pain only)

    M51.361 (… with lower extremity pain only)

    M51.362 (… with discogenic back pain and lower extremity pain)

    M51.369 (… without mention of lumbar back pain or lower extremity pain)

    ** M51.37_ (Other Intervertertebral disc degeneration, lumbosacral region)

    M51.370 (… with discogenic back pain only)

    M51.371 (… with lower extremity pain only)

    M51.372 (… with discogenic back pain and lower extremity pain)

    M51.379 (… without mention of lumbar back pain or lower extremity pain)

  • Acupuncture is covered for Medicare beneficiaries for chronic Low Back Pain, defined as:

    • Lasting 12 weeks or longer.

    • Nonspecific (no identifiable systemic cause like metastatic, inflammatory, or infectious disease).

    • Not associated with surgery.

    • Not associated with pregnancy.

    Acupuncture CPT codes

    Initial 15 minute code 97810 for w/out electrical stimulation (97811 for each addl 15 mins),

    OR

    97813, for w/ electrical stimulation (97814 for each addl 15 mins) are allowed per Date of Service (DOS)

    Annual Session Frequency Limits

    Medicare covers‍ ‍a maximum of 20 acupuncture sessions per beneficiary annually. The annual limit resets 12 full months after the date of the first covered service.

    Initial Session plus up to 11 Sessions covered (total of 12 sessions initially covered) - Within 90 day Timeframe per condition

    Additional Sessions = May be approved for coverage, for an additional 8 Sessions (With Improvement) - with KX Modifier required on codes for these sessions, 13-20

    Total Annual Max Treatments that are covered = 20 Sessions

    12 full months must pass from the 1st service to renew eligibility

    Do not report (time based services) 97810, 97811, 97813 nor 97814 with (needle insertion codes) 20560, 20561 - when both the time based services and the needle insertions performed. Report only the time-based accupunction codes.

  • Top 10 Claim Adjustment Reason (CARC) Codes for Denials

    CO-16 - Incomplete or Lacking Information: Occurs when claims miss vital data like modifiers, NPIs, or accurate patient demographics.

    CO-11 - Inconsistent Diagnosis/Procedure: The submitted ICD-10 codes fail to medically support the CPT procedure codes billed.

    CO-18 - Exact Duplicate Service: The same service was submitted multiple times for the identical provider, patient, and date.

    CO-29 - Filing Limit Exceeded: The claim was submitted outside of the insurance payer's mandated timeframe.

    CO-197 - Missing Pre-certification: The required prior authorization was not secured before the procedure was performed.

    CO-22 - Coordination of Benefits (COB): The payer identifies another insurer as primary; requires re-billing to the correct party.

    CO-50 - Lack of Medical Necessity: The payer deems the service non-essential or inappropriate based on the billing details.

    CO-45 - Charge Exceeds the Scheduled/Maximum Allowed amount: The requested amount exceeds the contracted or legislated maximum allowable fee.


    Are you encountering these denial codes in your office? By proactively addressing these issues before submission, you can significantly improve your practice's clean claim rate and accelerate your reimbursement cycle.

    We encourage you to stay updated on the payer guidelines to verify that claims are processed correctly, each time. 

    Check back to our website for more CARC denial code(s) review.

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