Get to the Point: Billing for Dry Needling and Payer Coverage Issues

The adoption of dry needling into rehab therapists’ practices, including the reaction from payers, has been a bumpy road, to say the least. Much of the discord and confusion dates back to 2020 when the American Medical Association (AMA) CPT Editorial Panel approved the trigger point dry needling codes as Level I CPT codes. Level I CPT codes must meet the following criteria:

• A procedure or service that is performed by many physicians or other qualified healthcare professionals across the United States.
• A procedure or service that is consistent with current practice.
• A procedure or service that has been proven to meet the clinical efficacy requirements outlined in the CPT code change application.

(Source: CPT 2023 Professional Edition, CPT Editorial Panel Synovec MS et al., American Medical Association, Chicago Il., 2022, page xv)

When the CPT Editorial approved these codes, the Center for Medicare and Medicaid Services (CMS) did not initially indicate that they would not accept the new dry needling codes. However, when the 2020 final rule was released, CMS noted they would not cover dry needling billing codes because they do not cover acupuncture. Then, they went on to indicate there might be a policy change around this coverage in the future. Subsequently, most commercial payers followed suit, deciding that they would not cover or reimburse for dry needling codes either. (More on this later.)

With all these conflicting regulations, it begs some serious questions around: 

• what dry needling technically is (and how it differs from acupuncture), 
• how physical therapists can furnish it, and 
• whether they can receive payment for it. 

So, let’s get into it.

How can I use trigger point dry needling billing codes?

The trigger point dry needling (TDPN) codes are listed in the CPT Manual with the muscle injection codes, which accounts for the description of the service as “insertion without injection.” According to research published by the Rheumatic Disease Clinics of North America, it’s clear that trigger points and tender points can be considered causes of myofascial pain and, as such, can benefit from treatment. To rehab therapists trigger points and tender points are areas of tenderness occurring in muscle, muscle-tendon junction, bursa, scar tissue, or fat pad, and can be treated by needle insertion.

Each dry needling CPT code type is differentiated by the number of muscles treated in the session. The two TPDN CPT codes are: 

• Code 20560: Needle insertion(s) without injection; 1 or 2 muscle(s).
• Code 20561: Needle insertion(s) without injection; 3 or more muscle(s). 

Codes 20560 and 20561 are both untimed for billing and include the cost of the needles and other supplies required for blood-borne pathogen needle insertion procedures. The code application and the clinical vignettes did not include the simultaneous application of electrical stimulation via an inserted needle. I’ll discuss this approach more in a bit.

Is trigger-point dry needling the same as acupuncture?

While 1) TPDN and acupuncture both use “dry” needles, and 2) TPDN may be performed with acupuncture needles, therapists cannot perform acupuncture using the TPDN codes. 

Acupuncture is an intervention used in Chinese Medicine (CM) and is based on using needles on specific points on meridians and other points identified in CM. CM also includes other interventions like cupping and moxibustion. While trigger points and acupuncture points may coincide in location on a patient, codes 20560 and 20561 are limited to TPDN only. 

As the continuing education course provider Myopain Seminars explains in this blog post, the practice of dry needling and acupuncture has many differences. This includes:

• the foundational basis of diagnostic criteria when performing dry needling,
• the use of modern medical understanding of anatomy, physiology, and pain science in TPDN, and
• a treatment mindset in TPDN that involves paying attention to the patient’s body.

Furthermore, acupuncture is separately licensed in most states and is not within the scope of physical therapy and occupational therapy practice. As such, TPDN and acupuncture are not interchangeable terms, and they have different CPT codes. I cannot emphasize enough that you cannot—and should not—bill acupuncture as TPDN even if you are licensed to perform acupuncture. Instead, licensed acupuncture providers should bill acupuncture CPT codes for acupuncture services. If your dry needling course involves education about needling acupuncture points, be very careful performing and documenting these techniques.

Can I use dry needling with manual therapy and neuromuscular re-education?

You should not include dry needling as part of manual therapy (CPT code 97140) or neuromuscular re-education (CPT code 97112). Dry needling has defined CPT codes for this service, and TPDN should never be bundled as part of another defined service. This kind of activity, known as treatment bundling, is a recognized form of billing fraud.

Since manual therapy is often part of a complete treatment plan that addresses soft tissue dysfunction and myofascial pain, you can include your soft tissue assessment and patient management time as part of your manual therapy minutes when doing TPDN in the same visit.

What else should rehab therapists understand about billing for dry needling with third-party payers? 

To best answer this, we must first talk about two terms used for TPDN services that aren’t paid for by a third-party payer. These are: 

• A “non-covered service,” which is not paid because the service is not part of the plan benefit.
• A “not medically necessary service,” which is a service provided to the patient that is either not a recognized medical service, is not an effective service, or is experimental with unproven effectiveness.

If you are in-network (a.k.a. a preferred or paneled provider) with the payer, your contract likely requires you to accept the payer’s determination of what constitutes a “not medically necessary service,” and therefore you cannot balance bill for a patient when the service is not medically necessary. Furthermore, the explanation of benefits (EOB) or electronic remittance advice (ERA) will not make the “not medically necessary service” payable by the patient. (So, if TPDN falls into the not medically necessary service bucket, you should not provide TPDN to those patients.) And, before you ask, you cannot provide it for free because federal and state anti-kickback laws make this practice risky. 

Here are a few other points to consider:

• If the payer considers TPDN a non-covered service, and you plan to have the patient pay, you need to be explicit in your documentation that the TPDN was paid for separately by the patient and was not billed to the payer as part of another service.
• If you are out-of-network for the payer, you do not have to abide by the payer’s determination on the EOB/ERA so that you can bill the patient for the TPDN.
• If the payer states that the service is not covered, whether you are in-network or out-of-network, you may collect the TPDN charges from the patient.
• Once you bill a payer for TPDN, you will know whether TPDN is covered, and can advise patients before you provide the service.

The best way to know if a payer pays for TPDN or whether they consider it not medically necessary is to check their physical therapy medical policy; you might find it under outpatient rehabilitation services or part of their trigger point injection policy. 

In the case of Medicare, as a non-covered service, you can collect from the patient at the time of service. You can use an ABN, and if the patient checks “option 1” (requesting that you bill the service to Medicare), bill the service with the GX modifier.

Once you are clear about the payer’s perspective to bill for dry needling, you can craft a solution for your patients that is safe from a compliance perspective. Just understand that for some patients (specifically, those who are in-network and their payer’s policy states it is not medically necessary), you may not be able to provide the service at all. To better streamline your billing processes, consider using an integrated billing service or revenue cycle management service that has experts ready and waiting to assist in your dry needling billing queries—and more.

Plus, while you’re here, why not shop Dry Needles in the WebPT Marketplace?