Acupuncture: Medicare Statutorily Excluded or Non-covered

We are having an internal discussion regarding the correct modifier to use for acupuncture, which is revolving around whether there is a difference between Statutorily Excluded and Non-covered.  The sides are 1) there is an NCD stating acupuncture is not covered, and by virtue of this NCD, it can be considered Statutorily Excluded (requiring a GY);  2) acupuncture is not strictly defined in the billing manual, it is only mentioned as a non-covered, and therefore GY is not appropriate. 3) Statutorily Excluded and Non-covered can both be billed with a GY.



  • In January 2017, CMS published a Med Learn Article called "Items and Services Not Covered under Medicare."  It lists 4 categories for Not Covered.  1) Not Medically Necessary.  One of the examples they list is acupuncture.  2)Non covered Services.  When you read this section, they appear to be more of the items you think to be excluded by law (services provided outside the US, cosmetic surgery, etc.) 3)Bundled Services and 4)Services reimbursed by other organizations.    Our practice would be to have the patient sign an ABN (to be safe) and then bill it without the GY modifier.

  • Here is the information I found on Medicare's website when looking into this for our Pain Clinic. According to this an ABN is not recovered but may be given. - Advance Beneficiary Notice of Noncoverage:  An ABN isn't required for items or services that Medicare never covers. Some of the items and services that Medicare doesn't cover include:

    • Long-term care (also called custodial care
    • Most dental care
    • Eye exams related to prescribing glasses
    • Dentures
    • Cosmetic surgery  
    • Acupuncture  
    • Hearing aids and exams for fitting them
    • Routine foot care

    Medicare Claims Processing Manual  Chapter 30 - Financial Liability Protections (Rev. 3698, 01-27-17) - Routine ABN Prohibition Exceptions (Rev. 1, 10-01-03)

    ABNs may be routinely given to beneficiaries and considered to be effective notices which will protect notifiers in the following exceptional circumstances: Services Which Are Always Denied for Medical Necessity - In any case where a national coverage decision provides that a particular service is never covered, under any circumstances, as not reasonable and necessary under §1862(a)(1) of the Act (e.g., at present, all acupuncture services by physicians are denied as not reasonable and necessary), an ABN that gives as the reason for expecting denial that: “Medicare never pays for this item/service” may be routinely given to beneficiaries, and no claim need be submitted to Medicare.

    If the beneficiary demands that a claim be submitted to Medicare, the notifier should submit the claim as a demand bill.

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