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Dosage of Acupuncture - a puzzle for Insurance Company

Posted on January 26, 2020 at 10:00 AM

Inquiring Minds Want To Know

I once stumbled upon an ancient Chinese curse: “I wish you to live at the times of great changes”. Right now, we definitely live in times of rapidly changing acupuncture world terrain. Is it a curse or a blessing? It seems that new requirements, advancements, or regulations for our profession surface every time I turn around. That can be a blessing, to gain greater acceptance by mainstream medicine. Or it can be a curse, if we do not adapt to necessary changes and are left in the “acupuncture parlor”.

A few major steps were made nationally and internationally to bring us to the blessed future. Some of them are in the area of legislation, others are in the arena of standardization. The biggest terra incognita remaining to unravel is – the DOSAGE OF ACUPUNCTURE.

More and more insurance companies are extrapolating on payment for acupuncture services. It is no longer a question whether acupuncture is effective or not. The questions that are being asked now are things like: how many sessions are needed? how frequently? what are the expectations?

There are not many research papers evaluating real clinical practice which include the diversity of acupuncture styles and pattern presentations. One of the most prominent, which used realistic dosage of acupuncture, and served as a ground for the VA (Veterans Administration) to start employment for acupuncturists, was “The Effectiveness of Individualized Acupuncture Protocols in the Treatment of Gulf War Illness: A Pragmatic Randomized Clinical Trial”. It was published by Lisa Conboy, Travis Gerke, Kai-Yin Hsu, Meredith St John, Marc Goldstein, and Rosa Schnyer, and can be found here: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0149161

So, this is YOUR chance to share what you’ve experienced, is an appropriate dose for acupuncture. Please look at the studies below, and share your expertise based on your style of acupuncture – be it 5 elements, Japanese, one of the famous masters, etc.

To start, lets understand the standard language of Traditional Medicine that I used for TCM diagnosis pattern and treatment principle. You can find the exact definition in the WHO (World Health Organization) manual entitled “WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region”. This manual can be downloaded here: http://www.wpro.who.int/publications/who_istrm_file.pdf

This manual provided terminology for the future ICD-11, Chapter 26 (Traditional Medicine1) diagnostic codes to be active in 2023. The beta version can be found here: https://icd.who.int/en/.

Case studies below use current billable ICD-10 diagnostic codes of western medicine, with the addition of non-billable ICD-11 (TM1) codes. This is how our billing will be in the future.

Please recall your clinical experience and email your comments and thoughts, being as specific as possible, to suzy@fsoma.org

1. Do you agree with the goal’s time frames? If no, why not?

2. If you practice a different style (Five Element, Japanese, Korean, etc.), would your goals differ because of the differences? If yes, how so? If no, please let us know that too.

3. Would you request different frequency of visits?

4. Do different medications (please specify) used in the past or present change the goal’s time frames, frequency and length of the treatment?

5. Comment on anything else you think is relevant.

 

Case Study #1:

30 years old male presenting with a chief complaint of “pulling” constant low back pain radiating to right buttock that started after camping trip 4 months ago to the lake and is worse with rainy weather. Severity of pain is 4/10. As well has frequent dull frontal headache and sensation of heaviness in the body. Has a frequent loose stool.

 

Objectively: No pathology was found on X-Ray

TCM Tongue: pink, with thicker white coat

TCM Pulse: soggy

Western medicine billable diagnosis: M54.5 Low back pain with right side sciatica

Non-billable ICD-11 (TM1) Diagnosis: SC61Lumbago disorder (TM1) due to SE82 Dampness factor pattern (TM1)

TCM treatment principle: relieve pain, expel wind-damp

Acupuncture Tx: position prone

TCM points - GB20, UB12, SP9, K7. UB23,25, Yaoyan, Right buttock Ashi.

Adjacent techniques: TDP lamp on lumbar region

Recommended acupuncture tx frequency:

• 2-3 times a week for 3 weeks,

• after that 1-2 times a week for 2-3 more weeks

Treatment Goal:

in 3 weeks pain reduction by ~ 50%

in 6 weeks pain reduction by ~ 75%

Take home recommendations:

TCM Herbal Rx: Qian Huo Sheng Shi Tang

Topical: Zheng Gu Shui Spray 3-6 times a day

Treatment Goal with addition of herbs:

• in 3 weeks pain reduction by ~ 75%

• in 6 weeks pain reduction by ~ 90-100%

Case Study #2

32 years old female presenting with chief complaint of dull low back pain with occasional sharp electric sensation radiating down to the knee on the lateral side of her right leg that started after lifting her 2 years old child 6 months ago. Severity of pain is 3-5/10. As well she has mild dysmenorrhea, PMS and alternating bowels. She is prone to depression.

Objectively: No pathology was found on X-Ray

TCM Tongue: pink, with thin white coat

TCM Pulse: string-like (wiry)

Western medicine billable diagnosis: M54.5 Low back pain with right side sciatica

Non-billable ICD-11 (TM1) Diagnosis: SC61Lumbago disorder (TM1) due to SE91 Qi stagnation pattern (TM1), SG2A Gallbladder meridian pattern (TM1).

TCM treatment principle: relieve pain, promote smooth movement of Qi, open Gall Bladder Meridian

Acupuncture Tx: prone

Points Auricular - LV, Shenmen

Points TCM: LI4, LV3, UB19,24,25, Yaoyan, R-GB29,30,31,34,41, R-SJ5

Adjacent techniques: Tuina on lumbar region

Recommended acupuncture tx frequency:

• 2 times a week for 4 weeks,

• after that 1 times a week for 4 more weeks

Treatment Goal:

in 4 weeks pain reduction by ~ 40%

in 8 weeks pain reduction by ~ 75%

Take home recommendations:

TCM Herbal Tx: Chai Hu Shu Gan San modified - (herbs expected to be taken for 3-6 months at therapeutic dose for low back pain, after that are tempered to maintenance dose for management of dysmenorrhea, PMS and mood)

Topical: Po Sum On Oil 3-6 times a day

Treatment Goal with addition of herbs:

• in 4 weeks pain reduction by ~ 75%

• in 8 weeks pain reduction by ~ 90-100%

 

Case Study #3

Example: 55 years old male presenting with chief complaint of “stiff “ low back pain with occasional “cramping” pain radiating down on the back of right leg all the way to the lateral side of the foot that started gradually 3 years ago and is worse with cold weather. Severity of pain is 5-7/10.

As well he has cold pale extremities, high triglycerides and decrease in libido

Objectively: MRI showed L5 bulging disk

TCM Tongue: pale, with moderate white coat

TCM Pulse: slow, deficient on right chi position

Western medicine billable diagnosis: M54.5 Low back pain with right side sciatica

Non-billable ICD-11 (TM1) Diagnosis added in comments window current EMR systems: SC61Lumbago disorder (TM1) due to SF97 Kidney yang deficiency pattern (TM1), SG26 Bladder meridian pattern (TM1)

TCM treatment principle: relieve pain, move Qi, warm Kidney Yang, open Bladder Meridian

Acupuncture Rx: prone

Points TCM: LI4, LV3, UB23, 25, K3, Yaoyan, R-GB30, R-UB36,37,39,40,56,62, R-SI3; Points Auricular: K

Adjacent techniques: TDP lamp on lumbar region, Moxa

Recommended acupuncture tx frequency:

• 2 times a week for 6 weeks,

• after that 1 times a week for 6 more weeks

• give one month of break and repeat if necessary.

• every year in the summer repeat course of acupuncture treatment for 6 weeks 1 time a week preventatively

Treatment Goal:

in 6 weeks pain reduction by ~ 25%

in 12 weeks pain reduction by ~ 50%

Take home recommendations:

TCM Herbal Tx: Du Huo Ji Sheng Tang – expected to be taken for 6 – 12 months. Possibly may need to be taken at maintenance dose long term.

Topical: Capsaicin cram 3 times a day or patch at skin tolerance

Treatment Goal with addition of herbs:

• in 4 weeks pain reduction by ~ 50%

• in 8 weeks pain reduction by ~ 75%

 

Case Study #4

75 years old female presenting with chief complaint of constant “burning, aching” low back pain, accompanied with “stabbing” pain extends to right glut. Pain started 15 years ago and becomes progressively severe and is worse on standing and walking. She cannot walk or stand longer than 15 minutes. Severity of pain is 6-8/10

As well has insomnia with difficulty to stay a sleep, reduction in memory, tinnitus, thinning hair, dry mouth, stiff aching knees, varicose veins and cyanotic feet.

Objectively: MRI showed degeneration of L3,4,5 discs, Spinal stenosis

TCM Tongue: red, moist, no coat

TCM Pulse: string-like and deficient on both chi positions

Western medicine billable diagnosis: M54.5 Low back pain with right side sciatica

Non-billable ICD-11 (TM1) Diagnosis added in comments window of current EMR systems: SC61Lumbago disorder (TM1) due to SF01Blood stasis pattern (TM1),

SF94 Kidney yin and yang deficiency pattern (TM1)

TCM treatment principle: relieve pain, break Qi, activate Blood, warm Kidney Yang, nourish Kidney Yin

Acupuncture Rx: prone

Points TCM: Li4, Liv3, HuaTuoJiaJi-L4,5, UB23, Yaoyan, K3, R-GB29,30, UB60, R-SI3, L-UB62, R-GB41, L-SJ5

Points Auricular: K

Adjacent techniques: TDP lamp on lumbar region, Gua Sha, Cupping, E-steam

Recommended acupuncture tx frequency:

• 2 times a week for 6 weeks,

• after that 1 times a week for 6 more weeks

• after that every second to every fourth week dependent on severity of pain

Treatment Goal:

• in 6 weeks pain reduction by ~ 10-15%

• in 12 weeks pain reduction by ~ 30%

Take home recommendations:

TCM Herbal Tx: Shen Tong Zhu Yu Tang + Liu Wei Di Huang Tang modified - indefinitely

Topical: Tiger balm 3-6 times a day + Wu Yang Plaster – at skin tolerance

Treatment Goal with addition of herbs:

• in 6 weeks pain reduction by ~ 30%

• in 12 weeks pain reduction by ~ 50%

 

Comment: These are just four possible scenarios. There are a many more combinations of TM1 patterns for WM billable diagnostic code of low back pain.

We look forward to hearing from you!

 

Categories: Acupuncture