ACPUNCTURE (97810-97814) COVERAGE
OHP/MEDICAID
Including Guideline Note #92
October 31, 2013 PRIORITIZED LIST OF HEALTH SERVICES
Line 1 PREGNANCY (Guideline Note #92)
Acupuncture pairs on Line 1 for the following conditions and codes:
Hyperemesis gravidarum ICD-9 codes: 643.00, 643.03, 643.10, 643.11, and 643.13 Acupuncture for
hyperemesis gravidarum is covered when a diagnosis is made by the maternity care provider and
referred for acupuncture treatment. Up to 2 sessions of acupressure/acupuncture are covered.
Breech presentation ICD-9 codes: 652.20 and 652.23. Acupuncture (and moxibustion) for breech
presentation is covered when a referral with a diagnosis of breech presentation is made by the
maternity care provider, the patient is between 33 and 38 weeks gestation, for up to 2 visits.
Back and pelvic pain of pregnancy ICD-9 codes: 648.70 and 648.73. Acupuncture is covered for back
and pelvic pain of pregnancy when referred by maternity care provider/primary care provider for up to
12 sessions.
Line 5 ABUSE OR DEPENDENCE OF PSYCHOACTIVE SUBSTANCE
Acupuncture is included on line 5 for treatment of abuse or dependencies of Alcohol using ICD-9
codes: 291.1, 303.9-303.93, and 305.00-305.03. Other drug dependencies and abuse, using ICD-9
codes: 304.00-304.93 and 305.20-305.93.
Line 6 TOBACCO DEPENDENCE (Guideline Note #4)
Acupuncture is included in line 6 only for pairing with tobacco dependence using ICD-9 code: 305.1305.12 or tobacco disorder complicating pregnancy: 649.00-649.04 AND following guideline note #4.
(Persons are eligible for tobacco dependence counseling if a documented quit date has been
established.) Benefit is limited to 10 total visits in 3 months per attempt to quit; May attempt to quit
2 times in 12 months. Visits may be for individual sessions or for group sessions or for acupuncture
sessions. (For more information see OHP prioritized list Line 1 or 6 and guideline note #4.) See
Trillium’s Tobacco Cessation Policies and Guidelines.
Line 15 HIV DISEASES (INCLUDING ACQUIRED IMMUNODEFICIENCY SYNDROME) AND
RELATED OPPORTUNISTIC INFECTIONS
Acupuncture is covered on line 15 when paired with HIV disease using IDC-9 code 042.0 and for
Asymptomatic HIV Status using code V08.
Line 68 SUBSTANCE-INDUCED DELUSIONAL AND MOOD DISORDERS; INTOXICATION
Acupuncture is included on line 68 for treatment of alcohol disorders using IDC-9 codes: 291.3-291.9,
and 303.00-303.03. Also, for treatment of other drug-induced disorders using ICD-9 codes 292.11292.
MCA_ZZ22NR Approved 01/23/2014
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Line 70 SUBSTANCE-INDUCED DELIRIUMS
Acupuncture is included in line 70 for treatment of alcohol-related delirium using ICD-9 code 291.0291.9 and drug-induced disorders using IDC-9 code 292.0-292.89.
Line 212 DEPRESSION AND OTHER MOOD DISORDERS, MILD OR MODERATE (Guideline
Note #92)
Acupuncture is covered on this line for the treatment of post-stroke depression only. Diagnosis of
depression in the first 3 years post-stroke can be defined using ICD-9 codes 296.20-296.90, 298.0,
and 311. Previous codes must accompany ICD-9 codes for cerebrovascular accident (CVA) or stroke
(ischemic) (434.91), embolic (434.11), hemorrhagic (430, 431, and 432.0-432.9), thrombotic (434.01),
or postoperative cerebrovascular accident (997.02). Also, V12.54 and 438.0-438.9 could be used.
Treatments may be billed to a maximum of 30 minutes face-to-face time and limited to 15 total
sessions, with documentation of meaningful improvement.
Line 400 DISORDERS OF SPINE WITH NEUROLOGIC IMPAIRMENT (Guideline Note #92)
Acupuncture is included on Line 400 only for pairing with disorders of the spine with myelopathy
and/or radiculopathy represented by the diagnosis codes 344.60, 722.1, 722.2, 722.7, and 724.4.
Acupuncture for the treatment of these conditions is only covered, when referred, for up to 12
sessions.
Line 435 MIGRAINE HEADACHES (Guideline Note #92)
Acupuncture pairs on Line 435 for ICD-9 Code: 346 (346.00-346.93), when referred, for up to 12
sessions. Only the above noted codes for migraine headaches are covered for acupuncture
services. No other codes on this line are covered for acupuncture services.
Line 489 OSTEOARTHRITIS AND ALLIED DISORDERS (Guideline Note #92)
Acupuncture pairs on Line 489 for osteoarthritis of the knee, ICD-9 codes: 715.16, 715.36, and
715.96, only when referred, for up to 12 sessions. No other codes on this line are covered for
acupuncture services.
(This is NON-FUNDED, below the line)
Line 562 ACUTE AND CHRONIC DISORDERS OF SPINE WITHOUT NEUROLOGIC
(Guideline Note #92)
Acupuncture pairs on Line 562 only with the low back diagnoses (344.60, 722.1, 722.2, 722.7, 724.4),
when referred, for up to 12 sessions.
Acupuncture pairs with chronic (>90 days) neck pain diagnoses (723.1, 723.8, 723.9, 847.0), when
referred, for up to 12 sessions.
Line 563 TENSION HEADACHES
(Guideline Note #92)
Acupuncture is covered for tension headaches, (ICD-9 Codes: 307.81, 339.10, 339.11, and 339.12)
on Line 563, when referred, for up to 12 sessions.
MCA_ZZ22NR Approved 01/23/2014
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