Documentation Standards Flashcards

Which CPT code is used for the initial 15 minutes of acupuncture with electrical stimulation?

Answer: 97813

CPT 97813 covers the initial 15 minutes of personal one-on-one contact for acupuncture with electrical stimulation.

When electroacupuncture is used, which detail is most important to document?

Answer: The points connected, the frequency and waveform, the intensity, and the duration

Stimulation parameters and the points used are needed for reproducibility, safety, and billing support.

A patient asks for a copy of their acupuncture records. Under HIPAA, how should the practice generally respond?

Answer: Provide access within 30 days, though a reasonable cost-based fee may be charged

HIPAA gives patients the right to access their records, generally within 30 days, for a reasonable cost-based fee.

Which practice best protects electronic health records?

Answer: Unique user logins, access controls, and audit trails

The HIPAA Security Rule calls for technical safeguards such as unique user IDs, access controls, and audit logs.

How long must acupuncture patient records be kept?

Answer: As long as state law requires, which is often several years, with longer periods for minors

Retention periods are set by state law and usually run several years, with extended periods for minors.

Which ICD-10-CM code type should be paired with acupuncture CPT codes on an insurance claim?

Answer: A diagnosis code that supports medical necessity, such as M54.50 for low back pain

Insurers require biomedical ICD-10-CM diagnosis codes that support medical necessity, and TCM pattern names are not billable codes.

What should the Plan section of an acupuncture SOAP note include?

Answer: Treatment frequency, planned follow-up, home care advice, and any referrals

The Plan section describes the next steps in care, including frequency, follow-up, self-care, and referrals.