CMS Pub. 100-04, ch. 32, § 410.2

Effective for claims with dates of service (DOS) on or after January 21, 2020, contractors shall recognize acupuncture

for cLBP services reported with CPT codes 97810, 97811, 97813, 97814, 20560, and 20561 as covered services under

National Coverage Determination (NCD) 30.3.3 no more than 20 times per annum.

NOTE: If the 1st service is performed on March 21, 2020, the next service beginning a new year cannot be performed

until March 1, 2021, 11 full months following the 1st service.

The attached includes the International Classification of Diseases (ICD)-10 diagnosis codes are applicable and must be

reported for acupuncture for cLBP services:

Contractors shall accept and process acupuncture for cLBP claims with the -KX modifier for the 13th through 20th

service per annum.

NOTE: The 1st through 12th service over a 90-day period do not require the –KX modifier. There is a 20 service

maximum per annum for this benefit.

NOTE: By applying the - KX modifier to the claim, the therapy provider is confirming that the additional services are

medically necessary as justified by appropriate documentation in the medical record.