16.3 Records Management, Professional Insurance, and ICD and CPT Coding
Key Takeaways
Document assessment findings, the treatment plan, the treatment given, the patient's response, and the follow-up plan, often in SOAP format.
Correct a paper record with a single line, the date, and your initials; never erase, obliterate, or rewrite a record after the fact.
ICD-10-CM codes describe diagnoses (why the patient was seen); CPT codes describe procedures and services (what was done).
Acupuncture codes 97810-97814 are based on 15-minute increments of personal one-on-one contact, with or without electrical stimulation; a separate E/M visit needs modifier 25.
Malpractice insurance covers professional negligence claims; general liability covers premises injuries such as slip-and-fall accidents.
16.3 Records Management, Professional Insurance, and ICD and CPT Coding
Quick Answer: Records management is 3% and insurance and billing 2% of the 2026 BIOM exam. Document assessment findings, the treatment plan, the response to treatment, and the follow-up plan. Keep records accurate, timely, secure, and retained as state law requires. Know the purpose of malpractice and general liability insurance, the difference between ICD (diagnosis) and CPT (procedure) codes, the acupuncture CPT codes, and how E/M codes are used.
What Belongs in the Chart
Most practitioners use the SOAP format:
| Part | Content | Example |
|---|---|---|
| S: Subjective | Chief complaint, history, symptoms, pain rating, patient-reported changes | "Low back pain 6/10, worse sitting; slept better since last visit" |
| O: Objective | Vital signs, examination and test findings, tongue and pulse | "BP 128/80; lumbar flexion limited 50%; tongue pale, swollen; pulse deep, weak" |
| A: Assessment | Biomedical diagnosis or referral diagnosis and Chinese medicine pattern; progress toward goals | "Chronic nonspecific low back pain; Kidney Qi deficiency with Cold-Damp" |
| P: Plan | Points, needle count, methods, retention, adjunctive therapies, home care, next visit, referrals | "BL 23, BL 40, KI 3; warm needle BL 23; 10 needles, 25 min; reassess in 3 weeks" |
Also record informed consent, needle counts and removal, adverse events and how they were managed, referrals and communications with other providers, missed appointments, and the patient's refusal of recommended care.
Maintaining Records
- Write entries promptly, legibly, and in ink or a secure electronic system, dated and signed.
- Corrections: on paper, draw a single line through the error, write the correction, and add the date and your initials. Electronic records must keep an audit trail of amendments. Label late entries as late entries. Never alter or destroy records, especially after a complaint or claim.
- Retention: follow state law, which commonly requires keeping adult records for several years after the last visit and minors' records until some years after they reach adulthood. HIPAA requires keeping privacy policies and related documentation for six years.
- Patient access: under HIPAA, patients have the right to inspect and obtain copies of their records, generally within 30 days, for a reasonable cost-based fee.
- Security and disposal: lock paper records, use secure passwords and encryption for electronic records, and shred or securely destroy records at the end of the retention period.
- Reporting: report suspected child or elder abuse and neglect as state law requires (Section 16.1), and report notifiable communicable diseases to the health department (Section 16.4).
Professional Insurance
| Type | What it covers |
|---|---|
| Professional liability (malpractice) | Claims of professional negligence, such as a pneumothorax, burn, or failure to refer |
| Claims-made policy | Covers claims made while the policy is active; needs "tail" coverage after the policy ends |
| Occurrence policy | Covers incidents that occurred during the policy period, whenever the claim is made |
| General liability | Injuries and property damage on the premises unrelated to treatment, such as a slip and fall in the waiting room |
| Other coverage | Workers' compensation for employees, product liability for herbs and supplements sold, and cyber liability for data breaches |
ICD and CPT Coding
| Feature | ICD-10-CM | CPT |
|---|---|---|
| Describes | Diagnoses: why the patient was seen | Procedures and services: what was done |
| Maintained by | WHO's ICD, adapted for the United States by the CDC's National Center for Health Statistics | American Medical Association |
| Format | Alphanumeric, such as M54.50 (low back pain, unspecified) or M54.2 (cervicalgia) | Five digits, such as 97810 |
Acupuncture CPT Codes
| Code | Description |
|---|---|
| 97810 | Acupuncture without electrical stimulation, initial 15 minutes of personal one-on-one contact |
| 97811 | Without electrical stimulation, each additional 15 minutes, with re-insertion of needles |
| 97813 | With electrical stimulation, initial 15 minutes |
| 97814 | With electrical stimulation, each additional 15 minutes, with re-insertion of needles |
Only one "initial" code is billed per day. Time is face-to-face time with the patient, not the time needles are retained while the practitioner is out of the room. Dry needling has separate codes (20560 for one or two muscles and 20561 for three or more).
Evaluation and Management (E/M) Codes
E/M codes describe office visits: 99202-99205 for new patients and 99212-99215 for established patients, chosen by the level of medical decision-making or the total time on the date of service. When a significant, separately identifiable evaluation is performed on the same day as acupuncture, the E/M code is reported with modifier 25. The routine pre-needling assessment is part of the acupuncture service and is not billed separately.
Medicare Coverage of Acupuncture
Since January 2020, Medicare covers acupuncture for chronic low back pain (lasting 12 weeks or longer, nonspecific, and not related to surgery or pregnancy):
- Up to 12 visits in 90 days, plus 8 more for patients who show improvement, with no more than 20 treatments a year.
- Treatment must stop if the patient is not improving or is getting worse.
- Licensed acupuncturists cannot bill Medicare directly. They may provide services under the appropriate supervision of a physician, physician assistant, nurse practitioner, or clinical nurse specialist if they hold a master's or doctoral degree in acupuncture or Oriental medicine from an ACAOM-accredited (now ACAHM) program and a current, full, active, unrestricted state license.
Billing Integrity
Avoid billing for services not rendered (NCBAHM Ground #11), upcoding (billing a higher level than performed), unbundling (billing separately for parts of one service), and routinely waiving copays for insured patients. The federal No Surprises Act requires a good faith estimate of expected charges for uninsured or self-pay patients. Documentation must support every code billed.
A practitioner discovers she recorded the wrong points in yesterday's paper chart entry. What is the correct way to fix it?
Use correction fluid to cover the error and write the correct points on top
Draw a single line through the error, write the correction, and date and initial it
Tear out the page and rewrite the whole entry neatly so the chart stays clean and readable
Leave the error, because records can never be corrected
What is the difference between ICD-10-CM and CPT codes?
ICD-10-CM codes describe diagnoses; CPT codes describe procedures and services
ICD-10-CM codes describe procedures; CPT codes describe diagnoses
Both describe only medications
CPT codes are used only for hospital inpatients
A practitioner provides 15 minutes of personal one-on-one acupuncture with electrical stimulation, then re-inserts needles and provides another 15 minutes with electrical stimulation. Which CPT codes describe this service?
97810 and 97811
97813 and 97814
97810 and 97813
99213 alone
A patient slips on a wet floor in the clinic's waiting room and breaks a wrist. Which type of insurance typically covers this claim?
Professional liability (malpractice) insurance
General liability insurance
Workers' compensation
Product liability insurance
Sections you finish are checked off in the contents.