1. Integrating Acupuncture into a Family Medicine Residency Kendra Unger, M.D. West Virginia University Department of Family Medicine

2. Disclosure I have no commercial interests to disclose

3. OBJECTIVES Define acupuncture Describe how acupuncture works List the major applications of acupuncture in a Family Medicine setting Describe the steps needed to effectively integrate acupuncture into a Family Medicine Residency

4. Acupuncture Penetration of the skin by thin, solid, metallic needle, which are manipulated manually or by electrical stimulation (NIH) Moxibustion, heat, pressure and lasers

5. The Acupuncture Point (LI-4)

6. The Acupuncture Channel

7. Deqi Patient Soreness Numbness Fullness Heaviness Heat Cold Pain Itching Muscular twitching Acupuncturist Heavy Tight Vibratory

8. The Science of Acupuncture

9. EBM World-Wide 1960-1995 3,425 clinical research or anecdotal reports World Literature Organic Lesions…………..40% Pain Problems……………..25% Surgical Analgesia ……….16% Neurological………………..10% Substance Abuse………….5% Psychiatric……………………4%

10. Organic Lesions Respiratory 13% Cardiovascular 12% Gastrointestinal 10% Gynecologic 10% Dermatologic 9% Genitourinary 9% Circulatory 8% Immunologic 6% Obstetric 5% Endocrinology 4% Hepatobiliary 4% Ophthalmologic 4% Oncologic 3% Otology 2% Rheumatologic 1% Pain Studies Musculoskeletal 67% Headache 12% Arthritis 9% Neuralgia 7% Dental 4% Malignant 1%

11. NIH 1997 Adult postoperative and chemotherapy nausea and vomiting Postoperative dental pain Addiction Stroke rehabilitation Headache Menstrual cramps Tennis elbow Fibromyalgia Myofascial pain Osteoarthritis Low back pain Carpal tunnel syndrome Asthma

12. By a show of hands

13. Application of Acupuncture in Family Medicine Chronic Pain Psychiatric Conditions

14. Remember this Slide! Serotonin Dopamine Norepinephrine GABA Endorphins Endogenous opioids NO Blood flow

15. Chronic Pain Treatment Medications NSAIDS/analgesics Antidepressants Anticonvulsants Muscle relaxants Opioids Benzodiazepines Herbals Other Ice/heat Physical therapy Chiropractor Massage therapy Pain clinic/injections Meditation/biofeedback CBT TENS Hypnosis Laser Magnet Surgery

16. Chronic Low Back Pain/Cervical Pain Percutaneous Electrical Nerve Stimulation (PENS)

17. Osteoarthritis

18. Peripheral Neuropathy Ba Feng and KB points (interosseous membrane)

19. Musculoskeletal Pain

20. Look Familiar? Serotonin Dopamine Norepinephrine GABA Endorphins Endogenous opioids NO Blood flow

21. Psychiatric Conditions ClassMechanismExamples TCADecrease reuptake of S and NE Elavil, clomipramine, imipramine, doxepin SSRISelectively inhibits S reuptake Celexa, Lexapro, Prozac, Paxil, Zoloft SNRIInhibits reuptake of S and NE Effexor, Cymbalta NDRIInhibits reuptake of NE and DA Wellbutrin CombinedSRI or S+NE and nervesTrazadone, Serzone NoradrenergicEnhances transmission of S and NE Remeron MAOIIncreases availability of NE and DA Nardil, Parnate, Marplan, Selegiline BenzodiazepineIncreases GABAXanax, Ativan, Klonopin

22. Look Familiar? Serotonin Dopamine Norepinephrine GABA Endorphins Endogenous opioids NO Blood flow

23. Acupuncture is low-risk “A” rating EBM –Low back pain –Knee and hip arthritis –Headaches –Neck pain

24. Integration of Acupuncture into a Family Medicine Residency

26. The Changing Face of Medicine Patient is a whole person Physician provides information so that the patient can make decisions consistent with his or her beliefs The patient in the captain of a multi- disciplinary practitioner team Healing is physical and spiritual

27. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture

28. Cultivate Acupuncture Culture Cultivate a culture supportive of acupuncture within your institution and department.

29. Education 30-60 % US population uses Complimentary and Alternative Medicine (CAM) NIH: 2/3 population over 50 uses CAM Institute of Medicine 2005 –Health professional schools incorporate sufficient information about CAM into the standard curriculum to enable licensed professional to competently advise their patients about CAM

30. Patient Education and Counseling 2012 –17% did not tell their GP they were using CAM because they expected or knew their GP would not approve of CAM use

31. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor

32. Faculty Sponsor Characteristics Possesses a certain temperament –Chronic pain –Open-minded Recognizes healing combinations Integrates Western and Eastern Medicine Develops a web of healthcare provider partners Educates learners Willing to accept criticism

33. My Transformation

34. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding

35. Secure Funding Training of Sponsor and future residents Equipment and start-up Conferences CME

36. Funding Sources Out-of-pocket Departmental budget Acupuncture donation fund Grants –National Center for Complementary and Alternative Medicine (NCCAM)

37. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor

38. Train Faculty Sponsor American Academy of Medical Acupuncture –“The purpose of the American Academy of Medical Acupuncture® is to promote the integration of concepts from traditional and modern forms of acupuncture with Western medical training and thereby synthesize a more comprehensive approach to health care.” – http://www.medicalacupuncture.org American Board of Medical Acupuncture –http://www.dabma.org

39. AAMA approved courses Medical Acupuncture for Physicians Acupuncture Course Acupuncture Integrative Medicine Program Advanced Certificate of Acupuncture-Levels I and II Complete Course in Medical Acupuncture for Physicians Contemporary Medical Acupuncture for Health Professionals International Structural Acupuncture for Physicians Medical Acupuncture at Downstate Medical Acupuncture Program: An Evidence Based Approach to TCM

40. AAMA Approved Courses Theory Scientific Basis Indications EBM Patient assessment and treatment development Practice management Clinical training, needle proficiency

41. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor

42. Obtain Credentialing and Privileges for Faculty Sponsor Institutional or state dependent Existing or start from scratch AAMA, ABMA and training courses

43. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor 6.Obtain Board Certification

44. Obtain Board Certification American Board of Medical Acupuncture –Board Exam –Clinical Experience General Requirements –Graduation from medical school –License to practice Medicine in a state or jurisdiction in US or Canada –Applicants do not have to be members of the AAMA or other professional society –Satisfactory moral and ethical standing

45. Acupuncture Board Exam Must meet educational eligibility requirement Conducted each Spring at the Annual Medical Acupuncture Symposium Review course offered 390 questions in 4 hours Combination of clinical vinettes, maps and applications

46. Acupuncture Experience Requirement Affidavit 2 years clinical experience following training course 500 medical acupuncture treatments More than one acupuncture paradigm 3 confidential letters of reference on character, professionalism and standards of clinical practice

47. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor 6.Obtain Board Certification 7.Determine Logistics of Treatment Environment, Equipment and Nursing

48. Determine Logistics of Treatment Environment, Equipment and Nursing Review institutional policy

49. Environment

50. Equipment

52. Nursing

54. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor 6.Obtain Board Certification 7.Determine Logistics of Treatment Environment, Equipment and Nursing 8.Determine Best Practice for Billing

55. Determine Best Practice for Billing CodeDescription 97810 Acupuncture, 1 or more needles; without electrical stim, initial 15 minutes of personal 1 on 1 contact with the patient. 97811 Acupuncture, without electrical stimulation, each additional 15 minutes of personal 1 on 1 contact with the patient, with re-insertion of needle(s). 97813 Acupuncture, 1 or more needles, with electrical stim, initial 15 minutes of personal 1 on 1 contact with the patient 97814Acupuncture, with electrical stim, each additional 15 minutes of personal 1 on 1 contact with the patient, with re-insertion of needle(s) CodeDescription 20552Injection(s); single or multiple trigger point(s), 1 or 2 muscles 20553Injection(s); single or multiple trigger points, 3 or more muscles 11900Intralesional scar injection; up to and including 7 lesions

56. How much should I charge? The Fair Medical Cost Lookup –http://www.fairhealthconsumer.org/medicalcos tlookup/http://www.fairhealthconsumer.org/medicalcos tlookup/ Institutional Recommendations Remember: You are a PHYSICIAN trained in Medical Acupuncture.

57. CodeDescriptionWVU Fair consumer Final 97810 Acupuncture, 1 or more needles; without electrical stim, initial 15 minutes of personal 1 on 1 contact with the patient. 87.0040.0140.00 97811 Acupuncture, without electrical stimulation, each additional 15 minutes of personal 1 on 1 contact with the patient, with re-insertion of needle(s). 72.0030.0230.00 97813 Acupuncture, 1 or more needles, with electrical stim, initial 15 minutes of personal 1 on 1 contact with the patient 94.00n/a42.00 97814Acupuncture, with electrical stim, each additional 15 minutes of personal 1 on 1 contact with the patient, with re-insertion of needle(s) 80.00n/a35.00 CodeDescriptionOurs Fair consumer Final 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscles 109.00162.00 109.00 20553 Injection(s); single or multiple trigger points, 3 or more muscles 123.00151.99 123.00 11900Intralesional scar injection; up to and including 7 lesions 93.0092.22 93.00

58. Avoid Pitfalls ALWAYS bill acupuncture separate Initial visit warrants E&M code Acupuncture treatments require a separate encounter with an appropriate code. Payment is due at time of service Keep consistent prices Do not charge insurance Use Medicare as your reference

59. “Tricks” of the Trade Some insurances will “bait and switch” If your patient requires “medical” treatment other than acupuncture, completely separate this out. Bill E&M for the medical visit to insurance and bill acupuncture code for the Medical Acupuncture treatment. Do NOT use modifier 25. Advanced Beneficiary Notice of Non- coverage

60. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor 6.Obtain Board Certification 7.Determine Logistics of Treatment Environment, Equipment and Nursing 8.Determine Best Practice for Billing 9.Train Residents

61. Train Residents PGYII Application process Involve Faculty Sponsor, Residency Director and Departmental Chair Temperament Good standing Enthusiastic AAMA accredited course

63. Residents

64. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor 6.Obtain Board Certification 7.Determine Logistics of Treatment Environment, Equipment and Nursing 8.Determine Best Practice for Billing 9.Train Residents 10.Design Resident Curriculum

65. Design Resident Curriculum Resident acupuncture clinic Didactic sessions –Residents in general, recruitment –Monthly Acupuncture Club EBM: Journal Club Best Practice Practice management Board prep M&M

66. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor 6.Obtain Board Certification 7.Determine Logistics of Treatment Environment, Equipment and Nursing 8.Determine Best Practice for Billing 9.Train Residents 10.Design Resident Curriculum 11. Advertise

67. Advertise Patient Education Services offered

70. Integrating Acupuncture into a Family Medicine Residency 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor 6.Obtain Board Certification 7.Determine Logistics of Treatment Environment, Equipment and Nursing 8.Determine Best Practice for Billing 9.Train Residents 10.Design Resident Curriculum 11. Advertise 12.Develop Community Ties

71. Develop Community Ties Mentorship –Local acupuncturists and herbalists –National Acupuncture Symposium Natural partnerships –Cancer center –Pain clinic –Anesthesia –Nursing home –Physical therapy –Massage therapy –Yoga/Tia Chi studio

72. Questions? 1.Cultivate Acupuncture Culture 2.Identify a Faculty Sponsor 3.Secure Funding 4.Train Faculty Sponsor 5.Obtain Credentialing and Privileges for Faculty Sponsor 6.Obtain Board Certification 7.Determine Logistics of Treatment Environment, Equipment and Nursing 8.Determine Best Practice for Billing 9.Train Residents 10.Design Resident Curriculum 11. Advertise 12.Develop Community Ties