Acupuncture SOAP Notes: Complete TCM Documentation Guide for LAcs
Master acupuncture documentation with comprehensive SOAP note examples, TCM diagnostic patterns, tongue and pulse charting, point selection rationale, herbal medicine documentation, and insurance billing compliance. Complete guide for Licensed Acupuncturists.
Why Acupuncture Documentation Matters
Acupuncture documentation serves critical functions beyond record-keeping. Proper SOAP notes demonstrate your expertise in Traditional Chinese Medicine diagnosis, justify treatment to insurance companies, protect against malpractice claims, and ensure continuity of care. As acupuncture gains wider acceptance in integrative medicine, thorough documentation of TCM diagnostic methods and treatment rationale is essential for professional credibility and reimbursement.
Professional Credibility
Detailed TCM diagnostics demonstrate expertise in tongue/pulse diagnosis and pattern differentiation
Insurance Reimbursement
Many insurers now cover acupuncture but require medical necessity and treatment plan documentation
Legal Protection
Documented informed consent, contraindication screening, and adverse event monitoring protect practitioners
Treatment Tracking
Tongue and pulse changes over time demonstrate treatment effectiveness and inform plan adjustments
Integrative Care
Clear documentation enables communication with physicians, PTs, and other healthcare providers
State Compliance
Meets state board requirements for LAc practice standards and scope of practice
TCM Documentation Standard
Acupuncture documentation must bridge Eastern and Western medicine. Include both TCM pattern differentiation (Kidney Yang Deficiency, Liver Qi Stagnation, etc.) AND Western biomedical diagnoses with ICD-10 codes. This dual approach satisfies insurance requirements while maintaining the integrity of Chinese medicine theory and demonstrating your unique diagnostic expertise.
The Acupuncture SOAP Format
The SOAP format adapted for acupuncture practice incorporates TCM diagnostic methods alongside conventional medical assessment.
S - Subjective
Patient-reported information including TCM intake
The subjective section captures chief complaint, symptom patterns, and TCM-specific questions about energy, digestion, sleep, temperature preferences, and emotional state. These details inform pattern differentiation.
Chief Complaint
Patient's primary concern in their own words (quoted)
History of Present Illness
OPQRST format: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity (0-10), Temporal pattern
TCM Intake Questions
Energy level, sleep quality, digestion, temperature preferences, emotional state, pain patterns in relation to TCM theory
Menstrual History (if applicable)
Cycle regularity, duration, flow quality, color, clots, pain, other symptoms
Functional Impact
How symptoms affect daily activities, work, sleep, relationships
Previous Treatments
What has helped or not helped, medications, other modalities tried
Review of Systems
Red flags: fever, unexplained weight loss, bowel/bladder changes, progressive weakness, night sweats
O - Objective
TCM diagnostics: tongue, pulse, palpation, observation
Objective findings in acupuncture include the Four Examinations: looking (observation, tongue), listening/smelling, asking (covered in subjective), and palpation (pulse, channels, abdomen). These are the foundation of TCM diagnosis.
General Observation
Overall appearance, affect, body language, complexion, vitality (Shen)
Tongue Diagnosis
Color (pale, red, purple, blue), shape (thin, swollen, cracked), coating (color, thickness, location), moisture level
Pulse Diagnosis
Rate, depth (superficial/deep), quality (wiry, slippery, choppy, weak, etc.), position-specific findings (Cun/Guan/Chi)
Palpation
Channel palpation, Shu points, Mu points, local areas of concern, temperature, texture, tenderness
Range of Motion
Affected areas measured in degrees, note pain reproduction
Postural Assessment
Alignment, gait, movement patterns
Vital Signs
Blood pressure, heart rate, temperature (when relevant)
A - Assessment
TCM pattern differentiation and Western diagnosis
Assessment synthesizes subjective and objective findings into TCM patterns (Qi/Blood/Yin/Yang imbalances, organ systems, pathogenic factors) and includes Western biomedical diagnosis with ICD-10 codes for billing.
TCM Pattern Differentiation
Primary and secondary patterns based on Eight Principles, Organ systems, Six Stages, or Four Levels
Channel Involvement
Which meridians are affected based on pain location and presentation
Treatment Principle
TCM therapeutic strategy (e.g., tonify Qi, nourish Blood, dispel Wind, warm Yang)
Western Diagnosis
Biomedical diagnosis with ICD-10 codes for insurance billing
Clinical Impression
Synthesis of findings, severity assessment, contributing factors
Prognosis
Expected outcomes and timeframe based on pattern, chronicity, patient factors
P - Plan
Acupuncture points, techniques, herbs, and lifestyle advice
Document specific acupuncture points with therapeutic rationale, needling technique, adjunctive therapies (moxa, cupping, e-stim), herbal formulas, treatment frequency, and TCM dietary/lifestyle recommendations.
Acupuncture Points
Specific points selected with rationale (e.g., LI4, ST36, CV6) organized by function
Needling Technique
Needle gauge/length, insertion depth, manipulation method (tonifying/reducing/even), retention time, patient position
Adjunctive Therapies
Moxibustion, cupping, gua sha, electroacupuncture, Tui Na, auricular therapy - specify method and duration
Herbal Medicine
Formula name (Chinese and English), dosage, frequency, duration, function
Treatment Frequency
Number of visits per week and total duration of treatment plan
Lifestyle/Dietary Advice
TCM dietary therapy, exercise recommendations, stress management, sleep hygiene
Patient Response
Immediate response to treatment, changes in symptoms, tolerance
Re-evaluation Date
When to reassess progress and modify treatment plan
TCM Diagnostic Methods Documentation
Tongue and pulse diagnosis are hallmarks of acupuncture practice. Proper documentation demonstrates expertise and supports pattern differentiation.
Tongue Diagnosis (She Zhen)
Observation of tongue body and coating reveals internal organ conditions
Pulse Diagnosis (Mai Zhen)
Palpation of radial artery in three positions and two depths on each wrist
Positions: Cun (distal), Guan (middle), Chi (proximal) Ć Left and Right wrists
Documentation Best Practice
Always document both tongue and pulse at initial evaluation and major re-evaluations. For routine visits, document changes or note "tongue and pulse unchanged." Example documentation:
Pulse: 68 bpm, deep quality, weak in Kidney (Chi) positions bilateral, slightly slippery in Spleen (Guan Right) position.
Complete Acupuncture SOAP Note Examples
Real-world examples demonstrating comprehensive TCM documentation for different scenarios and conditions.
Initial Acupuncture Evaluation
New patient with chronic low back pain
Date: 01/15/2025 Patient: Margaret Chen DOB: 05/22/1972 SUBJECTIVE Chief Complaint: "I've had chronic lower back pain for the past 3 years that gets worse during my menstrual cycle." History of Present Illness: 52 y/o female presents with chronic bilateral low back pain starting 3 years ago. No specific injury recalled. Pain rated 6/10 average, increases to 8/10 during menses. Describes pain as dull, achy, with occasional sharp stabbing. Worse in morning upon rising, worse with cold weather, improved with heat application and rest. Also reports fatigue, frequent urination (especially at night), cold extremities, and sensation of heaviness in legs. TCM Intake Questions: - Energy Level: Fatigued, especially in afternoon. Difficulty maintaining energy through day. - Sleep: Falls asleep easily but wakes 2-3x nightly to urinate. Dreams frequently. - Digestion: Loose stools in morning, occasional undigested food. Poor appetite. - Temperature: Feels cold easily, especially hands and feet. Prefers warm beverages. - Emotional: Mild anxiety about health, some fear/worry. Generally withdrawn when in pain. - Pain Pattern: Worse with exertion, cold, menstruation. Better with rest, warmth, pressure. - Gynecological: Menses every 28 days, 5-day duration, pale blood, moderate flow with clots. Low back pain significantly worse days 1-3 of cycle. Past Medical History: Hypothyroidism (on levothyroxine 75mcg). Two vaginal deliveries. Current Medications: Levothyroxine 75mcg daily, ibuprofen 400mg PRN for pain Previous Treatments: Physical therapy (minimal improvement), chiropractic care (temporary relief), massage therapy (helps temporarily) Social History: Office administrator, sits 6-8 hours daily. Married, two adult children. Non-smoker, rare alcohol use. Minimal exercise due to pain and fatigue. Review of Systems: Denies fever, bowel/bladder dysfunction, progressive weakness, saddle anesthesia, unexplained weight loss. OBJECTIVE Vital Signs: BP 118/74, HR 68, Wt 145 lbs, Ht 5'4" General Observation: Patient appears her stated age, mildly fatigued appearance. Moves cautiously when changing positions. Voice soft and somewhat weak. Posture/Gait: Forward head posture, rounded shoulders. Gait normal but slow, careful with transitions. Tongue Diagnosis: - Color: Pale, slightly purple on sides - Shape: Swollen with scalloped edges (teeth marks) - Coating: Thin, white coating - Moisture: Moist to slightly wet - Sublingual veins: Slightly distended and dark Pulse Diagnosis (Both Wrists): - Rate: 68 bpm, slightly slow - Depth: Deep - Quality: Weak overall, particularly in Kidney positions (Chi/Foot) bilateral - Specific Positions: * Left Kidney (Chi): Weak, thready * Right Kidney (Chi): Weak, thready * Spleen (Middle Right): Weak, slippery * Liver (Cun Left): Slightly wiry Palpation Findings: - Lumbar paraspinals: Bilateral tenderness, cold to touch, worse on pressure - Lower abdomen: Mild tenderness in lower jiao, some resistance - BL23 (Shenshu): Bilateral tenderness and depression - BL25 (Dachangshu): Bilateral tenderness - CV4 (Guanyuan): Slight tenderness - ST36 (Zusanli): Normal - KI3 (Taixi): Weak pulse, tender to palpation bilateral Range of Motion (Lumbar Spine): - Flexion: 60Ā° (guarded, pain at 6/10) - Extension: 20Ā° (limited, pain 7/10) - Lateral flexion: 30Ā° bilateral (pain 5/10) - Rotation: 35Ā° bilateral (stiff but minimal pain) Neurological: Motor strength 5/5 bilateral lower extremities, DTRs 2+ symmetrical, sensation intact ASSESSMENT TCM Pattern Differentiation: 1. Kidney Yang Deficiency (Primary Pattern) - Evidence: Cold extremities, frequent pale urination especially at night, weak deep pulse in Kidney positions, pale swollen tongue, low back pain worse with cold, fatigue, poor warming function 2. Kidney Qi Deficiency (Secondary) - Evidence: Weak low back and knees, frequent urination, chronic nature of complaint, deep weak pulse 3. Spleen Qi Deficiency (Contributing) - Evidence: Fatigue, loose stools with undigested food, poor appetite, pale tongue, weak Spleen pulse, scalloped tongue edges 4. Blood Stasis in Lower Jiao (Complicating) - Evidence: Stabbing pain quality, purple tongue coloration on sides, menstrual clots, slightly distended sublingual veins, pain worse during menses Western Biomedical Assessment: 1. Chronic mechanical low back pain (M54.5) 2. Fatigue (R53.83) 3. Lumbar myofascial pain syndrome (M79.1) Treatment Principle: - Tonify and warm Kidney Yang - Strengthen Spleen Qi - Move Blood and alleviate pain - Warm the channels and dispel cold Prognosis: Fair to good. Chronic Kidney deficiency patterns typically require longer treatment duration (3-6 months). Patient is motivated and condition is functional rather than structural. Lifestyle modifications and herbal support will enhance acupuncture outcomes. PLAN Acupuncture Treatment: Primary Points Selected: - BL23 (Shenshu) bilateral - Back Shu point of Kidney, tonifies Kidney, strengthens low back - GV4 (Mingmen) - "Gate of Vitality," tonifies Kidney Yang, warms lower back - CV4 (Guanyuan) - Front Mu of Small Intestine, tonifies Original Qi, strengthens Kidney - KI3 (Taixi) bilateral - Source point of Kidney, tonifies Kidney Yin and Yang - BL52 (Zhishi) bilateral - Tonifies Kidney, strengthens will, benefits low back - ST36 (Zusanli) bilateral - Tonifies Qi and Blood, strengthens Spleen - SP6 (Sanyinjiao) bilateral - Intersection of three Yin meridians, tonifies Kidney and Spleen - BL25 (Dachangshu) bilateral - Large Intestine Shu point, local point for low back pain Supporting Points: - LI4 (Hegu) bilateral - Moves Qi, promotes circulation, analgesic effect - GB34 (Yanglingquan) bilateral - Influential point for tendons, benefits low back Needling Technique: - Needle gauge: 0.25mm x 40mm (for back), 0.25mm x 30mm (for limbs) - Insertion depth: 0.5-1.0 cun depending on location - Manipulation: Even method for tonification points, gentle reinforcing manipulation - Needle retention time: 25 minutes - Patient position: Prone for back points, then supine for abdominal and lower leg points Adjunctive Therapies: - Indirect moxibustion on GV4 (Mingmen) and BL23 (Shenshu) bilateral - 15 minutes to warm Kidney Yang and dispel cold - Warming lamp on lower back during treatment - Cupping therapy (light-medium suction) on bilateral lumbar paraspinals - 5 minutes to promote local circulation and relieve muscle tension Patient Response to Treatment: Tolerated needles well. Reported feeling of warmth in lower back during moxa application. De qi sensation achieved at major points. Immediate reduction in muscle tension. Pain decreased from 6/10 to 4/10 post-treatment. No adverse reactions. Herbal Medicine Recommendation: Suggested Jin Gui Shen Qi Wan (Kidney Qi Pill from the Golden Cabinet) - classic formula for Kidney Yang Deficiency - Dosage: 8 pills three times daily, taken with warm water - Function: Warms and tonifies Kidney Yang, strengthens the lower back - Duration: 4-6 weeks minimum, reassess - Patent formula recommended for convenience and compliance - Discussed potential herb-drug interactions with levothyroxine (minimal risk with this formula) - Advised to take herbal formula 2 hours apart from thyroid medication Treatment Frequency & Duration: Phase 1 (Acute Relief - Weeks 1-4): 2x per week (8 treatments) Phase 2 (Consolidation - Weeks 5-12): 1x per week (8 treatments) Phase 3 (Maintenance - Months 4-6): 1x every 2 weeks (6 treatments) Total estimated: 22 treatments over 6 months Lifestyle & Dietary Recommendations: - Dietary therapy: Increase warming foods (cooked vegetables, soups, ginger tea, warming grains like oats). Avoid cold/raw foods, iced beverages, excessive dairy. - Specific foods to tonify Kidney Yang: Walnuts, black sesame seeds, lamb, cinnamon, ginger - Heat therapy: Apply warm compress or heating pad to low back 20 minutes daily - Gentle exercise: Walking 15-20 minutes daily, Tai Chi or gentle yoga when pain allows - Sleep hygiene: Warm bath before bed, keep bedroom warm, consider limiting fluids after 7pm to reduce nocturia - Avoid: Cold weather exposure, standing on cold surfaces, swimming in cold water Patient Goals: 1. Reduce average daily pain from 6/10 to 2-3/10 within 8 weeks 2. Decrease menstrual-related back pain from 8/10 to 4-5/10 within 3 cycles 3. Improve energy levels to sustain full work day without afternoon fatigue 4. Reduce nighttime urination from 2-3x to 0-1x per night 5. Return to light exercise (walking, gentle yoga) without pain exacerbation Home Care Instructions: - Perform gentle low back stretches 2x daily (demonstrated: knee to chest, pelvic tilts) - Moxa stick self-treatment (if comfortable): 10 minutes on CV4 and ST36 daily at home - Maintain warmth: dress in layers, keep low back covered, wear socks/slippers at home - Ergonomic setup: Use lumbar support cushion at work, take standing breaks every 30 minutes Re-evaluation: After 8 treatments (week 4) - reassess pain levels, pulse and tongue presentation, ROM improvements, and treatment plan adjustment Follow-up & Coordination of Care: - Encourage continued care with PCP for hypothyroid management - Will coordinate with patient's endocrinologist if thyroid dose adjustments needed - Patient to report any changes in thyroid medication - Red flags discussed: Immediately seek medical care if experiencing progressive weakness, bowel/bladder changes, or sudden severe pain Informed Consent: Discussed risks of acupuncture (minimal: slight bruising, temporary soreness, rare risk of pneumothorax with thoracic needling), benefits, expected treatment course, and alternatives (continued PT, pain management, medication). Patient verbalized understanding, all questions answered regarding needle sterilization, safety protocols, and treatment process. Written informed consent obtained. Insurance/Billing: CPT 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes CPT 97811: Each additional 15 minutes Diagnosis codes: M54.5 (Low back pain), R53.83 (Fatigue) Next Appointment: Scheduled for 01/19/2025
Routine Acupuncture Treatment
Established patient, migraine headache management
Date: 01/15/2025 Patient: David Martinez Visit #: 6 of 12 SUBJECTIVE Chief Complaint: "The migraines are much better, but I had one last week during a stressful work deadline." Since Last Visit: Overall significant improvement in migraine frequency. Had 1 migraine in past 2 weeks (compared to 2-3 per week at intake). Migraine last week rated 6/10 (previously 8-9/10), lasted 8 hours instead of usual 24-48 hours. Able to continue working with migraine medication, previously would miss work. Throbbing pain in right temple and behind right eye. Photophobia and phonophobia less severe than before treatment started. No nausea with last episode (previously significant nausea). Associated Symptoms: Still experiencing some neck tension and shoulder tightness, especially with computer work. Sleep improved - falling asleep more easily and sleeping through night. Stress level moderate this week due to work project. Current Medications: Sumatriptan 100mg (only needed once in past 2 weeks, previously using 2-3x per week) Compliance: Taking herbal formula (Tian Ma Gou Teng Yin) daily as prescribed. Following dietary recommendations (reduced coffee to 1 cup/day, avoiding aged cheeses and red wine). Practicing relaxation breathing exercises. OBJECTIVE General Observation: Patient appears well, good color, alert. Less tension visible in facial muscles compared to initial visit. Tongue Diagnosis: - Color: Pale red (improved from red sides previously) - Shape: Normal, slight red tip - Coating: Thin white, slightly yellow at root - Overall: Significant improvement from initial presentation Pulse Diagnosis: - Rate: 72 bpm (improved from 82 at initial visit) - Quality: Wiry quality decreased, now slightly wiry in Liver position only - Depth: Moderate - Liver (Cun Left): Slightly wiry but less pronounced - Overall: More balanced than initial presentation Palpation: - Neck and shoulder muscles: Mild tension bilateral trapezius (improved from severe) - GB20 (Fengchi): Slight tenderness bilateral (significantly improved) - GB21 (Jianjing): Mild tension - LI4 (Hegu): Less reactive than previous visits - Trigger points: Minimal, decreased from initial presentation - Head/temporal region: No active tenderness today ASSESSMENT TCM Pattern Update: 1. Liver Yang Rising (Improving) - Evidence: Wiry pulse less pronounced, temporal headaches reduced in frequency and intensity, irritability decreased, red tongue sides normalizing 2. Liver Qi Stagnation (Residual) - Evidence: Stress-triggered headaches, neck/shoulder tension, slightly wiry pulse in Liver position Progress Evaluation: Patient demonstrating excellent response to treatment. 70% reduction in migraine frequency, 30% reduction in intensity, 65% reduction in duration. Stress management and herbal therapy enhancing acupuncture effects. Pattern shifting from excess (Liver Yang Rising) toward more balanced state with residual Qi stagnation from work stress. PLAN Acupuncture Treatment Today: Primary Points: - LV3 (Taichong) bilateral - Source point, courses Liver, subdues Yang, primary point for Liver Yang Rising headaches - GB20 (Fengchi) bilateral - Expels wind, clears the head, benefits eyes and neck - GB34 (Yanglingquan) bilateral - Influential point of tendons, subdues Liver Yang - LI4 (Hegu) bilateral - Moves Qi, stops pain, combines with LV3 for "Four Gates" to regulate Qi - Taiyang (EX-HN5) bilateral - Extra point for headaches, especially temporal/migraine - GV20 (Baihui) - Calms spirit, subdues Liver Yang, lifts mood - PC6 (Neiguan) bilateral - Regulates Qi, calms spirit, reduces stress - GB41 (Foot Linqi) bilateral - Confluent point of Dai Mai, treats lateral headaches Additional Points for Stress/Neck Tension: - GB21 (Jianjing) bilateral - Releases neck and shoulder tension - SI3 (Houxi) bilateral - Confluent point of Du Mai, benefits neck and upper back Needling Technique: - Gauge: 0.25mm x 30mm - Method: Reducing technique on Liver points (LV3, GB20, GB34) with gentle drainage manipulation - Even technique on calming points (GV20, PC6) - Retention: 30 minutes - Patient position: Supine Adjunctive Therapy: - Gentle Tui Na massage to neck and shoulders: 10 minutes focusing on GB20, GB21, and trapezius - Ear seeds applied to Shenmen, Liver, Sympathetic points for continued stress reduction and headache prevention between treatments - Instructed on self-massage of ear seeds 3-4x daily Patient Response: Excellent tolerance. Reported deep relaxation during treatment, nearly fell asleep. De qi sensation achieved at distal points. Post-treatment reports feeling of lightness in head, significant reduction in neck tension. No adverse reactions. Treatment Plan Adjustment: Continue current treatment frequency (1x per week) for 6 more visits, then transition to every 2 weeks for maintenance if improvement continues. Patient approaching goal of <1 migraine per month. Herbal Medicine: Continue current formula: Tian Ma Gou Teng Yin (Gastrodia and Uncaria Formula) - Maintains good compliance and positive effects - No adverse reactions noted - Continue same dosage: 3 grams granules in hot water, twice daily Lifestyle Reinforcement: - Praised stress management improvements and dietary compliance - Encouraged continued coffee limitation - Recommend adding magnesium supplement (400mg daily) - discuss with PCP first - Continue mindfulness breathing exercises, especially during high-stress work periods - Maintain regular sleep schedule (noting improvement in sleep quality) Goals Progress Check: ā Goal 1: Reduce migraine frequency - ACHIEVED (from 2-3/week to <1/week) ā¬ Goal 2: Reduce intensity to <5/10 - IN PROGRESS (last migraine 6/10, previous 8-9/10) ā Goal 3: Reduce medication use - ACHIEVED (from 2-3x/week to occasional use) ā¬ Goal 4: Zero missed work days due to migraines - IN PROGRESS (2 weeks migraine-free work attendance) Re-evaluation: After 3 more treatments (visit 9), reassess whether to transition to bi-weekly maintenance care Next Appointment: Scheduled for 01/22/2025 Insurance/Billing: CPT 97810: Acupuncture, initial 15 minutes CPT 97811: Additional 15 minutes Diagnosis: G43.109 (Migraine, unspecified, not intractable)
Acupuncture for Acute Condition
Acute neck pain from motor vehicle accident
Date: 01/15/2025 Patient: Sarah Johnson Accident Date: 01/12/2025 SUBJECTIVE Chief Complaint: "My neck is so stiff and painful since my car accident three days ago." Mechanism of Injury: Patient was driver of vehicle rear-ended at stoplight on 01/12/2025. Impact from behind at approximately 20 mph. Airbags did not deploy, was wearing seatbelt. No loss of consciousness. Immediate onset of neck pain and stiffness, progressively worsening over 24-48 hours. Current Symptoms: - Neck pain 8/10, constant dull ache with sharp pain on movement - Severe neck stiffness, difficulty turning head - Headache at base of skull radiating to temples, 6/10 - Right shoulder pain 5/10 - Difficulty sleeping due to inability to find comfortable position - Mild dizziness with quick head movements Pain Pattern: Worse in morning, increases with any neck movement, computer work, driving. No position provides complete relief. Minimal improvement with ice or heat. Taking ibuprofen with limited effect. TCM Questions: - No radiating numbness/tingling into arms - No changes in bowel/bladder function - Emotional: Anxious about recovery, some fear after accident - Sleep: Disrupted, waking frequently due to pain Medical Treatment: Evaluated in Emergency Department day of accident. X-rays of cervical spine negative for fracture. Diagnosed with cervical strain. Prescribed muscle relaxants (cyclobenzaprine) and NSAIDs. Patient prefers to avoid muscle relaxants due to drowsiness, seeks acupuncture for pain relief. Past Medical History: Generally healthy, no chronic conditions Current Medications: Ibuprofen 600mg TID, cyclobenzaprine PRN (not taking) OBJECTIVE Vital Signs: BP 132/84 (elevated, likely from pain/stress), HR 78 General Observation: Patient in obvious discomfort, protective posturing of cervical spine. Moves head and neck as single unit. Appears anxious. Posture: Cervical spine held rigid in slight forward position. Loss of normal cervical lordosis. Elevated shoulders, guarded positioning. Tongue Diagnosis: - Color: Red on sides - Coating: Thin white - Shape: Slight purple on edges (indicating Blood stasis from trauma) - Overall: Acute trauma presentation Pulse Diagnosis: - Rate: 78 bpm, slightly rapid - Quality: Wiry, tight in all positions (indicating pain and Qi stagnation) - Particularly wiry in Gallbladder channels (neck pain correlation) Cervical Range of Motion (measured carefully): - Flexion: 15Ā° (severely restricted, pain 9/10) - Extension: 10Ā° (severely restricted, pain 9/10) - Right Rotation: 20Ā° (restricted, pain 8/10) - Left Rotation: 25Ā° (restricted, pain 8/10) - Right Lateral Flexion: 10Ā° (restricted, pain 8/10) - Left Lateral Flexion: 10Ā° (restricted, pain 8/10) Palpation Findings: - Severe muscle spasm bilateral cervical paraspinals C2-C7 - Marked tenderness and tightness bilateral upper trapezius - GB20 (Fengchi): Extremely tender bilateral - GB21 (Jianjing): Tender and knotted bilateral - SI3 and BL62 regions: Tender - Trigger points throughout levator scapulae, upper trapezius, and sternocleidomastoid - Marked restriction in all cervical segments on gentle motion palpation - Tissues feel cold and congested Neurological Screening: - Upper extremity strength: 5/5 bilateral (limited by pain) - Sensation: Intact all dermatomes C5-T1 bilateral - Deep tendon reflexes: 2+ biceps, triceps, brachioradialis bilateral - No signs of nerve root impingement - Negative Spurling's test bilateral (not performed with force due to acute injury) Red Flags Assessment: No bowel/bladder dysfunction, no progressive weakness, no saddle anesthesia. X-rays negative for fracture. No signs requiring immediate medical referral. ASSESSMENT TCM Pattern Differentiation: 1. Qi and Blood Stagnation in Neck/Channels (Acute - Primary) - Evidence: Acute trauma, severe pain, restricted ROM, tight wiry pulse, muscle spasm, purple tongue edges, pain worse with movement 2. Local Channel Obstruction (Tai Yang and Shao Yang Channels) - Evidence: Pain along Bladder and Gallbladder channel pathways, tender GB20 and GB21, occipital headache 3. Wind-Cold Invasion (Complicating) - Evidence: Stiffness, tissues cold to touch, headache, aversion to movement (protecting from external pathogenic factors) Western Assessment: 1. Acute cervical strain/sprain (whiplash) (S13.4XXA) 2. Post-traumatic headache (G44.301) 3. Cervical myofascial pain syndrome (M79.1) Treatment Principle: - Move Qi and Blood, remove stagnation - Relax tendons and stop pain - Promote circulation in local channels - Calm spirit and reduce anxiety Prognosis: Good. Acute soft tissue injury from MVA typically responds well to acupuncture. Expected recovery 4-8 weeks with appropriate treatment frequency. Patient is young and previously healthy, which are positive prognostic factors. PLAN Acupuncture Treatment - Gentle Protocol for Acute Injury: Distal Points First (to move Qi and prepare for local needling): - LI4 (Hegu) bilateral - Moves Qi, powerful analgesic, releases exterior - SI3 (Houxi) bilateral - Confluent point of Du Mai, benefits neck and upper back - BL62 (Shenmai) bilateral - Confluent point of Yang Qiao Mai, treats neck pain - GB41 (Foot Linqi) bilateral - Opens Dai Mai, treats lateral neck pain - LV3 (Taichong) bilateral - Courses Liver, moves Qi, reduces muscle spasm Local/Regional Points (needled gently): - GB20 (Fengchi) bilateral - Expels wind, releases neck tension, treats headache - GB21 (Jianjing) bilateral - Releases shoulder and neck, moves Qi and Blood - SI14 (Jianwaishu) bilateral - Local shoulder point, releases upper back - GV14 (Dazhui) - Intersection of all Yang channels, releases exterior - Tender Ashi points in upper trapezius (2-3 points) - Local circulation Spirit-Calming Points: - PC6 (Neiguan) bilateral - Calms spirit, reduces anxiety - HT7 (Shenmen) bilateral - Calms mind, aids sleep Needling Technique for Acute Trauma: - Gauge: Fine needles (0.20mm x 30mm) to minimize discomfort - Insertion: Very gentle, minimal manipulation initially - Method: Even technique, gentle lifting-thrusting to activate Qi - Depth: Shallow to moderate, avoiding deep needling in acute stage - Retention: 20 minutes (shorter than usual due to acute discomfort) - Patient position: Seated initially for assessment, then supine with neck support for treatment Adjunctive Therapies: - Cupping therapy: Very light suction (flash cupping technique) on upper back and shoulders to promote circulation without creating additional trauma - 3-5 minutes - NO moxa (avoiding warming in acute inflammatory stage) - Infrared heat lamp on shoulders at light intensity - 10 minutes for gentle warmth and muscle relaxation - Gentle Tui Na: Extremely light effleurage on neck and shoulders, no deep pressure or manipulation Patient Response to Initial Treatment: Tolerated treatment well despite initial apprehension about needles. Reported feeling of Qi movement (warmth, tingling) in neck during treatment. Visible muscle relaxation noted during session. Post-treatment ROM measurements: - Flexion: 25Ā° (improved from 15Ā°) - Extension: 20Ā° (improved from 10Ā°) - Rotations: 30-35Ā° (improved from 20-25Ā°) Pain decreased from 8/10 to 5/10 immediately post-treatment. Patient expressed relief and reduced anxiety about recovery. No adverse reactions. Treatment Frequency for Acute Phase: Phase 1 (Acute - Week 1-2): 3x per week (6 treatments) - frequent treatment essential for acute trauma to prevent chronic pattern Phase 2 (Subacute - Week 3-4): 2x per week (4 treatments) Phase 3 (Recovery - Week 5-8): 1x per week (4 treatments) Total: 14 treatments over 8 weeks, reassess at week 4 Herbal Medicine Recommendation: External Application: Zheng Gu Shui (Rectify Bone Liquid) topical liniment - Application: Apply to neck and upper back 3-4x daily, massage gently - Function: Invigorates Blood, dispels stasis, reduces swelling, stops pain - Duration: Throughout acute phase (2-4 weeks) Internal Formula: Modified Xue Fu Zhu Yu Tang (Blood Mansion Stasis-Expelling Decoction) - Function: Invigorates Blood, dispels Blood stasis, moves Qi, stops pain - Dosage: Granules or pills, standard dose 3x daily - Duration: 2-4 weeks during acute/subacute phase - Contraindications checked: No blood thinners, not pregnant Home Care Instructions: - Ice therapy: Apply ice pack to neck 15-20 minutes every 2-3 hours for first 48 hours - After 48 hours: Alternate ice (15 min) and gentle heat (15 min) 3-4x daily - Gentle ROM exercises: Starting day 3, perform gentle head rotations and tilts within pain-free range, 5 reps each direction, 3-4x daily - Sleep positioning: Use cervical pillow or rolled towel under neck, avoid stomach sleeping - Avoid: Sudden movements, looking up or down for extended periods, heavy lifting, high-impact activities - Work modifications: Frequent breaks from computer, ergonomic setup, avoid prolonged static postures Pain Management: - Continue ibuprofen as prescribed for anti-inflammatory effect - Can use cyclobenzaprine at night if muscle spasm prevents sleep - Gentle stretching and acupressure on LI4 and GB20 for pain relief between treatments Coordination of Care: - Will communicate with patient's PCP regarding treatment progress - Recommend follow-up with PCP if no improvement within 2 weeks - May refer for MRI if symptoms worsen or neurological changes develop - Physical therapy referral after acute phase (week 3-4) for rehabilitation exercises Red Flags & Warning Signs Discussed: Patient instructed to seek immediate medical care if experiencing: - Progressive weakness in arms or hands - Numbness or tingling in arms/hands that worsens - Loss of bowel or bladder control - Severe, worsening headache with vision changes - Difficulty swallowing or speaking Goals: 1. Reduce pain from 8/10 to 3-4/10 within 2 weeks 2. Improve cervical ROM by 50% within 3 weeks 3. Return to normal sleep pattern within 1 week 4. Resume normal daily activities within 4 weeks 5. Return to work (desk job) within 1-2 weeks with modifications Personal Injury Case Documentation: - Motor vehicle accident date: 01/12/2025 - Insurance claim number: Auto_2025_84729 - Attorney: Rodriguez & Associates (if applicable) - All treatment documentation will be provided for insurance claim - Detailed progress notes at each visit required for personal injury case Informed Consent - Acute Injury: Discussed acupuncture treatment for acute whiplash injury, realistic expectations (gradual improvement over several weeks), frequency requirements, and importance of compliance with home care. Reviewed minimal risks (slight bruising, temporary soreness). Explained that acupuncture complements but does not replace Western medical evaluation. Patient understands this is not a cure after one treatment. All questions answered. Written consent obtained. Follow-up: Next appointment scheduled for 01/17/2025 (in 2 days) Insurance/Billing: CPT 97810: Acupuncture, initial 15 minutes CPT 97811: Additional 15 minutes Diagnosis codes: S13.4XXA (Sprain of ligaments of cervical spine, initial encounter), G44.301 (Post-traumatic headache, acute, not intractable) Personal injury case billing to patient's auto insurance
Common TCM Patterns & Treatment Strategies
Understanding common patterns helps organize documentation and demonstrates clinical reasoning in point selection.
Qi Deficiency
Signs & Symptoms
Fatigue, weak voice, shortness of breath, poor appetite, pale tongue, weak pulse
Acupuncture Treatment
Tonify Qi - ST36, SP6, CV6, CV12, BL20, BL21
Classical Herbal Formula
Si Jun Zi Tang (Four Gentlemen Decoction)
Blood Deficiency
Signs & Symptoms
Pale complexion, dizziness, poor memory, scanty menses, pale tongue, thin/choppy pulse
Acupuncture Treatment
Nourish Blood - SP6, ST36, BL17, BL20, CV4
Classical Herbal Formula
Si Wu Tang (Four Substance Decoction)
Kidney Yang Deficiency
Signs & Symptoms
Cold extremities, low back pain, frequent pale urination, low libido, pale swollen tongue, deep weak pulse
Acupuncture Treatment
Warm and tonify Kidney Yang - BL23, GV4, CV4, KI3, KI7, moxa essential
Classical Herbal Formula
Jin Gui Shen Qi Wan (Kidney Qi Pill)
Liver Qi Stagnation
Signs & Symptoms
Irritability, mood swings, sighing, breast tenderness, PMS, wiry pulse, normal/red tongue
Acupuncture Treatment
Course Liver, regulate Qi - LV3, LV14, GB34, PC6, Yintang
Classical Herbal Formula
Xiao Yao San (Free and Easy Wanderer)
Blood Stasis
Signs & Symptoms
Fixed stabbing pain, purple tongue/lips, dark blood/clots in menses, choppy pulse
Acupuncture Treatment
Invigorate Blood, remove stasis - SP10, SP6, BL17, LI4+LV3
Classical Herbal Formula
Xue Fu Zhu Yu Tang (Blood Mansion Stasis-Expelling Decoction)
Dampness/Phlegm
Signs & Symptoms
Heavy sensation, brain fog, sticky tongue coating, slippery pulse, obesity, edema
Acupuncture Treatment
Resolve Dampness, transform Phlegm - SP9, ST40, CV12, BL20
Classical Herbal Formula
Er Chen Tang (Two-Aged Decoction)
Acupuncture Point Documentation
Document point selection with both location and therapeutic function to demonstrate clinical reasoning.
Command Points (Master Points)
Face/mouth, pain relief, moves Qi, releases exterior
Gynecology, stress, headaches, Liver Qi stagnation
Digestion, tonifies Qi & Blood, strengthens immune system
Neck/head, respiratory, releases exterior
Back Shu (Transport) Points
Lung Shu point - respiratory conditions
Heart Shu point - cardiac, mental/emotional
Liver Shu point - Liver Qi stagnation, eyes
Spleen Shu point - digestion, fatigue
Kidney Shu point - low back pain, tonify Kidney
Front Mu (Alarm) Points
Lung Mu point - respiratory, cough
Heart Mu point - anxiety, insomnia, chest pain
Liver Mu point - Liver Qi stagnation, digestive issues
Stomach Mu point - digestive disorders
Small Intestine Mu point - tonifies Qi, gynecology
Spirit (Shen) Points
Primary spirit point - calms mind, anxiety, insomnia
Calms spirit, nausea, chest pain, stress
Lifts spirit, mental clarity, headaches
Third eye point - calms mind, sinus, insomnia
Point Documentation Example
- LI4 (Hegu) bilateral - Powerful analgesic, moves Qi, releases exterior Wind
- LV3 (Taichong) bilateral - Source point of Liver, courses Liver Qi, subdues Yang
- ST36 (Zusanli) bilateral - Tonifies Qi and Blood, strengthens Spleen and Stomach
- GB20 (Fengchi) bilateral - Expels Wind, clears head, benefits eyes and neck
- PC6 (Neiguan) bilateral - Calms spirit, regulates Qi, treats nausea
Combined to regulate Qi flow, address Liver Yang Rising pattern, and calm Shen.
Adjunctive Therapies Documentation
Moxibustion, cupping, electroacupuncture, and other modalities require specific documentation for safety and billing.
Moxibustion (Jiu Fa)
Burning of mugwort herb to warm channels, expel Cold, tonify Yang
Types/Methods
Direct (on skin), Indirect (on needle/ginger/salt), moxa stick (hovering)
Indications
Yang deficiency, Cold conditions, chronic pain, digestive weakness, turned breech baby
Contraindications
Pregnancy (certain points), Heat conditions, high fever, hypertension
Documentation Example:
"Indirect moxa applied to CV4 and ST36 bilateral for 15 minutes to warm and tonify Yang Qi"
Cupping (Ba Guan)
Application of glass/plastic cups with suction to move Qi/Blood, release muscle tension
Types/Methods
Stationary, moving/sliding, flash cupping, wet cupping (not common in US)
Indications
Muscle tension, pain, respiratory conditions, digestive issues, Blood stagnation
Contraindications
Bleeding disorders, on varicose veins, broken skin, pregnancy (lower back/abdomen)
Documentation Example:
"Medium-suction cupping applied to bilateral lumbar paraspinals for 10 minutes. Moderate cupping marks present, resolved within 5 minutes of removal. Patient tolerated well."
Electroacupuncture (EA)
Electrical stimulation applied to acupuncture needles for enhanced effect
Parameters
Frequency: 2-100 Hz, Intensity: to patient tolerance, Duration: 15-20 minutes
Indications
Chronic pain, neurological conditions, muscle atrophy, addiction support
Contraindications
Pacemaker, pregnancy (lower abdomen/lumbar), epilepsy, broken skin
Documentation Example:
"EA applied to LI4-LI11 bilateral at 2 Hz continuous wave, moderate intensity, 20 minutes for pain management"
Gua Sha (Scraping)
Scraping skin with smooth tool to promote Blood circulation and release muscle tension
Technique
Apply oil, scrape at 45Ā° angle with moderate pressure until petechiae/sha appears
Indications
Muscle pain, fever, common cold, acute conditions, chronic tension
Contraindications
Bleeding disorders, broken skin, recent surgery, thrombocytopenia
Documentation Example:
"Gua sha performed on upper back and neck using horn scraper with moderate pressure for 5 minutes. Moderate sha appearance. Patient reported immediate relief of muscle tension."
Auricular (Ear) Acupuncture
Stimulation of ear points corresponding to body parts/organs via microsystem
Indications
Pain, addiction, anxiety, weight loss, insomnia - often adjunct to body acupuncture
Contraindications
Ear infection, pregnancy (certain points), broken skin on ear
Documentation Example:
"Ear seeds applied bilateral: Shenmen, Sympathetic, Liver, Kidney points. Patient instructed to massage seeds 3-4x daily for continued therapeutic effect."
Insurance & Billing Documentation Requirements
Acupuncture coverage is expanding, but insurers require specific documentation to approve claims and prevent denials.
Medical Necessity Documentation
Document clear medical diagnosis (ICD-10), symptom severity, functional limitations, and rationale for acupuncture treatment
Example: Patient with chronic migraine (G43.709) experiencing 12 headache days per month with 7/10 pain, missing work 2-3 days monthly, failed trials of propranolol and topiramate. Acupuncture indicated for headache prophylaxis.
Treatment Plan
Specific frequency (treatments per week), duration (total weeks/visits), measurable goals, and re-evaluation timeline
Example: 2 treatments per week for 6 weeks (12 visits total) to reduce migraine frequency by 50% and intensity to <4/10, re-evaluate at visit 12.
Progress Documentation
Document measurable changes in symptoms, functional improvements, or clinical findings at regular intervals
Example: Visit 6 re-eval: Migraine frequency decreased from 12/month to 6/month (50% reduction), average intensity from 7/10 to 4/10, zero missed work days in past 2 weeks.
Proper CPT Coding
Use correct acupuncture CPT codes: 97810 (initial 15 min), 97811 (each additional 15 min), 97813/97814 (with electrical stimulation)
Example: CPT 97810 + 97811 for 30-minute session without e-stim, or CPT 97813 + 97814 for 30-minute session with electroacupuncture
State Licensing Compliance
Document provider credentials (L.Ac., Dipl.Ac., etc.), license number, and ensure practice within scope for your state
Example: All notes should include provider signature with credentials and license number as required by state regulations
Important Insurance Notes
- Medicare does NOT typically cover acupuncture except for chronic low back pain (effective 2020)
- Many commercial insurers cover acupuncture but may limit visits (commonly 12-20 per year)
- Pre-authorization may be required - verify coverage before treatment and document authorization numbers
- Herbal medicine is rarely covered by insurance - clarify this with patients and document out-of-pocket consent
Common Documentation Mistakes to Avoid
These frequent errors undermine clinical credibility, lead to claim denials, and increase legal liability.
Documenting only point numbers without rationale or function
Avoid:
Points used today: LI4, ST36, LV3, PC6, GB20.
Better:
LI4 (Hegu) bilateral - moves Qi, powerful analgesic; ST36 (Zusanli) bilateral - tonifies Qi and Blood, strengthens Spleen; LV3 (Taichong) bilateral - courses Liver Qi, reduces stress; PC6 (Neiguan) bilateral - calms spirit; GB20 (Fengchi) bilateral - expels Wind, relieves headache. Combined to regulate Qi flow, reduce stress-related symptoms, and address migraine pattern of Liver Yang Rising.
Why it matters: Insurance reviewers and other providers need to understand clinical reasoning. Point selection should clearly relate to TCM diagnosis and treatment principle.
No tongue or pulse diagnosis documented
Avoid:
Patient reports neck pain. Treatment provided.
Better:
Tongue: Pale with scalloped edges, thin white coating. Pulse: Deep and weak in Kidney positions bilateral, overall slow quality (62 bpm). Findings indicate underlying Kidney Qi deficiency contributing to chronic neck weakness and pain.
Why it matters: Tongue and pulse are fundamental TCM diagnostic tools. Documenting findings demonstrates competence and supports pattern differentiation. Required by many insurance companies and essential for legal protection.
Vague or missing TCM pattern differentiation
Avoid:
Patient has back pain. Treatment for pain relief.
Better:
TCM Pattern: Kidney Yang Deficiency with Cold-Damp obstruction. Evidence: Low back pain worse with cold weather, improved with warmth; frequent pale urination; cold extremities; pale swollen tongue; deep weak pulse in Kidney positions. Treatment principle: Warm and tonify Kidney Yang, dispel Cold-Damp, strengthen low back.
Why it matters: TCM pattern differentiation is the foundation of acupuncture treatment planning. Without clear pattern identification, treatment appears generic rather than individualized. Essential for demonstrating expertise.
Not documenting needling technique, depth, or retention time
Avoid:
Acupuncture performed with good results.
Better:
Needling technique: 0.25mm x 30mm needles, insertion depth 0.5-1.0 cun. Reducing method with gentle drainage manipulation applied to LV3, GB20, GB34 for Liver Yang Rising. Even method on HT7, PC6 for calming spirit. Needle retention 30 minutes. Patient positioned supine. De qi sensation achieved at all points.
Why it matters: Specific technique documentation demonstrates skill level, supports billing, and provides important clinical information. Different techniques (tonifying vs. reducing) have different therapeutic effects and should be documented.
Failing to document informed consent for acupuncture
Avoid:
Patient agreed to treatment.
Better:
Informed consent obtained: Discussed acupuncture procedure, realistic expectations (gradual improvement over multiple sessions), minimal risks (possible slight bruising, temporary soreness, rare risk of pneumothorax), benefits, alternatives (medication, PT, chiropractic). Explained needle sterilization and safety protocols. Patient verbalized understanding, all questions answered. Written consent form signed and in chart.
Why it matters: Informed consent is legal requirement for invasive procedures including acupuncture. Must document what was discussed and that patient understood and agreed. Critical for malpractice protection.
Not documenting patient response to treatment
Avoid:
Patient tolerated treatment well. See you next time.
Better:
Patient response: Tolerated needles well. De qi sensation achieved at LI4, ST36, LV3. During treatment, reported feeling of relaxation and warmth spreading through body. Post-treatment: Pain decreased from 7/10 to 3/10, ROM improved (neck rotation increased from 40Ā° to 60Ā° bilateral), visible reduction in muscle tension. No adverse reactions. Patient expressed satisfaction with immediate pain relief.
Why it matters: Documenting immediate response demonstrates treatment efficacy, supports medical necessity for continued care, and tracks what techniques work best for individual patient. Insurance companies often require evidence of positive response.
Inadequate herbal medicine documentation
Avoid:
Recommended herbs for patient.
Better:
Herbal formula prescribed: Xiao Yao San (Free and Easy Wanderer) granules, 3 grams in hot water twice daily with meals. Function: Soothes Liver, strengthens Spleen, nourishes Blood - addresses pattern of Liver Qi stagnation with underlying Blood deficiency. Duration: 4 weeks, reassess. Discussed potential herb-drug interactions (patient takes no medications). Reviewed preparation method. Provided written instructions in English. Patient verbalized understanding and willingness to comply.
Why it matters: Herbal prescribing requires detailed documentation including formula name, dosage, frequency, duration, function, and patient education. Necessary for safety, legal protection, and tracking outcomes. Some states require specific herbal documentation.
Copy-paste documentation without individualization
Avoid:
Using identical tongue/pulse findings and point selection for multiple consecutive visits.
Better:
Visit 1: Tongue pale with thick white coat. Visit 4: Tongue pale pink with thin white coat (improved). Visit 8: Tongue normal pink, thin coating (nearly resolved). Pulse progression documented similarly. Point selection adjusted based on changing presentation - reducing tonification points as deficiency improves, adding different points as new symptoms emerge.
Why it matters: Documentation must reflect actual findings at each visit. Identical notes suggest fraud or negligence. Clinical findings should change over time with treatment, and documentation should reflect this progression or explain lack of change.
Frequently Asked Questions
What should be included in acupuncture SOAP notes?
Acupuncture SOAP notes must include: Subjective (chief complaint, TCM intake questions, symptom patterns), Objective (tongue diagnosis, pulse diagnosis, palpation findings, general observation), Assessment (TCM pattern differentiation, Western diagnosis with ICD-10 codes, treatment principle), and Plan (specific acupuncture points with rationale, needling technique, adjunctive therapies like moxa/cupping, herbal recommendations, treatment frequency). Documentation should demonstrate clear clinical reasoning connecting TCM diagnosis to point selection.
How do I document tongue and pulse diagnosis properly?
Tongue documentation should include: color (pale, red, purple, blue), shape (thin, swollen, cracked, scalloped), coating (color, thickness, location, moisture), and any notable features. Pulse documentation should include: rate (bpm), depth (superficial/deep), overall quality (wiry, slippery, choppy, weak, etc.), and position-specific findings at Cun/Guan/Chi on both wrists. Example: "Tongue: Pale and swollen with scalloped edges, thin white coating. Pulse: 64 bpm, deep and weak in Kidney positions bilateral, slightly slippery in Spleen position." These findings should correlate with your TCM pattern diagnosis.
What is TCM pattern differentiation and why is it important?
TCM pattern differentiation is the process of identifying the underlying imbalance based on symptoms, tongue, pulse, and other signs. It provides the foundation for treatment planning in Chinese medicine. Patterns include concepts like Qi/Blood/Yin/Yang deficiency or excess, organ system involvement (Liver, Kidney, Spleen, etc.), and pathogenic factors (Wind, Cold, Dampness, Heat). Proper documentation shows clinical expertise, justifies point selection, demonstrates individualized treatment, and is increasingly required by insurance companies. Example: "Pattern: Liver Qi Stagnation with Liver Blood Deficiency - evidenced by irritability, menstrual irregularity, wiry pulse, pale tongue with red sides."
How should I document acupuncture point selection?
Document both the point location and its therapeutic function/rationale. Include point name in both Western notation and pinyin when possible. Example: "LV3 (Taichong) bilateral - Source point of Liver channel, courses Liver Qi, subdues Liver Yang, treats headaches and stress; LI4 (Hegu) bilateral - powerful analgesic, moves Qi, releases exterior; ST36 (Zusanli) bilateral - tonifies Qi and Blood, strengthens Spleen and Stomach. Combined as treatment for Liver Yang Rising headaches with underlying Qi deficiency." This demonstrates clinical reasoning and connects point selection to your TCM diagnosis.
What CPT codes are used for acupuncture billing?
Primary acupuncture CPT codes: 97810 (initial 15 minutes of acupuncture without electrical stimulation), 97811 (each additional 15 minutes without e-stim), 97813 (initial 15 minutes with electrical stimulation), 97814 (each additional 15 minutes with e-stim). For a typical 30-minute session without electroacupuncture, bill 97810 + 97811. For 30 minutes with e-stim, bill 97813 + 97814. Time-based billing requires documentation of actual treatment time. Some insurers may also cover cupping (97140) or therapeutic exercise (97110) when performed separately.
How do I document moxibustion, cupping, and other adjunctive therapies?
For each adjunctive therapy, document: type/method, location, duration, purpose, and patient response. Moxibustion example: "Indirect moxa applied to GV4 (Mingmen) and BL23 (Shenshu) bilateral for 15 minutes to warm and tonify Kidney Yang, dispel Cold from low back. Patient reported pleasant warmth, no burning or discomfort." Cupping example: "Medium-suction stationary cupping applied to bilateral lumbar paraspinals and upper back for 10 minutes to move Qi and Blood, release muscle tension. Moderate cup marks present, faded within 10 minutes. Patient tolerated well, reported immediate relief of tightness." Include any contraindications checked and informed consent obtained.
What are common red flags acupuncturists must document?
Document screening for: progressive neurological deficits, bowel/bladder dysfunction, saddle anesthesia, unexplained weight loss, fever with pain, severe night pain, history of cancer, recent major trauma, bleeding disorders (before cupping/gua sha), pregnancy (certain points contraindicated), pacemaker (before electroacupuncture). If red flags present, document referral to appropriate medical provider and modification of treatment plan. Example: "Patient reports new onset numbness in both hands with progressive weakness over 2 weeks. Immediate referral made to neurologist Dr. Smith. Acupuncture treatment focused on supportive care only, avoiding strong stimulation pending medical evaluation."
How often should acupuncturists re-evaluate patients?
Perform comprehensive re-evaluations every 6-12 treatments (typically every 3-6 weeks for patients receiving 2x/week treatment). Re-assessment should include: updated tongue and pulse diagnosis, symptom severity changes, functional improvements, ROM measurements (if applicable), review of treatment goals, and treatment plan modifications. Brief progress notes at each visit with full re-evaluation periodically. Document measurable changes: "Re-evaluation visit 8: Migraine frequency decreased from 12/month to 4/month (67% reduction), intensity from average 8/10 to 4/10, medication use from 12 doses/month to 3 doses/month. Tongue and pulse show improved balance. Continue current protocol for 4 more weeks then transition to maintenance frequency."
Focus on Healing, Not Documentation
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