By Anthony W. Hamm, DC, MS
Dry needling has become an accepted procedure for the management of myofascial trigger points, offering a viable option to pain medications and surgical intervention. The procedure can also be applied to specific muscle motor points, spinal segments, and other structures including ligaments, tendons and joint capsules for pain relief. In clinical practice it is often used in conjunction with other physical medicine procedures and modalities to manage pain and improve function. These may include, but are not limited to, therapeutic exercise, manipulation and mobilization.
Needle insertion is an invasive procedure in which a solid filament needle is inserted into the skin and muscle, typically directed at a myofascial trigger point. The needle may or may not be manipulated and electrical stimulation may be used where indicated. Dry needling is considered a western medical technique versus acupuncture, which is utilized in traditional Chinese medicine based on the metaphysical theory of balancing energy flow through meridians in the body.
Dry needling is commonly performed by a variety of qualified health professionals including chiropractors, physical therapists, physiatrists, rheumatologists and pain management specialists. Physical therapy and chiropractic use of dry needling is determined by state scopes of practice. Currently, the majority of states approve the use of dry needling by chiropractors and physical therapists. Most states require additional training or certification for dry needling and this varies by state jurisdiction.
The utilization of dry needling procedures is based on appropriate patient history including chief complaints, history of present illness, and review of systems along with a current list of medications and supplements. Physical findings should include identification and location of myofascial trigger points, pertinent ranges of motion, neurological, and vascular assessment. Pain rating and functional outcome assessment tools should be used.
A treatment plan should be documented including frequency and duration. Prior to initiation of treatment, both absolute and relative contraindications should be considered. Patients should be apprised of the benefits and potential risks of the procedure and consent is mandatory. The patient should be re-assessed on each subsequent session.
Over the past two-three years, the American Chiropractic Association (ACA) and the American Physical Therapy Association (APTA) worked collaboratively to create CPT nomenclature describing the work of dry needling. Once accepted by the AMA CPT Editorial Panel, the codes were referred to AMA Relative Value Health Care Professionals Advisory Committee (HCPAC) for recommended work and practice expense values. This process concluded in early 2019 and the new codes are listed in CPT 2020 (CPT 2020 Professional Edition, American Medical Association p. 120).
- CPT® Code 20560 Needle insertion(s) without injection(s), 1-2 muscles, describes the work of dry needling to 1 or 2 muscles *
- CPT ® Code 20561 3 or more muscles, describes the work of dry needling to 3 or more muscles*
*Muscle(s) treated must be identified in the patient health record for both of these services.
These CPT® codes are listed in the Surgery/Musculoskeletal section of CPT 2020. This in no way implies that dry needling is a surgical procedure. Because the AMA CPT reference is related to nomenclature rather than a strict classification system, there may be some procedures appearing in sections other than those where one would expect they be classified. Further, placement is loosely based on where a provider or coder might easily find a code.
Coverage determinations for needle insertions without injection will be based on corporate medical policy of each individual carrier/payer beginning in 2020.
Dr. Hamm is a past ACA president and ACA’s current representative to the AMA RUC Health Care Professionals Advisory Committee.