February 5, 2020 
 
Carol Blackford 
Director, Hospital and Ambulatory Policy Group 
Centers for Medicare and Medicaid Services 
7500 Security Boulevard 
Baltimore, MD 21244 
 
Submitted electronically 
 
RE: Reconsideration of Medicare coverage of CPT codes 20560 and 20561 (Needle insertions without injections) 
 
Dear Director Blackford: 
 
On behalf of our more than 100,000 member physical therapists, physical therapist assistants, and students of physical therapy, the American Physical Therapy Association (APTA) writes to respectfully request that the Centers for Medicare and Medicaid Services (CMS) reconsider its decision to designate the new CPT codes (20560 and 20561) describing dry needling as “non-covered” under the Medicare Physician Fee Schedule (PFS). APTA is dedicated to building a community that advances the physical therapy profession to improve the health of society. As experts in rehabilitation and habilitation, physical therapists play a unique role in society in prevention, wellness, fitness, health promotion, and management of disease and disability for individuals across the age span, helping individuals improve overall health and prevent the need for avoidable health care services. Physical therapists’ roles include education, direct intervention, research, advocacy, and collaborative consultation. These roles are essential to the profession’s vision of transforming society by optimizing movement to improve the human experience. 
 
Thank you for your consideration of APTA’s detailed comments below. 
 
Clinical Efficacy of Dry Needling 
 
There have been numerous studies demonstrating the distinctiveness and clinical effectiveness of dry needling.1 Dry needling was first referenced in literature in the 1940s. The wide use of dry needling began in the late 1970s. Its origins lie in trigger point injections.2 Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, and muscular and connective tissues for the management of neuromusculoskeletal pain and movement impairments. Dry needling is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue; diminish persistent peripheral nociceptive input; and reduce or restore impairments of body structure and function leading to improved activity and participation. 
1 Gerber LH, Sikdar S et al, Beneficial Effects of Dry Needling for Treatment of Chronic Myofascial Pain Persist for 6 Weeks After Treatment Completion. PM & R 9(2):105-112 (Feb. 2017); Cerezo-Téllez E, Torres-Lacomba M et al, Effectiveness of dry needling for chronic nonspecific neck pain: a randomized, single-blinded, clinical trial. Pain. 157(9):1905-1917 (Sept. 2016); Brennan KL, Allen BC, Maldonado YM, Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial. J Orthop Sports Phys Ther. 47(4):232-239 (April 2017); Pecos-Martín D, Montanes-Aguilera FJ et al, Effectiveness of Dry Needling on the Lower Trapezius in Patients with Mechanical Neck Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil., 96(5):775-81 (May 2015); Gerber LH, Shah J et al, Dry Needling Alters Trigger Points in the Upper Trapezius Muscle and Reduces Pain in Subjects with Chronic Myofascial Pain. PM R 7(7):711-718 (July 2015).  
2 Legge D, A History of Dry Needling, J Musculoskeletal Pain: 1–7 (May 2014). https://www.researchgate.net/publication/262695179_A_History_of_Dry_Needling. 
 
Moreover, dry needling is not a type of acupuncture; it is an intervention separate and apart from acupuncture. Dry needling may be incorporated into a treatment plan when myofascial trigger points (MTrPs) are present, which may lead to impairments in body structure, pain, and functional limitations. MTrPs are sources of persistent peripheral nociceptive input, and their inactivation is consistent with current pain management insights. Dry needling also is indicated with restrictions in range of motion due to contractured muscle fibers or taut bands, or other soft tissue restrictions, such as fascial adhesions or scar tissue. MTrPs have been identified in numerous diagnoses, such as radiculopathies, joint dysfunction, disk pathology, tendinitis, craniomandibular dysfunction, migraines, tension-type headaches, carpal tunnel syndrome, computer-related disorders, whiplash associated disorders, spinal dysfunction, post-herpetic neuralgia, complex regional pain syndrome, nocturnal cramps, and other relatively uncommon diagnoses such as Barré Liéou syndrome, or neurogenic pruritus, among others.  
 
Development of Dry Needling Codes 
 
Two CPT codes that describe dry needling, CPT Code 20560, Needle insertion(s) without injection(s) 1-2 muscles, and CPT Code 20561, Needle insertion(s) without injections, 3 or more muscles, now exist in the Current Procedural Terminology (CPT) code set. The process to develop the CPT codes that describe dry needling began in June 2018 when APTA and the American Chiropractic Association submitted a code change application to the CPT Editorial Panel requesting that a new Category I CPT code be approved for the provision of dry needling.  
 
For Calendar Year 2020, the American Medical Association (AMA) CPT Editorial Panel approved two new codes (CPT Codes 20560 and 20561) to report dry needling of musculature trigger points. The CPT Editorial Panel ultimately approved these codes as representing a unique procedure not previously described in the CPT manual, recognizing that because dry needling is not acupuncture, the acupuncture codes 97810-97814 are not appropriate to describe dry needling services. During the AMA January 2019 RVS Update Committee (RUC) meeting, the AMA Health Care Professionals Advisory Committee (HCPAC) surveyed and reviewed these codes. 
 
In the 2020 PFS proposed rule, CMS proposed to designate the two new dry needling codes (20560 and 20561) as “always therapy” procedures and assigned an “A” status to the codes.3 In the 2020 PFS final rule, although CMS adopted values for these codes, it did not finalize these codes as “always” or “sometimes” therapy services, stating that these codes are non-covered unless otherwise specified through a national coverage determination.4 
3 CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies proposed rule https://www.govinfo.gov/content/pkg/FR-2019-08-14/pdf/2019-16041.pdf, page 40572, 40667. 
4 CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies final rule https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F, page 62724. 
5 https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Dry_Needling/APTADryNeedling LawsByState.pdf. 
6 Sticking it to the Pain with Dry Needling, Menorah Park, https://www.menorahpark.org/lifestyle/senior-stories/sticking-it-to-the-pain-with-dry-needling. 
 
Dry Needling Is Within Physical Therapists’ Scope of Practice 
 
Physical therapy state practice acts began identifying dry needling as within the scope of practice of physical therapists beginning in 1984. As of this writing, 35 states and the District of Columbia have laws allowing physical therapists to perform dry needling.5 In these states, the performance of dry needling by a physical therapist is allowed, provided the physical therapist does so competently and does not profess to be engaging in the practice of another profession. For example, it would be inappropriate and a violation of state law for a physical therapist to refer to the performance of dry needling as “acupuncture,” as acupuncture describes the scope of services and interventions provided by an acupuncturist. Conversely, the performance of an intervention such as therapeutic exercise by an acupuncturist should not be referred to as “physical therapy,” as “physical therapy” describes the services provided by a licensed physical therapist. 
 
Expanding Medicare Beneficiary Access 
 
Dry needling can be an effective treatment for pain. It has been known to help in pain management following surgery, and can even serve as a safer, less-invasive alternative to cortisone injections.6 Medicare coverage would provide greater access to dry needling for Medicare beneficiaries. 
Conclusion  
 
APTA respectfully requests that CMS convert the procedure status of the two new dry needling codes (20560 and 20561) from “N” (Noncovered code) to “A” (Active code) in its 2021 PFS rulemaking. As CMS is aware, the presence of an “A” indicator does not mean that Medicare has made a national coverage determination regarding the service; Medicare Administrative Contractors remain responsible for coverage decisions in the absence of a national Medicare policy. 
 
APTA appreciates the opportunity to provide feedback to CMS regarding CPT codes 20560 and 20561. Should you have any questions, please do not hesitate to contact Kara Gainer, director of regulatory affairs, at karagainer@apta.org or 703/706-8547, or Steve Postal, senior specialist, regulatory affairs, at stevepostal@apta.org or 703/706-3391.  
 
Thank you for your consideration. 
 
 
Sincerely, 
 
 
C:\Users\heathersmith\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\JQGL4HOH\Sharon Dunn Signature 2015.png
 
Sharon L. Dunn, PT, PhD 
Board-Certified Clinical Specialist in Orthopaedic Physical Therapy 
President 
 
 
cc: 
Gift Tee, Director, Division of Practitioner Services 
Marge Watchorn, Deputy Director, Division of Practitioner Services 
 

