With the appointment of Bruce Milliman, ND, to the American Medical Association’s CPT Editorial Panel’s Health Care Professional Advisory Committee (HCPAC), the naturopathic profession now has representation in a process that determines much of what happens regarding third party insurance reimbursement in American health care.

There has been, and will continue to be, a strong public push to have CAM services covered in health benefits packages. This is coming at a time when new benefits are pushing insurers close to the breaking point. On the other hand, broader CAM coverage may in fact offset costs, especially in end-stage acute care, as CAM is generally less expensive and emphasizes prevention. Access to coding policy is the only way to open a system which has until now been largely inaccessible to the licensed CAM professions.

The CPT (Current Procedural Terminology) Editorial Panel is a joint committee between Centers for Medicare and Medicaid Services and the AMA, empowered by federal law to codify medical services and procedures for third-party reimbursement. The CPT panel is comprised of 15 medical physicians, including 10 nominated by AMA. CPT panel meetings are not open to the public. HCPAC is composed of twenty non-AMA providers charged with advising the CPT panel on codes for non-conventional care. In addition to its recent addition of an ND, HCPAC includes representatives for all the major licensed CAM professions, including chiropractic, acupuncture, and massage.

Inclusion of non-MDs in the coding process is important because, in aggregate, the total number of CAM providers and nurses is more than triple the population of conventional physicians. Public demand for CAM (not including nursing and other non-MD/DO interventions) is significantly higher and growing faster than for conventional primary care (Eisenberg DM, et al. “Trends in Alternative Medicine Use in the United States, 1990–1997.” JAMA. 1998; 280: 1569–1575).

Codes that accurately describe CAM are essential for capturing data on safety, efficacy and cost-effectiveness. Without accurate codes, many holistic practitioners are burdened by manually-adjudicated claims, disenfranchisement from the benefits of standardized transactions, and reliance on generic codes that results in a loss of information needed to effectively manage care and conduct accurate research. Generic codes compromise actuarial analyses and—even worse—promote fraud and abuse.

To address these concerns, the Foundation for Integrative Healthcare, in conjunction with Alternative Link, has proposed a system called Alternative Billing Codes (ABC). ABC Codes pertain to alternative medicine, nursing and other integrative health care (see story, p. 1). The ABC system has garnered some support from federal health care policymakers, who have suggested that the ABC codes be incorporated under the rubric of CPT category II codes. However, there are concerns with ABC codes. They did not arise from a consensus-building process, and they are perhaps unreasonably numerous (over 4,000), which could place a disproportionate paperwork burden on providers.

The ABC codes have support from many groups, including the American Bar Association’s Committee on CAM, the American Massage Therapy Association, the American Nurses Association, and the American Preventive Medical Association. But Alternative Link has not received broad support from other key organizations, including the American Association of Naturopathic Physicians, the American Chiropractic Association, and major national acupuncture associations, and has had difficulty obtaining substantive communication from the CPT Editorial Panel.

ABC codes were developed for a vast range of CAM services and related supplies, some of which may deter their wider acceptance. Further, there are some significant gaps in the ABC system. The Integrated Healthcare Policy Consortium established a task force for coding issues in 2002, members of which met in early 2003 with both Alternative Link and the leadership of the CPT Editorial Panel. The Consortium determined the need for codes describing specific naturopathic medical services. Among the issues are the following:

1. Manipulation codes currently specify either Osteopathic (98925–98929) or Chiropractic (98940–98943) manipulative treatment. In some jurisdictions, naturopathic physicians may not be allowed to use these code groups.
2. Physical medicine and Rehabilitation codes (97001–97546 especially) are in some jurisdictions similarly off limits for NDs, and in any event, do not completely specify the range of treatments, modalities and procedures used by NDs.
3. The gray area between preventive medicine and health promotion should be further delineated in the development of appropriate codes for all practitioners involved in holistic medicine. This would be not only to the benefit of healthcare professionals, but for the benefit of our appalling (and growing) national health debt.

The introduction of new codes and the modification of existing codes is onerous work, requiring the participation of a broad range of provider groups to reach consensus on changes that may improve healthcare delivery to patients.

Michael Traub, ND, is immediate past-president of the American Association of Naturopathic Physicians. He practices in Kailua-Kona, Hawaii, and is on staff at North Hawaii Community Hospital.