A national reimbursement coding system for holistic medicine is on the horizon. The question is, will those codes be integrated into the American Medical Association’s Current Procedural Terminology (CPT) codes or will they be a free-standing independent system?
Alternative Link, a company based in Albuquerque has already developed a comprehensive set of more than 4,000 5-letter codes to describe nearly every healing modality practiced by alternative health care providers. Their system is harnessed to a powerful database called Health Intel, which among other things, defines the legal scope of practice for every type of health care provider on a state-by-state basis. Alternative Link’s goal is to provide a complete reimbursement and utilization review infrastructure for all of alternative medicine.
Existing CPT and Healthcare Common Procedure Coding System (HCPCS) codes, though integral to care delivered by MDs and DOs, only covers 20% of all existing health care practitioners. Moreover, CPT does not specifically cover many holistic health services even if they are given by conventional physicians, explained Synthia Molina, Alternative Link’s CEO, at the annual meeting of the American Holistic Medical Association.
AMA’s CPT system does have codes for a few CAM services as well as certain non-physician services. However, the CPT system tends to assign CAM to Category 3, which is “investigational or experimental” status. Such services generally do not get reimbursed. Further, the CPT system does not describe holistic therapies in enough detail to allow creation of relative value units (RVUs). CPT lacks CAM-related medicolegal and state regulatory logic to facilitate e-processing of claims by the plans. “There’s lots of sand in the works,” Ms. Molina told Holistic Primary Care.
The absence of adequate codes creates many roadblocks to integrative health care. Without specific codes, it is nearly impossible to do the kind of outcomes research and cost-efficacy measurements needed to determine the precise role of natural therapeutics in management of common conditions. Lack of codes means lack of reimbursement, which bars many people with limited money from obtaining potentially beneficial services. Holistic physicians seeking reimbursement often use non-specific or unclassifiable “99” codes, which frequently throws claims into manual review, creating administrative headaches.
The Other 80 Percent of Healthcare
Alternative Link’s Alternative Billing Concept (ABC) codes, are “focused on that 80% of health care not currently covered by existing code sets,” said Ms. Molina.
The new code set and the Health Intel database are now in use in several hundred clinics around the country as part of a pilot project authorized by the Department of Health and Human Services last year.
The codes are the result of more than a decade of work by Melinna Giannini, formerly an insurance administrator, and her colleagues. The odyssey began after Ms. Giannini needed treatment for a serious kidney condition. She realized that insurers were ready to spend tens of thousands of dollars on costly, high-tech end-stage care, but almost nothing on comprehensive, prevention-oriented natural medicine and self-care.
ABC codes are based on a five-character system like CPT, but they use letters rather than numbers. Each code defines a specific service and also the type of practitioner delivering it. The system includes MDs, naturopaths, osteopaths, registered nurses, nurse practitioners, certified nurse midwives, chiropractors, massage therapists, and many others. The Health Intel database determines whether such a service is legally part of the scope of practice of the given practitioner in the given state. The system also defines practitioner-specific RVUs, to streamline reimbursement.
“The idea is that health plans will develop credentialing criteria based on the material in our database, and then network with practitioners who meet these credentials and recognize their legal scope of practice,” Ms. Molina told Holistic Primary Care in an interview. “The reimbursement codes provide standards for payment of these services. It is all harmonized with state regulations because plans have major malpractice risk if they pay for something that is out of the scope of practice of a given practitioner. So, a CAM benefits package has to reflect legal practice scopes based on the state laws.”
Nationally Standardized Language
While creating reimbursement infrastructure is central to Alternative Link’s mission, research is another essential aspect. “You, as health care professionals, think of coding as the basis for claims. But behind the scenes, health plans use them for actuarial studies to determine what in medicine is most and least cost-effective. They use them to develop benefits packages, prior authorization guidelines, and utilization guidelines,” said Ms. Molina. The ABC system provides a nationally standardized language for gathering meaningful actuarial data.
She acknowledged that integrating holistic modalities into standard benefits would be a long, difficult process. Even in the realm of conventional medicine, it is never easy to get insurers to ante up for a new modality or drug.
“Historically, AMA and HHS have created prevalence requirements: You have to prove something is widely used before the CPT committee will even consider creating a reimbursement code for it. But everyone, health care plans and physicians alike, wants to know that there is an established code and payment mechanism before they start to utilize a new modality or service. It is something of a Catch 22,” said Ms. Molina. She added that in conventional medicine, there are companies “who specialize in putting the fear of God into health plan medical directors by insinuating that some new drug or service is being incorporated by competing plans.”
No such companies have emerged in support of holistic medicine, but the alternative coding endeavor does have a significant ace in the hole: strong support from policymakers in Washington, DC.
Friends in High Places
Last year, HHS Secretary Tommy Thompson committed to an evaluation of ABC as a freestanding and independent coding system. This led to a pilot project involving clinics around the country that will use the codes in electronic claims transactions. HHS will monitor the process to determine how well the codes work in real-world practice. Several high-ranking members of Congress, including Rep. Frank Pallone (D-NJ), strongly support the project.
Federal authorities have also pushed the American Medical Association, which controls the entire CPT coding system, to reckon with the issue of codes for holistic health care. Last year, the National Committee on Vital and Health Statistics (NCVHS)—a public advisory committee to HHS secretary Thompson—advised AMA to meet with Alternative Link to see if the ABC codes could provide a basis for nationally standardized CAM codes, and whether they could be harmonized with the CPT system. HHS essentially gave the CPT committee a soft-handed ultimatum: either work with the ABC codes or develop a comparable set of codes on its own.
Since then, representatives of Alternative Link have met with members of the CPT editorial committee several times, and there have been long chains of correspondence. According to Ms. Molina, Alternative Link would welcome the opportunity to incorporate the ABC codes and the Health Intel logic into the CPT system. But based on the dialogs so far, she said that AMA seems intent on developing their own codes, at their own rather slow pace.
“AMA faces considerable challenges. One of their prime sources of revenue is the licensing fees for their codes and coding manuals. The existence of codes in integrative medicine could displace services provided by their membership. AMA can’t yet serve the integrative care market (via reimbursement codes) because it would be violating its own organizational mission, which is to advance the interests of conventional physicians,” Ms. Molina said.
AMA Brings Natural Medicine to the Table
AMA has, in recent months, brought a number of non-MD health care professionals to the CPT policy table. The Health Care Professionals Advisory Committee (HCPAC) is composed of twenty non-MD or DO health professionals assembled to advise the CPT Editorial Panel on codes for non-conventional care. HCPAC includes representatives of many major licensed CAM professions, including chiropractors, acupuncturists, and massage therapists. Bruce Milliman, ND, recently joined HCPAC, as a representative of the American Association of Naturopathic Physicians (see The Naturopathic Perspective, p. 6).
The CPT committee appears to be working in good faith with members of HCPAC, and has shown serious intention to develop meaningful codes. Their timeline, however, is another question. How this will play out in light of the existing ABC codes and the HHS-mandated pilot project remains to be seen.
Though Alternative Link sought to be inclusive in its coding scheme, critics contend that development of the codes went on without input or consensus from many of the organizations representing holistic health professionals. According to Michael Traub, ND, former president of the AANP, the ABC codes do not yet have buy-in from his organization, the American Chiropractic Association, or any of the groups representing licensed acupuncturists.
Reimbursement: A Devil in Disguise?
Not everyone within the natural medicine professions believes third-party insurance coverage is a good idea. Many holistic practitioners are happy with their limited but hassle-free fee for service practices, and have little desire to see their professions subjected to the same sort of third-party pressures that have ravaged conventional medical care. Indeed, a growing number of conventionally trained physicians, weary of constant tussles with health plans, are opting out and shifting back to fee-for-service or retainer-based practice.
Though she acknowledged the reality of the difficulties, Ms. Molina, like many others who support the movement toward reimbursement, believe it is essential for the continued growth of holistic health care and the broadening of access to comprehensive health services. But she admitted that coding and third party reimbursement will likely shake things up for many practitioners. “The absence of CAM codes gives AMA cartel-like power because the health plans basically cannot see what cannot be coded. CAM codes create competitive pressure on both sides of the fence. An absence of codes equals invisibility, and for many, that is comforting.”
