BREAKING THE HEALTH CARE CODES
PART 1 of 2
Carolyn Dean, MD, ND and
It will take much more than a village to change the face of medicine. In fact, it will take millions of people working together and some independent souls striking out on their own to break down the decades� old wall that limits our access to low-cost, safe, and effective natural healing methods. Elissa and I do our part by documenting the errors of modern medicine and taking you step-by-step into the world of natural healing arts. Others, like Melinna Giannini, CEO of ABC Coding Solutions (formerly Alternative Link) do it by creating new medical billing codes that embrace the natural healing arts. And fellow health freedom fighter, Tim Bolen, gets credit and our thanks for being the first to break the story about these codes back in early 2003. Links -----> [Read] [Read] [Read]
The mind boggling medical billing system of American health care is a complex coding system called Current Procedural Terminology (CPT codes) that was established in 1966 by the AMA. AMA owns most of these billing codes, which garner hefty annual licensing fees. AMA also sells all the instructional paraphernalia necessary for every doctor to correctly fill out the forms. In addition, each year, thanks to changing government rules, these codes have to be updated resulting in updated instruction manuals.
There has never been a law against including codes to cover all the natural healing arts practices Elissa and I advocate. But it doesn�t take a mathematician to realize that with the AMA in charge of the coding system it�s hardly likely they will allow the competition in on the gravy train of automatic payment for services rendered.
CPT codes are used to document what an allopathic doctor does for a patient �each event being translated into a 5-digit number that goes to an insurance company or the government for payment (i.e., a health payer). All you have to do is think of a department or grocery store where every item has a bar code, and if it doesn�t, the item can�t be sold without a clerk running back to the aisle to find the price. Swiping a bar code across the cashier�s scanner not only calculates the price but also automates inventory control and financial management. It�s the same for health care, without a code there is no way to calculate appropriate payment and no itemization of what has transpired. It�s that simple.
All the data entry related to health care in the U.S. is based on medical codes developed by the AMA (CPT codes or Health Care Common Coding Procedures (HCPCS I)) and codes for supply items, dentistry, and limited procedures developed by the Centers for Medicare and Medicaid Services (HCPCS II). Even though the current coding system covers only a fraction of what is happening in health care�coded interventions are the only transactions that are tracked, marketed, and reimbursed. It is also why so little is known about what really transpires in the marketplace with regards to natural healing arts practitioners who are paid cash because they have no way to bill through insurance channels.
There is much more to these codes than just billing. Practitioners use them for medical record-keeping and practice management; health plans use codes to process insurance claims and to design and manage benefits. Researchers use them to identify what type of care works best, and actuaries use codes to help make public policy decisions for our national health care system. So without the codes for natural healing arts services we are not able to document the effectiveness of care or the money that is saved by using them. It�s a lose-lose situation. Patients lose, practitioners lose, and the nation keeps losing millions of dollars paid out to ineffective and costly drug-based medicine. I would say it�s a very serious problem because--he who controls the billing codes controls the way medicine is practiced in this country.
Actuaries are a type of mathematician that help businesses and government assess the potential financial risk of certain events and help formulate policies that minimize the cost of that event. When it comes to assessing the cost of health procedures all that actuaries have to measure is based on costs tied to conventional medicine. For example, they add up the number of Caesarian sections and the number of natural deliveries done in the country and predict a future cost of delivery based on historical data. Since they can�t measure coded data from midwives, they have no way of knowing that patients who see midwives have a much lower rate of cesarean section than patients who see MDs, who have an absurdly high rate �of about 30%.
That explains why doctors who provide options to the �standard� drugs and surgery are often �opted out� of insurance because they don�t have codes to describe what they do and health payers can�t pay for something that isn�t coded.
It�s also why we can only depend on surveys to tell us what forms of natural healing arts people are using �we have no other way of gathering the data. In fact, in 1993, Dr. David Eisenberg stunned the health care establishment when he did a simple telephone survey and found that 34 percent of the U.S. population was using natural health care and paying out of pocket to do so. Because there were no codes for these services, nobody knew what was happening.
There used to be state codes (HCPCS III) that individual states created to meet their needs �such as Alaska Medicaid�s codes for behavioral health paraprofessionals who serviced rural and bush communities. These communities didn�t have access to professional caregivers. The state codes were abolished in 2003, costing many state Medicaid programs millions of extra dollars when they had to rely on CPT and HCPCS II codes.
Having to fit everything a practitioner does into an allopathic code leads to a high degree of inexactness �a mismatch between what is done and the code that has to be used. When such claims are rejected �or even worse, declared illegal, there is a costly trail of paperwork. Every time a doctor sends in a paper claim to a health payer it costs upwards of $20 for all the administrative costs involved. If that claim is rejected, that $20 is lost forever. When the health payer rejects a claim it suffers the very same administration costs �and another $20 is lost. Most rejected claims happen when the doctor uses the wrong code or tries to fit a code into something outside the system. When the use of codes is declared illegal, a doctor can be fined or even lose his license.
Because the AMA CPT and government codes do not include non-allopathic modalities, many doctors limit their practice to allopathic medicine, which limits the type of care available to the public. Those MDs who use the codes have to fit their care into a CPT code�round pegs into square holes. Once bitten, twice shy describes a doctor who is fined for using the wrong codes. Vagueness in the CPT codes and draconian measures to enforce them severely affects our choice of health care.
There are very limited codes for the services of over 20 types of practitioners including chiropractors, homeopaths, naturopaths, advance practice nurses, holistic doctors, acupuncturists etc. Some practitioners work with MDs and bill under a doctor�s license but each state has its own rules and regulations. Even though all states allow nurse practitioners to bill directly for their care, nurses lack appropriate codes. While insurance companies may direct them to bill using CPT codes, the American Nurses Association has determined that the AMA�s codes do not describe or document that the care is from a nurse.
Most nurse practitioners have a collaborative agreement with a doctor and work under a doctor�s supervision in order to facilitate reimbursement. When a nurse practitioner has to bill under a doctor�s supervision, the insurance company pays the doctor, who then pays the nurse practitioner �usually keeping the lion�s share. This keeps the whole payment system for medical care and other health professionals under the control of a medical doctor. And perhaps you can see why MDs don�t favor any change in this monopoly
As for acupuncturists, naturopaths, and midwives, in some states they are prohibited from practicing. Because there is so much discrepancy in state scope of practice laws, health payers haven�t bothered to find out what each practitioner can do in each state. Because of potential legal liabilities, in most cases they just don�t pay for these services. To be fair, they don�t want to pay a claim illegally but it suits them just as well to not pay �it saves them the hassle of processing claims without codes.
The following pie graph gives you some idea of who is left out of the medical monopoly equation.
To level the playing field, ABC Coding Solutions and its CEO, Melinna Giannini, have developed the only coding system in the U.S. that can automatically determine which practitioners can legally use any code in any state to bill for integrative healthcare services. ABC Coding Solutions has correlated laws governing the scope of practice of health practitioners in all 50 states to each ABC code. For example, their system identifies professionals in all states who have �prescriptive authority.� Today, over 4,400 ABC codes are tied to scope of practice regulations for 17 practitioner types.
Ms. Giannini, with a background in insurance, knew the health care system was unhealthy. But it wasn�t until she experienced a chronic illness that she became a victim of that very system. She struggled for two years, going to allopathic doctors (who used CPT codes) to the tune of $15,000 -all legal and absolutely ineffective. After none of the allopathic treatments worked, it only took a few visits with a doctor who provided non-CPT coded care and $500 out of pocket for her to get well and get the message.
Ms. Giannini had enough common sense to be outraged that an insurance company would happily pay the $15,000 for treatments that don�t work and not pay the $500 for treatments that did. She was also aware of the constant media coverage about the rising costs of health care and realized that no one was addressing codes for the natural healing arts. The doctor that helped her get well was forced to operate outside the �system�, which also forces millions of other patients like Ms. Giannini outside as well.
Knowing that practitioners had to be tied to insurance plans for patients to get reimbursement, Ms. Giannini attempted to create networks of integrative health care practitioners. But everywhere she turned, she kept running up against the code problem. Ms. Giannini, with her considerable insurance knowledge, then began exploring coding through the AMA.
Although the AMA was told by the government in 1993 to create codes for non-MDs, the organization has not applied themselves to the task. Truthfully, it�s like asking the fox to be fair to the chickens or asking Ford to create service and supply codes for Chrysler! Nurses have tried for decades to get codes through participation on a coding panel with the AMA. Today, out of over 8,000 CPT codes for medical care, there are four CPT codes for chiropractors and acupuncturists, and massage therapists have one code.
In January 2003, Ms. Giannini convinced Tommy Thompson, the former Secretary of the Department of Health and Human Services (HHS), that there were critical gaps in HIPAA code sets. Thompson gave her the authority to begin working to close these gaps. For part two, click on 2 below.
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Dr. Carolyn Dean is a medical doctor, naturopathic doctor, herbalist, acupuncturist, nutritionist, as well as a powerful health activist fighting for health freedom as president of Friends of Freedom International. Dr. Dean is the author of over a dozen health books, the latest of which is "Death By Modern Medicine".
Elissa Meininger is vice president of Friends of Freedom International and co-founder of the Health Freedom Action Network, a grassroots citizens' political action group. She is also a health freedom political analyst and can be heard on the natural health radio show SuperHealth, broadcast weekly on station KEBC (Information Radio 1340) in Oklahoma City.
E-Mail: [email protected]
The mind boggling medical billing system of American health care is a complex coding system called Current Procedural Terminology (CPT codes) that was established in 1966 by the AMA. AMA owns most of these billing codes, which garner hefty annual licensing fees.