AMA Ownership of the CPT Codes: Perspective from Executives at ABC Codes, the "Alternative Link"
Written by John Weeks
AMA Ownership of the CPT Codes: Perspective from Executives at ABC Codes, the "Alternative Link"
Summary: For those in the integrative practice movement for over a decade, the subject of coding cannot be considered without the thought of a new Mexico-based business originally known as Alternative Link, and its founder Melinna Giannini. This business declared early that understanding the value of these therapies and fields would require a coding set that appropriately reflected them. In a long and exacting labor, the firm developed the ABC Codes, morphed into ABC Coding Solutions and developing products for not just "CAM" but for nursing (where many also chaff at the CPT) and Dubai Healthcare City. I contacted Giannini for comment and an update. Here is the column she co-authored with Mathias Kaesebier, the firm's executive vice president. At risk with current CPT coding, they argue, are health reform initiatives relative to non-discrimination and comparative effectiveness research.
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Would their coding set better position integrative medicine in reform?
The exploration of the double whammy of ownership of Current Procedural Technology (CPT) codes by one guild, the American Medical Association (AMA), and the roughly $70-million royalty the guild receives, led me to think of Melinna Giannini. In the late 1990s, Giannini and her associates at Alternative Link began development of an alternative coding set known as ABC Codes to better capture outcomes in complementary and alternative healthcare, integrative and nursing practices. I told Giannini that the Integrator would be very interested in a response or update, in the light of the AMA CPT discussion. Giannini and Alternative Link's executive vice president Mathias Kaesebier, a former CEO of the US division of Heel Inc, responded with this column.
_______________________________
Significant Coding Issues in Key Health Reform Initiatives Relative to Integrative Medicine
"Thank you for inviting us to comment on the
Integrator's article and blog concerning medical coding and the
affect this has on millions of health professionals.
"First of all, we commend you for bringing this topic up
at critical time in the healthcare
industry. Procedure codes and who controls them will affect the future
of all health professions in the U.S. We believe that ABC codes
can level the playing field.
"The role Integrative Medicine will play in the future will be impacted by two
new healthcare reform measures that also
relate to coding. These are:
1. The
non-discrimination clause in Section 2706 of the Patient's Rights and Affordable Health Care Reform
Act (the Act) states:
"A group health plan and
a health insurance issuer offering group or individual
health insurance coverage shall not discriminate with respect to participation under the plan or coverage against
any health care provider who is acting
within the scope of that provider's license or certification under applicable State law."
2. The
new law also focuses on identifying cost-effective options to existing medical care based on Comparative
Effectiveness Research.
Kaesabier: ABC's executive VP
"Here is why robust coding is essential to both measures:
1. Non-discrimination: The main difficulties in implementing
the non-discrimination clause are the variances
in state scope of practice laws and
the lack of procedure codes for Integrative Medicine. Without a coding infrastructure, gaining payment for
services becomes cumbersome and expensive.
Integrative Medicine will remain cumbersome and expensive to
the insurance industry until such a
coding infrastructure is in place. The [insurance] industry
will most likely lobby against this non-discrimination provision until a solution is found. ABC codes are mapped to the medical codes required
for billing and were designed to validate scope of practice rules as insurance
claims are filed.s
2. Comparative Effectiveness
Research (CER) could potentially level the playing field for Integrative Medicine by
identifying cost-effective treatment options
to conventional medicine. Claims data will be used for CER to identify effective treatments in the
future because it is plentiful and
relatively inexpensive to mine. However, Integrative Medicine lacks
the robust metadata generated from codes
as insurance claims are filed. The data
that is available for Integrative Medicine can provide cost comparisons to conventional medicine cannot
indentify specific treatment patterns that work or don't work for a given diagnosis or diagnostic related group.
The mandated medical codes can be used for
this purpose.
"Global vs. U.S. Politics: When a
government does not limit use to the medical codes mandated in the U.S., ABC
codes have proven effective. For example, Dubai Healthcare
City tested ABC codes in 2008 and
subsequently mandated their use in claims filed by CAM and
osteopathic providers in 2009. In 2010, a Middle East insurance company
agreed to process claims based on ABC codes. For more information, go
to to this link.
"We believe transferring ownership of ABC codes to an
organization representing all health professions would provide
a counterweight to the medical monopoly on coding."
"In 2003, when ABC codes were granted an exception under
federal law to be tested in electronic healthcare claims, over 11,000 providers
registered to be potential users of ABC
codes. We believe transferring ownership of ABC codes to an
organization representing all health professions would provide
a counterweight to the medical monopoly on coding. We
believe that such an organization either exists or could be formed and
this organization could potentially buy or license ABC codes. Such an
arrangement could also generate revenue from publishing and licensing to
support Integrative Medicine. Transferring ownership of ABC codes to such
an organization would benefit the entire U.S. healthcare system by reducing the
cost of communications between providers and payers and identifying cost
effective options to current care models.
"We invite any interested party to contact us regarding this
proposal. Please email
"
Comment: The early debate over the ABC Codes versus the CPT broke over a worry over a kind of apartheid. Mightn't a separate coding set relegate "CAM" to a second class citizen status? The argument is reasonable, yet at the same time the case for an "alternative link" documentation system has never been stronger than it is today. Has subservience to the AMA's priorities allowed practitioners the ability to adequately document and make their case? How rational is it to leave such important decisions in the hand of a single guild, dedicated to limiting other professions, that has just 17% of MDs as members? Ludicrous.
Giannini and Kaesebier are right that coding will be a critical language of comparison under CER.
If what integrative practitioners do is not well-reflected in the codes used, we have garbage in, and garbage out. I like thinking about the ABC Codes being passed on to a set of interests who own them together, as the firm is willing to consider. Yet the idea that the AMA would allow anyone else to both break their monopoly and then benefit from a royalty for another set of codes is repelled by the history of power relations in US medicine. Unbelievable.
An ultimate code set will rightfully be a commons. Yet, in my feelers to organizations that might take on the challenge of prying the AMA's fingers loose, such a commons appears to have the same likelihood of creation as does heaven on earth.
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