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Your Comments: CPT/ICD and the Fit of Naturopathic/Integrative Medicine - Drs. May and Milliman PDF Print E-mail
Written by John Weeks   
Saturday, 19 May 2007

Your Comments:  Do the CPT and ICD Codes Fit with Integrative/Naturopathic Practices - Drs. May and Milliman Play "Stump the Chump"

Summary: Can integrative medical practices be appropriately reflected and billed using the American Medical Association's CPT codes and the ICD diagnostic codes? Or is whole-person care bastardized by jamming it into that system? This Your Comments article is a very thoughtful exchange between two professionals with significant experience in 3rd party payment. Among the commentators is Bruce Milliman, ND, a member of an advisory panel to the AMA's CPT coding committee. Milliman asserts that a good deal of whole person practice can fit the CPT/ICD structure. He invited others to challenge him, saying "stump the chump."  Robert May, ND, who spent a good deal of the last decade as an executive working in complementary medicine managed care, decided to take Milliman up on the challenge. I sent May's comments to Milliman for his responses. Was he stumped?
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Image
... the color of coding is green ...
Something about data on income stirs significant dialogue. An Integrator report on a
salary survey of naturopathic physicians published by the Association of Accredited Naturopathic Medical Colleges did just that.

Among the commentarists was Bruce Milliman, ND, an adviser to the CPT coding committee of the American Medical Association. Milliman asserted in that commentary that a good deal of whole person, integrative practice can fit the CPT structure. He invited others to send in responses to challenge him, saying "stump the chump." 

Robert May, ND, who spent a good deal of the last decade working in complementary medicine managed care, decided to take Milliman up on the challenge. (May's earlier comments on the salary survey are available here.)  May sent the Integrator a thoughtful response on many payment-related issues. I then shipped May's comments over to Milliman for his responses. This article reflects this very thoughtful exchange between these two experienced leaders.  Have you got any responses of your own?



Milliman:
(from his prior comments)   ...
I know, in fact, of very few things that naturopathic physicians do, that are not code-able (go on, take me up on the challenge, and let's play 'stump the chump'). The problem, also shared with our MD counterparts, is that the reimbursement is often not adequate (witness CMS fee schedules).

Image
Robert May, ND - challenging the fit
May:
The short answer to the stump the chump challenge posed in your last issue is 'colonics.' 

Milliman: There is a mechanism for introducing new codes into Current Procedural Terminology (CPT), a significant component of which requires demonstrating consensus within the specialty society or the profession advancing the code change proposal via the CPT Editorial Panel process.  If our profession has the will, the vision and the energy, I suggest that a code proposal for colonic irrigation be initiated by interested proponents. It is my charge to facilitate such proposals arising from within our profession and it would be my very great pleasure to do so with this or any other code proposal for as long as I have the honor of occupying the position. 

Having said that, not all services provided by health care professionals, whatever their degree, are insurance reimbursable. Many codes are proposed, and most are (reimburseable). Except in the case of obstipation/stool impaction, colonic irrigation as a reimbursable procedure (as opposed to enhancing normal bowel function through diet and lifestyle) is currently considered to be an elective procedure, similar to cosmetic Botox injections, chelation therapy, many surgeries and other interventions.  Elective procedures are rarely reimbursable, whether they have codes or not. That being said, it may well be that we as a profession will choose to udertake an exploration of the appropriateness of the descriptor 'elective' when applying it to this or other procedures traditionally employed by our profession.


Image
Bruce Milliman, ND: sleeping with his ICD-9
May: 
Even through the CPT system, the process seems like it would be very slow - while the effects on the naturopathic profession are occurring much more rapidly. However, there are other significant aspects of naturopathic medicine that are not supported by the CPT system either, and are likely put at risk by the current integration process that requires CPT codes. There are costs involved in using the CPT system, and it is important the naturopathic community actively engage questions about risks inherent in unquestioned compliance with mainstream definitions of care and their link to reimbursement.
Milliman:  I concur that is desirable that the naturopathic community discuss issues relating to participation in third party reimbursement, as well as providing access to as many people needing our care as possible. CPT is not, however, cast in stone and as the very title implies, it is constantly being edited.  If the system does not meet needs, let’s propose some edits to make it work better.  I would submit that to simply opt out is clearly to the detriment of our ability to our fulfill our ‘prime directive’:  Caring for the patients we serve..
May: As Dr. Milliman notes, it is quite possible for NDs to function within the CPT system. However, the system is clearly not tailored to naturopathic practice and it requires compromise, if not contortions, to work within it. Over time, the net effect of the CPT system, and the larger process of integration as it is currently occurring, is a reduction in depth and scope of naturopathic practice. Below are significant aspects of traditional naturopathic medicine that i believe are not supported by the CPT system.

    
 

May's View:
Practice Areas
not Supported
by the CPT System


Traditional Procedures

Wellness

Constitutional Perspectives

Education

Lifestyle management
& dietary counsel

Stress management


Current Procedural Terminology, the CPT system developed by the American Medical Association, reflects the prevailing paradigm of modern Western medicine - allopathic, disease-oriented, acute care – and defines provider / patient interactions and procedures. Third party payers require use of these codes for reimbursement. Office visits and procedures not recognized in the CPT system are not eligible for reimbursement. As a result, the system exerts a very strong influence on the nature and range of care, particularly so in states like Washington where insurance coverage of naturopathic medicine is more widespread.

Below are some additional examples of where traditional naturopathic practice is not supported, and is likely put at risk, by the CPT system:

Traditional Procedures – Numerous traditional naturopathic practices have no place in the CPT system.  For example: naturopathic manipulation is not included, nor are physical medicine treatments used for non-musculoskeletal conditions. Other traditional practices such as constitutional hydrotherapy, iridology, and (again) colonic irrigation are not recognized at all. 
Milliman: For those interventions that should, in the considered judgment of our profession, be but are not currently codeable, the mechanism exists to propose an edit to the code set. See the above comment. These traditional procedures may be equally or even more meritorious of the discussion regarding the distinction between ‘elective’ and ‘necessary‘ or better yet, ‘indicated.’ After all, how many currently coded procedures, already approved for reimbursement are, in the opinion of many experts, not only not indicated or not necessary, but may actually be harmful?
May: (continuing with his list of traditional naturopathic practice):

Wellness As mentioned above, mainstream health care and reimbursement is based upon an acute care, disease-based model.  It does not recognize, nor have any resources for describing states of wellness and the strategies (CPT coded procedures) to assess other than ‘within normal limits’ or no acute signs of distress.  Assessing and promoting vitality is not recognized because it is not a disease state, and it is certainly not recognized for reimbursement.  The most vital aspect of the naturopathic principles:  the vis medicatrix naturae, or healing power of nature has no place in the predominant system, and as a result, procedures addressing this are not acknowledged nor paid for.

Constitutional Perspectives – Naturopathic physicians routinely assess, discuss, refer to, and attempt to support an individual’s constitution:  the aggregate expression of vital energy and its potential for health and disease.  This is seen most clearly in homeopathic case taking, an office encounter with no CPT recognition.  Constitutional medicine is by definition multi-factorial and usually takes more time and is not always tied to the direct management of discrete pathologies, a requirement of CPT coding and billing.

Education  A primary tenet of naturopathic medicine is that the physician is also a teacher; that primary care is empowerment to the patient; and primary prevention a positive action – not just avoidance, cessation, or early detection.  All of these are achieved through education and are not necessarily tied to specific diagnoses. The current system does not recognize education from this naturopathic perspective, and only views education in a disease management capacity.


Lifestyle Management and Dietary Counsel  This area is a primary specialty of naturopathic medicine.  Allopathic perspectives have begun to recognize this for select conditions, but not with the same primacy and in the same global fashion that NDs employ in nearly all patient encounters.  In most health plan benefit designs, lifestyle and dietary counsel are usually severely limited and relate only to management of specific pathologies, such as diabetes and heart disease, or to cessation of high-risk behaviors such as smoking.


 
Milliman:

"I have endured the
unjustifiable chides and
prods by my colleagues
for sleeping with a copy
of the International
Classification of Diseases,
9th Revision (ICD-9) on
my bed stand long enough.

"Now I am going to
speak out!"


 
Stress Management – A subcategory of lifestyle counseling, stress management fall squarely within the philosophy and practice of naturopathic medicine.  However, because there are little if any recognition of clinical procedures addressing this, or diagnostic categories to define it, practitioners are not paid for directly addressing stress-related conditions.  This limits patients to disease-only care, or pushes providers to “creative / contorted” coding and billing practices.
Milliman:  Taking the previous five points as a whole, the resolution for all of them falls under the caveat provided and previously cited and excerpted (from the ‘green pages’ section in the front of the CPT book, entitled Evaluation and Management (E/M) Services Guidelines):  “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting…), then time (CPT’s emphasis) may be considered the key or controlling factor to qualify for a particular level of E/M services…The extent of counseling and/or coordination of care must be documented in the medical record.”
May: (continuing) In fact, the CPT/ICD pairing is an additional challenge top traditional naturopathic practice. Diagnostic (ICD-9) codes are closely tied to CPT codes, as they are required on all third party claim forms.  These codes also reflect the predominant allopathic perspective on disease.  Many conditions described or recognized by traditional naturopathic medicine, and other alternative systems of healing, are not included – and not recognized as viable descriptors of states of human health or illness. Examples here include traditional naturopathic assessments such as liver congestion.  
Milliman: Oops, you hit my Achilles heel there, Dr. May! I have endured the unjustifiable chides and prods by my colleagues for sleeping with a copy of the International Classification of Diseases, 9th Revision (ICD-9) on my bed stand long enough, and now I am going to speak out!  For “liver congestion” (which you will find listed under 'Congestion, liver'…in fact all of the disorders mentioned may be directly accessed under the even still recognized, albeit antiquated, terms herein employed) try 573.0;  for 'adrenal insufficiency' try 254.4 and/or 255.5);  for 'systemic Candida infection' try 112.0, 112.1, 112.2, 112.3, 112.4, 112.5, 112.81, 112.82, 112.83, 112.84, my personal favorite 112.85, 112.89 or if none of those work there is always 112.9;  for 'food sensitivities'  try 693.1, 691.8 or 692.5;  for any 'assessments related to energy states' (qi) try what is for many clinicians a personal favorite, and the bane of all third party payers: 780.79 (mind/body dysfunction).
 
Milliman's

 
ICD-9 Guide

    
Sample
Condition

 Sample
Codes

 
Congestion,
liver
573.0 
  Adrenal
insufficiency
254.4,
255.5 
  Systemic
Candida
infection
112,0,
112,1,
112.2,
112.3
  Food
sensitivities
693.1,
691.8,
692.5
  Asessments
related to
energy states
780.79 
 

 
Really, these are too numerous to go into here, but I think my point has been made:  For example the final example to follow, 'neurasthenia' is, as are all of the other cited examples, specifically coded in exactly the language used by Dr. May), or assessments such as neurasthenia (try 300.5) and other historic terms.

I am not just ‘nit-picking‘ here and obviously wanted to demonstrate that primary source verification is sometimes lacking in our discussions, and this is precisely my point in dialoging with Dr. May through his commentary.   I feel that many of us fall into this trap and unfortunately may simply ‘throw the baby out with the bathwater’ and wind up not talking about our deeper issues.
May: (then acknowledges various benefits from integration) Naturopathic physicians are required to use CPT codes in order to participate in third party reimbursement, and this increases access to care for patients who otherwise couldn’t afford to pay out of pocket, or who wouldn’t otherwise consider seeing an ND. This is an important goal and clearly supported by inclusion in benefit plans and third party reimbursement.

Other benefits of integration for naturopathic/CAM practice include higher standards for documentation and professional communication, greater emphasis on physical exam and provider accountability and efficiency.  Care management strategies do protect patients, save money and increase the quality of care in many instances.  However, these benefits alone are not sufficient to justify the potential unexamined loss of traditional approaches to care. To date, the process of integration has been very one-sided – far more assimilation than mutual sharing, and over time this has the potential to depreciate, if not eliminate, essential attributes of naturopathic medicine, and other CAM professions, as well.


 
May:

"As the number of insured
patients increases, pressure
will increase for NDs to limit
their services to those defined
by CPT.

"Over time this will very likely
decrease the scope of
naturopathic therapeutics –
a potentially ironic result in
light of current efforts in
Washington to expand
pharmaceutical prescription
rights."

 
While more people may have access to services, the care they receive will be limited to what is recognized and reimbursable – defined by a system that is unsympathetic to, if not inimical to, the essence of traditions being integrated.  As the number of insured patients increases, pressure will increase for NDs to limit their services to those defined by CPT. Over time this will very likely decrease the scope of naturopathic therapeutics – a potentially ironic result in light of current efforts in Washington to expand pharmaceutical prescription rights.
Milliman:  This is an interesting hypothesis, and is meritorious of an open forum discussion within our profession.  I see it as the difference between ‘could’ (after all, it happened to the Osteopaths, didn’t it?) and ‘must’ (yes, Little Bear, you can control your own destiny if you truly believe and really, really want to, and never give up!)

May: (turning to what he calls "a suggestion for discussion") It is important for NDs to consider letting go of the assumption that insurance coverage can, or should, cover all aspects of naturopathic, or any type of alternative care.  If the naturopathic profession can define, affirm and protect its essential identity, it will help individual practitioners function within CPT as much as possible, while being creatively independent for services that are not.
Milliman:  Totally!
May: Is it possible that NDs could view insurance benefits as an introduction for patients to naturopathic practice, not carte blanche entitlement to everything the profession offers?  Could an ND work within the limitations of CPT definitions, and inform the patient that traditional naturopathic care goes well beyond that – even if at this time it is not covered by insurance.  Admittedly, this would require a heroic shift in thinking, for providers and patients, but it places priority on the strength and depth of naturopathic medicine and protects the soul of the profession while also fitting into the current system of third party reimbursement. 

Integration has potential, but it not without significant dangers, not unlike a powerful medication - with the potential for side effects – far more dangerous when unquestioned.
Let’s talk about this. 
Milliman:  In the end, I believe Dr. May and I are essentially in agreement, and I fully support and advocate for an open forum, perhaps to include other ‘broad scope’ jurisdictions such as Oregon and Arizona.  Such a forum could discuss and create ‘best practices’, utilizing our Principles and the use of lesser levels of intervention, where safe, effective and cost effective, first. It is important to note that ‘best practices’ are not guidelines which restrict practice, but rather are an articulation of multiple effective pathways with suggestions for differential decision making algorithms. The State associations and specialty societies should lead in this effort and the sooner the better. Insurers are already developing their own guidelines, and if we don’t have consensus-based best practices as a counterpoint, our worst nightmares (dictation by the insurers as to what we must do in given clinical situations) could become reality.

May: (who was given a final review of Milliman's comments and a chance to add some comments of his own)
I have to take issue with Dr. Milliman's suggestion that so many of the critiques can be dealt with via the counseling provision of CPT office visit codes. CPT codes require a diagnosis of a disease state, and some of the categories I mentioned are not recognized as disease either in diagnostic coding, in benefit design, or general allopathic medicine.

While I appreciate Dr. Milliman's ability to use the ICD-9 diagnostic codes in practice, I don't feel that what naturopathic medicine has traditionally referred to is the same as the conditions described in the ICD-9 system. This is where NDs must at times be contortionists to use the ICD/9 system. Is it possible to use the ICD/9 system? Clearly, to a certain degree it is, as Dr. Milliman demonstrates. But I doubt that the authors of the ICD/9 system would agree that what naturopathic physicians mean by liver congestion or systemic candida infection or adrenal insufficiency are identical to the allopathic conditions referenced in the coding above. (And I admit my oversight: neurasthenia is referenced in the ICD/9 system. However, as a mental health code it would be ineligible for naturopathic reimbursement by most payers due to limited benefit definitions of who can treat mental illness.)


Overall, naturopathic medicine, and other CAM professions, need to become more aware of the shortcomings of the CPT and ICD/9 systems. Not to reject the system overall, but to understand its limitations and more rigorously defend essential elements of our traditions that are not recognized by the mainstream allopathic system.

The practices of many NDs have already changed due to requirements of the prevailing reimbursement and coding system, and not necessarily for the better. It will be to the detriment of our professionto underestimate the potential changes that this aspect of integration could have. Hopefully, this dialogue will prompt input from others and an ongoing discussion of this important subject.

Comment:  I thank both May and Milliman for their time in presenting their perspectives. The dialogue is extremely important. The recent Integrator article on the movement of chiropractic away from broad scope practice, partly under pressures of what insurance would cover, underscores points made in prior Integrator articles by Tino Villani, DC about how practice tends to conform to payment patterns, regardless of what is in the best interest of the patient. 

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Last Updated ( Tuesday, 22 May 2007 )
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