ABC Coding Solutions - Alternative Link

Please note that the information contained in this article concerning alternative medicine treatments and their underlying principles and theories is provided for educational purposes only. It does not represent a position of either AHIMA or the author regarding the efficacy or scientific validity of these treatments.

This article is second in a two-part series. See "Coding Notes" in April for an introduction to and a look at other alternative therapies.

Chiropractic Medicine
The characteristic that distinguishes chiropractic medicine from other forms of holistic healthcare is the emphasis on spinal adjustment, which is a unique form of spinal manipulation. The basic concepts of chiropractic medicine include the belief that deviations of structural mechanics, especially of the spine, cause perturbations of the nervous system. Disease is believed to be a result of minor perturbations of pathways within the nervous system. Chiropractors do not believe that the site of the symptom is the site of its cause. Rather, the source of the pain should be sought somewhere along the path of the nerves leading to and from the site of the symptoms. It is thought that deviations in structural mechanics (subluxations) of the spine irritate the nervous system and are the cause of various illnesses.

The chiropractic spinal adjustment is believed to be a physiological support mechanism that can correct subluxations and restore health. In addition to the spinal adjustment, chiropractic patient management can also include mobilization of the spine, physical therapy, and rehabilitative, nutritional, and psychological counseling.

Chiropractic medicine views the body as being far more than the sum of its parts. The chiropractic view of holistic medicine is based on the idea that the human body is an integral unit, and that as long as it maintains its integrity, it will remain healthy. While chiropractors are trained in state-of-the-art diagnostic techniques, and chiropractic examinations are remarkably similar to those conducted by conventional medical physicians, chiropractors evaluate the information gleaned from diagnostic tests and examinations from a perspective that recognizes the intricate structural and functional interplay between different parts of the body. The drug-free, noninvasive treatment strives to restore the whole person and not simply mask or reduce symptoms. Although it is inherently conservative in nature, chiropractic medicine recognizes the need for medical treatment in certain acute and emergency situations, but prefers natural remedies whenever possible.

Chiropractors are licensed healthcare practitioners.

Herbal Medicine
Herbalists use the leaves, flowers, stems, berries, and roots of plants to prevent, relieve, and treat illness. Although many herbal treatments are considered experimental from a scientific perspective, many conventional medications were originally derived from plants. Salicylic acid, a precursor of aspirin, was originally derived from willow bark and the meadowsweet plant. Vincristine, used to treat certain types of cancer, comes from periwinkle. Prior to the development of antibiotics, the herb echinacea (which comes from the purple coneflower) was commonly used to fight infection. This herb boosts the immune system by stimulating the production of disease-fighting white blood cells.

Relatively speaking, scientific research has been conducted on few of the existing herbs. Modern pharmacology is only interested in the active ingredient, so most research has focused on identifying and isolating active ingredients rather than studying the medicinal properties of the whole plant. Herbalists, however, believe that the power of a plant lies in the interaction of all of its ingredients.

The US Food and Drug Administration (FDA) does not regulate herbal products. They can be marketed only as dietary supplements because manufacturers and distributors cannot make any specific health claims without FDA approval. However, for the first time, the Physicians' Desk Reference recently published a volume detailing information about prescribing more than 600 herbal treatments. It includes the pharmacologic effects of each plant, documented indications, and a summary of other usages and applicable precautions, warnings, contraindications, adverse reactions, and overdose data.

Homeopathy
Homeopathy is a natural pharmaceutical science that uses various plants, minerals, or animals to produce substances that are given in very small doses to stimulate the immune system. Homeopathic theory is based on the observation that drugs given in excessive dosages sometimes reproduce or aggravate the very symptoms that they suppress when given in standard dosages. Based on this observation, homeopathic proponents believe that medicinal substances administered in minute quantities trigger a healing response and counter the symptoms that larger doses of the same substances can induce. The underlying principle for this matching process is known as the "law of similars." This law is also applied in conventional medicine. For example, allergy treatments involve the use of small doses of allergens in order to create an antibody response. Immunizations are also based on the law of similars.

Since homeopaths believe that one's symptoms represent the body's efforts to reestablish homeostasis or balance, they select a substance that would, in overdose, cause similar symptoms to those the patient is experiencing. The substances thus work with, rather than against, the body's own natural defense mechanisms. Methods that simply suppress, control, or manage symptoms should be avoided since such therapies compromise the innate tendency of the body to defend and heal itself.

Homeopaths first identify the specific physical, emotional, and mental symptoms that various substances cause in overdose. Second, homeopaths interview their patients at length in order to discover the totality of physical, emotional, and mental symptoms the person is experiencing. The homeopath seeks to find a substance that would cause similar symptoms and then gives it in small, specially prepared doses. It is thought that the smaller the dose, the more effective the substance would be stimulating the body's natural healing forces. In fact, standard homeopathic preparations contain plant, animal, or mineral substances in such minuscule concentrations that they cannot be detected by chemical analysis.

Homeopaths have found that patients treated for chronic diseases sometimes experience a temporary exacerbation of their symptoms as their bodies' defenses are stimulated by the homeopathic medications.

Homeopathy became popular in this country and Europe during the 1800s because of its success in treating the many infectious diseases prevalent during that time, including yellow fever, scarlet fever, and cholera. The death rate from these diseases was lower in homeopathic hospitals than in conventional hospitals.

Many homeopathic practitioners are conventionally trained medical doctors who have furthered their training with the study of homeopathy. Other homeopathic practitioners include dentists, podiatrists, psychologists, physician assistants, nurses, naturopaths, chiropractors, and veterinarians. There are also lay people who have studied homeopathy, but there are a number of legal issues surrounding their practice. Since homeopathic medicines are legally considered "drugs," many states require that anyone prescribing these medications is a physician or licensed to prescribe drugs.

Sales of homeopathic medicines in the US have grown at a rate of 25 to 50 percent per year.

Naturopathy
Naturopathy is a system that is concerned with the whole person, rather than just the illnesses the individual may have. The holistic principle of looking at the overall condition of health (or ill health) in the context of the individual's lifestyle, dietary pattern, stress levels, attitudes, beliefs, habits, relationships, environment, and social background is essentially naturopathic. Naturopathic practitioners believe in the existence of a healing force in nature that can be stimulated and directed by a proper diet and lifestyle. Naturopathy recognizes and uses the fact that the body is a self-healing organism, working with the knowledge that if the right environment and opportunity for self-healing can be created, repair, recovery, and good health will result.

Naturopathic practitioners believe that most forms of illness are self-limiting and that most disorders, such as open wounds, infections, indigestion, and emotional problems generally resolve on their own. The mechanisms by which these problems are resolved are known as "homeostasis." This is the self-balancing, self-repairing process that is achieved when the immune system is working efficiently. When these self-repair systems become overwhelmed or deficient, they may require assistance, and this is where treatment enters the picture.

The basic principles of naturopathy:

utilize the healing power of nature
first, do no harm
find the cause
treat the whole person
preventive medicine

From a naturopathic point of view, it is essential that treatment modalities encourage the self-healing mechanisms rather than dictate to them or force them into particular actions. Naturopaths believe that symptoms should not be the main focus of treatment. Rather, they should be recognized as being the expression of self-healing in action and should be allowed to run their course. For example, a fever is evidence of the body's defense mechanisms dealing with something out of the ordinary, such as an infection. Naturopathic care would be aimed at helping the immune system do its job efficiently. Initially, this care would include dietary modification and/or controlled fasting. Methods would also be used that would make life more comfortable while the body's internal processes are doing their job. For example, massage and osteopathic manipulative techniques can assist in the drainage of lymphatic fluid in order to help carry debris from the site of infection. Naturopathic practitioners may use a combination of manipulative therapies, which move soft tissue as well as bones. These therapies are similar to the techniques used by osteopaths, chiropractors, massage therapists, and physical therapists.

Hydrotherapy or acupuncture might be used to reduce discomfort and assist the self-healing functions of the body. Naturopathy encourages the self-healing potential through removal of obstacles to the self-healing process and treatment that assists this process.

Naturopathic methods include dietary modifications, controlled fasting, stress reduction, hydrotherapy, exercise, and lifestyle changes. Clinical nutrition is a cornerstone of naturopathic medicine. Naturopathic theory suggests that most illnesses are caused by digestive disturbances, which have led to a toxic environment in the body. As the body is overwhelmed by toxins it is unable to eliminate, the health of the body breaks down and symptoms surface. Nutritional changes are felt to be a key component of reversing the disease process.

Hydrotherapy improves digestive function by bringing additional blood (and all of its healing components) to the internal organs. The most common form of hydrotherapy is called the "constitutional," whereby two towels are dipped in hot water and placed on the front of the patient for five minutes. The hot towels are replaced with one cold towel for ten minutes. The same procedure is performed on the back of the patient. During the hot portion of the treatment, the upper blood vessels are dilated while the deeper ones constrict. The cold portion of the treatment constricts the outer blood vessels and dilates the inner ones. The combination forces more blood to both the inner and outer systems, allowing the body to bring more healing nutrients to its organs and to carry away toxins.

Naturopathic treatment may involve the use of herbs. Although herbs are the principal ingredients for some of the drugs used in conventional medicine, naturopathic practitioners use herbs in a different manner than conventional physicians. While many drugs prescribed by physicians are intended to impose an external order on the body (such as drugs that lower blood pressure but do not correct the cause of the high blood pressure), the naturopath's goal is to correct the underlying problem. In the case of a weakened heart, a naturopathic practitioner would use herbs that nourish and strengthen the heart.

Some naturopathic practitioners may perform minor procedures, such as circumcisions, wound repairs, fracture repairs, and removal of foreign bodies or cysts.

There are several accredited colleges that educate naturopathic practitioners. A number of states license them as primary care providers. Some insurance companies cover naturopathic care.

In 1983, the World Health Organization recommended the integration of naturopathic medicine into conventional healthcare systems.

Osteopathy
Osteopathy is a system of healthcare that recognizes that the self-healing, self-regulating ability of the body is dependent upon a number of factors, including favorable environmental conditions (internal and external), adequate nutrition, and normal structural integrity. Osteopathy also recognizes the importance of the musculoskeletal system, its proneness to dysfunction, and the repercussions of musculoskeletal dysfunctions. The basic premises of osteopathy include:

The human body is an integrated unit in which structure and function are reciprocally and mutually interdependent (there is no part of the body that is not interrelated with every other part, via the nervous system)
Through complex mechanisms and systems, the human body is self-regulating and self-healing in the face of challenges and diseases (homeostasis)
Optimum function of the body's systems is dependent on the unimpeded flow of blood and nerve impulses
The musculoskeletal system comprises a major system of the body and its importance goes far beyond that of providing a supportive framework
There are components of disease within the structure of the musculoskeletal system that are not only the manifestations of disease processes, but are frequently important contributory factors in disease processes. These may be close to or distant from the disease processes and are usually amenable to appropriate treatment

Osteopathy is patient oriented rather than disease oriented. It utilizes structural diagnosis and manipulative therapy as part of its philosophy and practice and therefore as part of total patient care. Osteopathic manipulation is the means by which areas of dysfunction are diagnosed, appraised, and treated. Even when such treatment is aimed at relieving symptoms such as a backache or stiff neck, the result is to normalize the physiological functions by reducing spinal dysfunction. Osteopathic manipulative therapy attempts to restore function to areas of the musculoskeletal system that are responding to increased or abnormal stimulation and are modifying nerve impulses from and to the various body structures and organs.

Osteopathic manipulative therapy may also be used to restore physiological motion to areas in which there is restriction or dysfunction. By restoring or improving function in the musculoskeletal system, it is anticipated that all connected parts will benefit, whether these are other parts of the musculoskeletal system or areas influenced via nerve or circulatory pathways. Osteopathic manipulative therapy is not aimed at specific disease processes, but rather at normalizing the musculoskeletal structures with a view to benefiting overall function and thereby maximizing the body's homeostatic, self-regulating, and healing activities. There are a variety of osteopathic manipulative methods, which can be classified into three groups:

Soft Tissue Techniques
Soft tissue techniques may involve stretching movements across or along the lines of the muscular fibers and deep pressure techniques, as well as stretching and separation of muscle and other soft tissue fibers, especially where muscles originate or insert into bony structures. Soft tissue techniques often involve working on fascia or connective tissues. They usually precede manipulation of the bony structures, but can frequently achieve mobilization and normalization of joint structures on their own. This can result from the improvement of rigid or tense tissues, allowing a previously restricted joint to achieve free range of motion. Soft tissue techniques may be used diagnostically as well as therapeutically.

Direct Techniques
In direct techniques, the osteopathic physician attempts to overcome limitations to normal movement by taking the joint involved towards, or through, the restrictive barrier that is preventing normal motion. This might involve thrust techniques in which a high-velocity, low-amplitude thrusting movement forces the bony articulation to move.

Indirect Techniques
Indirect techniques do the opposite of attempting to overcome resistance. For example, the part in question might be moved away from the planes of restricted motion towards the planes of easier, unrestricted motion. There is a constant search for the position of greatest ease, and the osteopathic physician introduces a mild degree of strain. This results in a reflex release of previously restricted tissues. The essence of this technique is the introduction of the mild strain while the joint is held in a position opposite to the direction in which there is a limitation of movement.

Combinations of direct and indirect techniques, sometimes preceded or followed by soft tissue methods, are often employed.

Most patients consulting osteopathic physicians do so in hopes of obtaining relief from musculoskeletal aches and pains. However, a growing number of patients are consulting osteopathic physicians about a wider range of health problems, including migraine headaches, tinnitus, dizziness, asthma, functional cardiac problems, digestive problems, and menstrual irregularities.

Osteopathic and chiropractic medicine grew out of similar roots, but they have evolved to the point that their similarities are mainly seen in the areas of pain and dysfunction of the back and neck. Their differences become more apparent when considering general healthcare. Except for additional emphasis on musculoskeletal diagnosis and treatment, the scope of osteopathy is essentially that of medicine.

Osteopathic physicians are licensed healthcare practitioners. There are approximately 19 accredited colleges of osteopathic medicine. Osteopathic physicians are permitted to obtain residency training at medical hospitals.

Coding for Alternative Medicine
Most of you are probably aware that codes exist in CPT and ICD-9-CM for some types of alternative medicine treatments. For example, CPT codes 97780-97781 describe acupuncture treatments, codes 90875-90876 and 90901-90911 describe biofeedback training, codes 98925-98929 describe osteopathic manipulative treatment, and codes 98940-98943 describe chiropractic manipulative treatment. In ICD-9-CM, codes 99.91-99.92 describe acupuncture, code 93.35 includes acupuncture with smouldering moxa, code 94.39 includes biofeedback in psychotherapy, and codes 93.61-93.67 describe osteopathic manipulative treatments.

But how many of you are aware that a coding system has been developed exclusively for alternative medicine? The national alternative medicine codes were developed by Alternative Link, a privately held company that develops software to support alternative healthcare billing, reimbursement, and office management functions.

Development of a coding system for alternative medicine began in 1996 and the main objective was to produce a system that would compatibly interact with mainstream medical billing systems and would facilitate third-party reimbursement decisions for selected forms of alternative medicine. Alternative Link holds the copyright for this coding system, which contains more than 4000 codes that describe what is said, done, ordered, prescribed, or distributed by providers of alternative medicine. Disciplines covered by this system include acupuncture, holistic medicine, massage therapy, homeopathy, naturopathy, ayurvedic medicine, chiropractors, and midwifery. The Nursing Intervention Classification (NIC) codes have also been incorporated into this coding system. The system was designed to give managed care organizations a tool to negotiate practitioner services in any state.

The codes, known as ABC codes, are intended for use by all health plans, healthcare clearinghouses, and healthcare providers for processing all electronic transactions that require a code for an alternative medicine procedure, service, supply, etc. The coding system software facilitates linkage between providers, clearinghouses, and payers because it is fully ASC X12N compliant and incorporates an EDI-based architecture. A relative value unit was added to each code to allow fee capitation in any location. This information is built into CAM-Net� products, which are distributed as:

an interactive database that supports managed care organizations wishing to build contracts with alternative providers
ASCII flat files for automated payer decision support
published resource materials for desk reference
lease agreements with clearinghouses for electronic claims routing

The codes have been incorporated into the National Library of Medicine's Unified Medical Language System.

Figure 1 -- ABC Code