- Most people have no idea that there is a healthcare codes
monopoly and don't even know what it means. It's time we did.
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- Billing Codes
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- The billing system of American healthcare is based on
a complex coding system called Current Procedural Terminology (CPT codes).
Established in 1966 by the American Medical Association (AMA), the codes
garner the AMA hefty annual licensing fees. Each time a CPT code is used,
the AMA gets paid.
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- There has never been a law against including codes to
cover all healthcare practitioners but the AMA has developed very few codes
for non-medical practitioners. This keeps other practitioners from becoming
equal business partners in the world of insurance reimbursement for services
rendered.
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- CPT codes are designed to document what a medical doctor
does for a patient. 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 healthcare,
without a code there is no way to calculate appropriate payment and no
itemization of what has transpired. It's that simple.
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- The current coding systems cover only a fraction of what
is happening in healthcare-coded interventions are the only transactions
that are tracked, marketed, and reimbursed. This is why so little is known
about what transpires in the marketplace with regard to healthcare practitioners
who are paid cash.
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- Without codes for all types of healthcare practitioners
we can't document the effectiveness of their care or the potential money
that is saved by including them in insurance reimbursement. 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.
For example, healthcare trends are tracked by data obtained from insurance
companies. Since insurance companies can't measure data they don't have,
they have no way of knowing, for example, that patients who see midwives
have a much lower rate of cesarean section, about 10-15%, compared to patients
who are delivered by obstetricians with over twice the rate of about
30%.
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- Lack of relevant data is also why we can only depend
on small samples and surveys to tell us what forms of natural healing arts
people are using because we have no other way of gathering the data.
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- It's Getting Worse, Not Better
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- There used to be state codes (HCPCS III) that individual
states created to meet their needs. The state codes were abolished in 2003,
costing many states' Medicaid programs millions of dollars.
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- Square Pegs in Round Holes
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- Being required to fit everything a practitioner does
into an allopathic/medical code leads to a high degree of inexactness.
Because CPT codes include very few non-medical modalities, many doctors
must limit their practice to allopathic medicine-so they can get paid by
insurance, which, in turn, limits the type of care available to the public.
Practitioners who use non-allopathic modalities have to fit their care
into a CPT code-square pegs into round holes. For example, all states allow
nurse practitioners to bill directly for their care, but they lack appropriate
codes. So, while insurance companies may direct them to bill using CPT
codes, the American Nurses Association has determined that CPT codes do
not describe or document that the care is from a nurse. ABC codes solve
this problem, for all practitioners by giving each practitioner their own
set of codes.
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- State of Exclusion
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- Due to discrepancies in state "scope of practice
laws", insurance companies don't know the scope of practice for each
type of practitioner in each state, and because of potential legal liabilities,
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.
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- This graph shows practitioners left out by the medical
monopoly in coding:
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- ABC Codes
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- Knowing the limitations of the CPT codes, a unique company
called ABC Coding Solutions developed "ABC Codes" that describe
services, remedies, and equipment items used by all healthcare practitioners,
not just medical doctors. And, they include codes for most aspects of alternative
medicine as well including homeopathic remedies.
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- Ms. Giannini, the CEO of ABC Coding Solutions knew the
healthcare system was unhealthy. But it wasn't until she experienced a
chronic illness that she became a victim of it herself. She struggled with
her illness for two years, going to medical doctors who billed her insurance
company a total of $15,000 -all legally coded and absolutely ineffective.
After none of the medical treatments worked, it only took a few visits
and with a doctor who provided care that was not in the CPT codes, and
$500 in out of pocket expenses, to get her well.
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- Ms. Giannini found it incredible that an insurance company
would gladly pay $15,000 for treatments that didn't work and refuse to
pay $500 for treatments that did. The doctor that helped her get well is
one of millions of practitioners forced to operate outside the "system",
which also forces millions of patients like Ms. Giannini outside as well.
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- Playing Monopoly
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- The AMA was told by the federal government in 1993 to
create codes for non-MDs, but they haven't complied. It's like asking Ford
to create service and supply codes for Chrysler! Nobody is going to willingly
stop something that works in their favor. Nurses have tried for decades
to get nursing codes by participating on a coding panel with the AMA without
much luck. And, as of 2006, out of over 8,000 CPT codes for medical care,
there are only four CPT codes for chiropractors and acupuncturists, and
massage therapists have one code.
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- Cut the Bureaucracy
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- ABC Coding Solutions keeps current on the legal scope
of practice of all practitioners in all 50 states and ABC codes legally
reflect the practices of more than 3 million underserved healthcare practitioners.
But they are not meant to supercede the current codes; when used together
with CPT and government codes, ABC codes support a complete, accurate,
and precise documentation of patient encounters and a common language for
comparing the economic and health outcomes of competing approaches to care.
The fact that ABC Coding Solutions can determine if a code is legal or
not saves billions in administrative costs spent haggling over inappropriate
codes.
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- ABC Coding Solutions estimates that using ABC codes will
save more than $51 billion per year in U.S. healthcare costs when implemented
across the healthcare industry.
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- Using the example of the Medicaid Behavioral Health Department
in Alaska, by using ABC codes in place of state codes that were retired
in 2003, this department saved $2 million in one year. This department
has thus far used ABC codes to process more than 500,000 health claim and
payment transactions. A Medicare Advantage plan in New Mexico has paid
claims on ABC codes for over five years with similar outstanding results.
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- Having ABC codes will not change healthcare overnight-but
ABC codes are a big step in the right direction. Unlike technologies that
cost millions and take years to return a profit, ABC codes are a turn-key
operation and begin saving everyone money immediately.
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- With ABC codes, insurance companies, government and the
public will have information to make informed decisions on healthcare spending
and reimbursement.
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- Consumer Directed Healthcare (CDHC)
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- CDHC and Health Savings Accounts (HSAs) are an attempt
to "solve" the problem of rising healthcare costs. They raise
consumer awareness about the real costs of healthcare and help people make
better decisions about how to spend their healthcare dollars. However,
they are currently set up using only the medical model of care and AMA
CPT codes. They do not currently address the demands of millions of people
who want alternate options to prescription drugs and surgery.
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- ABC codes, however, allow all practitioners to effectively
document their care and thereby potentially participate in insurance reimbursement
and HSAs. Thus ABC codes will help maximize the benefits of HSAs by providing
consumer access to a wider variety of caregivers.
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- What You Can Do
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- ABC codes have been in use since 2003. However, ABC codes
need to leap over one more hurdle. They need to be named a permanent government
standard so that insurance reimbursement will be also become standard for
all types of health care.
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- ABC codes are authorized for use through October of 2006.
We have until then to lobby our elected officials to have ABC codes made
a government standard. Please visit <http://www.ABCcodes.com>www.ABCcodes.com
for information on how you can urge your elected officials to break the
healthcare codes monopoly. From there you can send your elected officials
an email urging them to support naming ABC codes a permanent government
code-set. You may also contact <http://abccodes.com>http://abccodes.com
ABC Coding Solutions at 1-877-621-5465.
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- We don't need more caregivers in America, instead we
need to rethink coding. Coding is creating an artificial bottleneck for
direct consumer access to quality healthcare. Consumers are demanding choice
in healthcare. You can help create choice by demanding that ABC codes are
available to document the care that consumers are already using.
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- Carolyn Dean M.D., N.D. is a medical doctor, naturopathic
physician, researcher, educator, and wellness consultant. She has written
eleven highly-acclaimed books, the most widely read is The Miracle of Magnesium
along with her most recent, The Yeast Connection and Women's Health, IBS
for DUMMIES, and Hormone Balance: A Woman's Guide to Restoring Health and
Vitality. Dr. Dean disseminates the message of health and self-responsibility
in both private Wellness Telephone Consultations and at public seminars.
You can find her at <http://www.drcarolyndean.com>http://www.drcarolyndean.com
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- Originally Published in Total Health for Longevity,
June 2006
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