Delivering Integrative Healthcare Delivering Integrative Healthcare Under Consumer-Driven Health Plans: Under Consumer-Driven Health Plans:
An ABC Coding Case StudyAn ABC Coding Case Study
6121 Indian School Road NE, Suite 131Albuquerque, NM 87110
Tel: 505-875-0001 Fax: 505-875-0002 www.alternativelink.com
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Delivering IHC Under CDH PlansDelivering IHC Under CDH PlansAn ABC Coding Case Study
Case Study Overview
Enabling Technologies & Outcomes
Implications & Imperatives
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Case Study Overview Case Study Overview Using ABC Codes to Improve Care, Claims &
OutcomesArdent / Lovelace Sandia / Bridgesdeployed the nation’s only system
for automatically processing insurance claims for integrative healthcare.
The system was designed to save more than 75% in claims management costs
for one of the fastest growing segments of care.
It was also designed to improve the economic & health outcomes of care
so more beneficiaries could get better care at a lower cost.
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Promote a unique brand image & attract healthier beneficiaries Appeal to wellness-oriented populations
Reduce administrative & medical costs in the senior plan Leverage information technology & focus on high cost
CAM-responsive diagnoses
Expand savings to other plans & enhance overall performance Apply best IHC / CDH practices
Case Study OverviewCase Study OverviewArdent / Lovelace Sandia / Bridges (Business Goals)
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Empower patients through education
Provide access to an integrative healthcare team
Promote open communication between patients & practitioners
Focus on restoring & maintaining total well being
Measure success, identify what works & replicate it
Case Study OverviewCase Study OverviewArdent / Lovelace Sandia / Bridges (Care Goals)
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Unbiased Measurement!
Ardent / Lovelace Sandia / Bridges (Data Goals)
Case Study OverviewCase Study Overview
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International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM )
AMA’s Physician’s Current Procedural Terminology (HCPCS Level I/CPT)
Healthcare Common Procedure Coding System (HCPCS Level II)
Code on Dental Procedures & Nomenclature (CDT)
National Drug Codes (NDC)
What Was Missing & Why Did It Matter?
Case Study OverviewCase Study OverviewCoding & the National Health Information Infrastructure
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40% - 69% of Americans use
integrative healthcare.
56% of Americans believe health
plans should cover integrative
healthcare.
>8 states have passed health freedom
legislation to support access to
integrative healthcare.
60% of physicians have made
integrative healthcare referrals.
50% of physicians will increase
usage of integrative healthcare.
70% of family physicians want
integrative healthcare training.
80% of medical students want
integrative healthcare training.
64% of medical schools offer
courses in integrative healthcare.
67% of HMOs offer integrative
healthcare of some kind.
Case Study OverviewCase Study OverviewCritical Insight: Growing Demand for IHC / CDH
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Acupuncture Allopathic Medicine Ayurvedic Medicine Body Work Botanical Medicine Chiropractic Clinical Nutrition Conventional Nursing Holistic Medicine Holistic Nursing
Homeopathic Medicine Indigenous Medicine Massage Therapy Mental Healthcare Midwifery Naturopathic Medicine Oriental Medicine Osteopathic Medicine Physical Medicine Somatic Re-education
Case Study OverviewCase Study OverviewCritical Insight: Shifting Consumer Demand
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629 million CAM office visits 1.4 billion CAM office visits
386 million PCP office visits 1.1 billion for MD/DO office visitsSource: http://www.medinfo.ufl.edu/cme/grounds/pauly/; Eisenberg,et al, JAMA,Nov11,1998, Vol 280, No 18;
HHS 1999/2000; Alternative Link 2004
Case Study OverviewCase Study OverviewCritical Insight: Growing Number of IHC / CDH
Encounters
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Advanced Practice & Registered Nurses
Alternative Medicine Practitioners
Conventional Physicians
Nutritionists& Dieticians
Pharmacists
Physical & Occupational
TherapistsMental & Behavioral Health Practitioners
Focus of Physician-Oriented HCPCS/CPT Codes
Focus of ABC Codes for Integrative Healthcare
Case Study OverviewCase Study OverviewCritical Insight: Growing Number of IHC
Practitioners
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New IHC / CDH data elements included...
ABC Codes
Think: “More Complete, Accurate & Precise Codes (Like UPCs)”
Practitioner Identifiers (Code Modifiers)
Think: “Qualifications of the Caregiver”
Relative Value Units (RVUs)
Think: “Resource-Driven Pricing Rationale”
Legal Practice Guidelines
Think: “Per Intervention, Per Practitioner & Per State Legality”
Enabling Technologies & Enabling Technologies &
Outcomes Outcomes Data Standards for Research, Management &
Commerce
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Example:
Coding hierarchy of ABC code BABAQ Erchonia Energy Balancer, each 30 minutes, Electrical or magnetictherapies, Physical modalities, Multi-specialty interventions.
B A B AQ
AQ - Erchonia Energy Balancer Treatment, each 30 mins.
B - Heading: Electrical or Magnetic Therapies
A - Subsection: Physical Modalities
B - Section: Multi specialty interventions
Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Modifier Major Practitioner Types
1A Doctor of Chiropractic1B Licensed Massage Therapist1C Doctor of Oriental Medicine 1D Registered Midwife1E Naturopathic Doctor or Physician1F Clinical Nurse Specialist1G Certified Nurse Midwife1H Nurse Practitioner1J Licensed Practical Nurse1K Registered Nurse1L Doctor of Osteopathy1M Medical Doctor1N Physician Assistant
Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Code Y/N RVU Code Description Expanded DefinitionNAAHK Y 5.2 Pressure ulcer prevention, Providing care and education to prevent pressure ulcers.
Common interventions,Interventions, Nursing
NAAGN Y 23.3 Pain management and Initial hour of alleviating or reducing pain to the comfort level of thecontrol, direct care, initial patient. For additional time, see code NAAGO.hour, Commoninterventions, Interventions,Nursing
CCBAC Y 3.0 Radius carpal, Closed The application of force by hand or device to osseous and/or connectivejoint adjustment, Chiropractic tissue structures of the radius carpel to restore normal anatomical and/orservices, Practice physiological structure and function. specialities
CCAAE Y 8.0 Spinal manipulation, initial The application of force by hand or device to osseous and/or connectivearea, Chiropractic tissue structures of the spine to restore normal anatomical and/ormanipulation, Chiropractic physiological structure and function. See code CCAAF for additionalservices, Practice areas.specialities
Legal?ABC Code
Financial ValueHierarchic Description Detailed Description of Intervention
Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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Financing Improved pricing Improved contracts Improved revenues
Administration Improved inter- & intra-organizational interactions Improved allocation of organizational resources Improved operating efficiencies Improved bottom line
Delivery Improved patient-practitioner & practitioner-practitioner relationships Improved understanding of optimal treatment pathways Improved outcomes, esp. for chronic conditions
Enabling Technologies & Enabling Technologies &
Outcomes Outcomes ABC Codes, Practitioner Identifiers, RVUs & Legal Practice
Guidelines
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ABC codes, practitioner identifiers, RVUs & legal practice guidelines create bottom line performance improvements by supporting...
electronic data collection (for research)
electronic data analysis (for management)
electronic data interchange (for commerce)
Implications & ImperativesImplications & ImperativesImproved Care, Claims & OutcomesImproved Care, Claims & Outcomes
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ABC Coding Manual for Integrative Healthcare
Practitioner Guides to Billable Interventions Using ABC Codes
Superbills for Integrative Healthcare
HealthIntel Database (Codes, Identifiers, RVUs & Legal Logic)
ABC / CPT / HCPCS II Crosswalk
Relative Values for Integrative Healthcare Using ABC Codes
CAM Market Report
Implications & ImperativesImplications & ImperativesImproved Care, Claims & OutcomesImproved Care, Claims & Outcomes
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Need for Management Tools to Improve Business Processes in Healthcare
Need for Need for Commerce Tools Commerce Tools to Support Industry Efficienciesto Support Industry Efficiencies
Need for Research Toolsto Identify the Most Cost-Effective Approaches to Care
ABC Codes
Need for Complete Standards to Support the National Health Information Infrastructure
Need to Resolve U.S. Healthcare Challenges: Access, Quality & Costs
Need for Need for Expanded StandardsExpanded Standardsto Support Consumer Demand for Integrative Healthcareto Support Consumer Demand for Integrative Healthcare
Implications & ImperativesImplications & ImperativesMore Complete, Accurate & Precise Data for the NHIIMore Complete, Accurate & Precise Data for the NHII
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Alternative Link delivers information products & consulting services
that help health-promoting organizations & individuals finance, administer & deliver cost-effective care
that improves individual & public health, business & industry efficiencies & socioeconomic development.
6121 Indian School Road NE, Suite 131Albuquerque, NM 87110 USA
Tel: 505-875-0001 Fax: 505-875-0002Email: [email protected]
Web Site: www.AlternativeLink.com
Implications & ImperativesImplications & ImperativesImproved Access, Quality & Cost-ManagementImproved Access, Quality & Cost-Management