delivering integrative healthcare under consumer-driven

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: Mail@AlternativeLink.com

Web Site: www.AlternativeLink.com

Implications & ImperativesImplications & ImperativesImproved Access, Quality & Cost-ManagementImproved Access, Quality & Cost-Management