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ACMA Publication April 1, 2006
ACMA Coding vs. CPT Coding
American Chinese Medicine Association (ACMA)
Introduction Many insurance companies requested the American Chinese Medicine Association (ACMA) to provide billing codes for the professional practice of Chinese Herbal Medicine (CHM) by doctors of Chinese Medicine (CMD). Because the CPT Coding has been used in Western Medicine (WM) for many years, some insurance companies asked for CPT codes for the CHM practices. However, WM and CHM are two completely different medicines. Due to these differences, the CPT coding is actually invalid to CHM. This article is to elucidate this issue in order to clear the confusion on the coding issue. Differences Between Chinese Herbal Medicine and Western Medicine The confusion on the coding issue originates from the fundamental differences between Chinese Herbal Medicine (CHM) and Western Medicine (WM). Generally speaking, Chinese Herbal Medicine and Western Medicine differ in the following areas [1, 2]: Systemic Differences Western Medicine Philosophical Foundation Differences Chinese Herbal Medicine was founded on fundamental Chinese philosophies, such as yin-yang theory, five-element theory, etc. These philosophies are an integral part of Chinese culture and history, and are quite different from Western Medicine’s philosophy. Therefore, the two medicines have been built on different philosophical foundations. Framework Differences The framework of Chinese Herbal Medicine is composed of various theories and methodologies, such as channel and collateral theory, zang xiang theory, Chinese medical etiological theory, Chinese medical pathogenetic theory, Chinese medical diagnostic methods, bian zheng lun zhi, etc. These are quite different from Western Medicine. Structural Differences In Western Medicine, the burden of designing protocols and procedures rests upon the Western Medicine's profession. Therefore, Western Medicine is a standardized medicine, with a standardized structure. In Chinese Herbal Medicine, the burden of designing protocols and procedures in practicing Chinese Herbal Medicine rests upon doctors of Chinese Medicine (CMD). Therefore, Chinese Herbal Medicine is an individualized medicine, with an individualized structure. Approach Differences Chinese Herbal Medicine employs a systematic approach in diagnosis and treatment. This is quite different from the analytical approach of Western Medicine. Principle The principle of the Chinese Herbal Medicine system is holistic, while the Western Medicine has an allopathic principle. Diagnostic Differences Chinese Herbal Medicine uses Chinese Medicine’s four diagnostic methods, which are quite different from Western Medicine’s diagnostic methods. Treatment Differences Chinese Herbal Medicine employs bian zheng lun zhi methodology, treatment principles, eight treatment methods etc, which are very different from Western Medicine. Fundamental Characteristics Differences The fundamental characteristics of Chinese Herbal Medicine are holism and bian zheng lun zhi, which are very different from Western Medicine too. Due to above differences between Chinese Herbal Medicine (CHM) and Western Medicine (WM), it is inappropriate to apply Western Medicine's CPT Coding to the CHM practices. CHM coding need to follow Chinese Herbal Medicine's characteristics. CPT Coding Invalidity in CHM Western Medicine (WM) is a standardized medicine. Because the WM treatment procedure is standardized, it is relatively stable. So it is possible to use CPT codes for each standardized procedure in WM. However, in contrast to WM, the Chinese Herbal Medicine (CHM) is an individualized medicine. Based on above differences between WM and CHM, it can be concluded that the CPT coding is invalid in CHM. 1. CPT Coding Invalidity for Different Patients in CHM In WM, different patients with the same diseases are treated with the same WM protocol and procedure. Therefore, it is possible to use the same CPT code to describe the same procedure for different patients in WM. In CHM, however, different patients with the same disease may be treated very differently based on their zheng differences [3]. This is because in CHM, disease is only one parameter. There exists another more important parameter -- zheng -- which determines the diagnoses and treatments in CHM. Due to the zheng parameter, there is no single herb, formula, or treatment procedure universal to all patients of the same disease. So in CHM, it is impossible to apply the same herb, formula, or CHM treatment procedure to all patients with the same disease. Mathematically speaking, the CHM treatment is not a constant but a function of patients. Therefore, the CPT coding, which is designed to be the same for different patients of the same disease, is invalid when applied to different patients of the same disease in CHM. 2. CPT Coding Invalidity for the Same Patient in CHM In WM treatments, one protocol and treatment can be applied to a patient for relatively long time. Therefore, the CPT coding for the procedure is relatively stable, and can be used to describe the procedure. In CHM, however, the same patient's CHM treatments should be adjusted and changed very frequently during the course of the patient's treatments based on the zheng changes [3]. There is no herb, formula, or treatment procedure that can be applied for relatively long time to a patient. So in CHM, it is impossible to apply the same CHM treatment procedure to the same patient for relatively long time. As a result, if use a CPT code for a CHM procedure, the CPT code will be unstable and challenged due to the frequent adjustment of CHM treatments. Mathematically speaking, the CHM treatment is not a constant but a function of time. Therefore, the CPT coding, which is designed to be applied to a patient for relatively long time, is invalid when applied to the same patient in CHM. 3. CPT Coding Invalidity for Patients at Different Locations in CHM In WM treatments, patients at different locations with the same disease are treated by the same protocol and procedure. So the CPT coding is stable with patients in different locations as long as the disease is the same. In CHM, however, patients with the same diseases may be treated very differently if they are located in different regions. This is because CHM needs to take into account of the regional and environmental factors affecting patients in that area. For example, the causes of diseases for patients in coastal region and in inland region may be different. This difference should be considered in the CHM treatments. Mathematically speaking, the CHM treatment is not a constant but a function of space. Therefore, the CPT coding, which is designed to be applied to all patients no matter where they locate, is invalid when applied to CHM. 4. CPT Coding Invalidity for Holistic Approach in CHM Western Medicine is a specialty oriented medicine. Each procedure involves one specialty. Therefore, it is possible to describe the procedure within the specific specialty by one CPT code. CHM, however, is a holistic medicine. As a holistic medicine, each procedure in CHM involves many specialties because many organs and systems need to be taken into consideration simultaneously in CHM. For example, there is a diabetes patient with vision problem. In CHM, the vision problem cannot be treated in ophthalmology specialty alone. According to CHM holistic approach, the ophthalmology disease has to be treated in conjunction with diabetes treatment. Examples like this exist for most disease treatments in CHM. Because the CPT Coding is designed for allopathic approach only, it is not designed for the holistic approach. As a result, there is no CPT code that can span and cross several specialties at the same time, which are able to describe procedure involving multi-specialties simultaneously. There is also no CPT code which can integrate many different specialties together. Therefore, the CPT coding is invalid for the holistic approach in CHM. 5. CPT Coding Invalidity for Therapeutic Procedure in CHM Each pharmaceutical drug usually contains one ingredient. It is possible to describe the therapeutic procedure with a CPT code. CHM, however, is quite different. One herb in CHM usually contains dozen to several dozens ingredients. A CHM formula may contain a hundred to several hundreds ingredients. On one hand, if there exist corresponding CPT codes for each of those CHM functions, hundred or several hundreds of CPT codes may be needed in order to describe a CHM therapeutic procedure. On the other hand, for many of the CHM therapeutic functions, there is no corresponding CPT code to use yet. The goal of coding is to simplify the documenting process by using one code to describe one procedure. If a CHM therapeutic procedure needs several hundred (rather than one) CPT codes to describe, the CPT coding has lost its original meaning -- to simplify documenting process. What we need is a coding system can document the CHM procedure with one code rather than several hundred codes. Therefore, the CPT coding is invalid for the therapeutic procedure in CHM. 6. CPT Coding Invalidity for Insurance Company to Process CHM Claims In Western Medicine treatments, the CPT codes are relatively stable for certain period of time. So the insurance company does not need to spend too much time adjusting the CPT codes every week or every day. In CHM, however, the situation is completely different. Most patient's treatments should be adjusted on a weekly or biweekly basis (no more than one month). Some patient’s treatments should be adjusted on a daily basis. If a patient’s treatments are adjusted on a weekly or biweekly basis, the CPT codes need to be adjusted on a weekly or biweekly basis. If the patient’s treatments are adjusted on a daily basis, the CPT codes need to be adjusted on a daily basis too. This frequent adjustment of CPT codes in CHM treatments would be impractical to insurance companies. If the patient’s CHM treatments are adjusted on weekly or daily basis, the CPT codes should be adjusted on weekly or daily basis too. Then the insurance company may have not finished the previous CPT codes paper work yet, the new CPT codes are keep on coming every week or every day due to the weekly or daily adjustments of CHM treatments. This pattern would keep on going every week or everyday as the patient’s CHM treatments are adjusted. The insurance company then would spend huge amount of time in keeping on adjusting CPT codes for CHM treatments every week or everyday for the same patient. As a result, the insurance company may never finish the CPT codes paper work for the same patient because the CPT codes paper work will keep on arriving every week or everyday without ending. All above frequent adjustments of CPT codes are just for one patient who receives CHM treatments. As a result, the insurance company would be occupied by one patient’s CPT code adjustments paper work, and would not have enough time to take care of more patients. Then, the insurance company would be out of business due to short of time to take care of more patients. So it is impractical for insurance companies to use CPT codes for CHM treatments. Therefore, the CPT coding is invalid for insurance company to use in processing claims for CHM treatments. ACMA Coding In order to solve above CPT coding invalidity in CHM, the American Chinese Medicine Association (ACMA) has developed and established a practical coding system appropriate for the professional practice of CHM by doctors of Chinese Medicine (CMD) – ACMA Coding. ACMA Coding is designed for reporting CHM diagnostic and treatment procedures. The purpose of ACMA Coding is to provide a uniform language that accurately describes CHM diagnoses, treatments, and services in order to serve as an effective means for reliable communication among CMD and other healthcare providers, patients, and third parties. The precursor of the ACMA Coding was the coding system developed and used for the professional practice of Chinese Herbal Medicine (CHM) by doctor of Chinese Medicine (CMD) at the American Chinese Medicine Association (ACMA) and the Center for Holistic and Herbal Therapy (CHHT). After five years use and test, it has been proved that this coding system is able to take into consideration of the unique characteristics that CHM has, and can be applied successfully to cover the professional practice of CHM by CMD. Based on above coding used at ACMA and CHHT, the ACMA Coding was developed and established in response to the insurance industry's requests and needs. 1. Diagnostic Codes (D Codes) Definition: ACMA Coding Diagnostic Codes are codes designed to describe the CHM diagnostic procedures. Characteristics: The CHM diagnostic method is called "Four Diagnostic Methods" [2]. This is the standardized diagnostic method practiced in CHM for thousands of years by CMD. There is no blood test, lab test, scan, etc. in CHM diagnosis. The ACMA Coding Diagnostic Codes have taken into consideration of the unique characteristics of the "Four Diagnostic Methods". Techniques: Due to the characteristics of "Four Diagnostic Methods", a standardizing technique has been used in developing the ACMA Coding Diagnostic Codes. Tests: After many years use and tests, it has been proved that the Diagnostic Codes are able to take into consideration of the unique characteristics of the "Four Diagnostic Methods", and can be applied successfully to cover the professional practice of CHM by CMD. 2. Treatment Codes (T Codes) Definition: ACMA Coding Treatment Codes are codes designed to describe the CHM treatment procedures. Characteristics: The CHM treatment method is called "Bian Zheng Lun Zhi" [2, 3]. This is the standardized treatment method practiced in CHM for thousands of years. There is no pharmaceutical drug used in the CHM treatment procedure. The ACMA Coding Treatment Codes have taken into consideration of the unique characteristics of the "Bian Zheng Lun Zhi" methods. Techniques: Due to the characteristics of the "Bian Zheng Lun Zhi" methods, a weighted average technique has been employed in developing the ACMA Coding Treatment Codes. Tests: After five years use and test at ACMA and CHHT, it has been proved that the Diagnostic Codes are able to take into consideration of the unique characteristics of the "Bian Zheng Lun Zhi" methods, and can be applied successfully to cover the professional practice of CHM by CMD. 3. Class A Diseases Definition: Class A Diseases are the diseases which have been used as data base in statistics to develop and establish the ACMA Coding. These are "blue chips" diseases which are representative and can develop stable coding for other diseases treated in the professional practice of CHM by CMD. List of Class A Diseases: angina pectoris, premature beats, tachycardia, bradycardia, heart failure, hypertension, high cholesterol, cold, cough, influenza, sinusitis, acute/chronic bronchitis, acute/chronic pneumonia, asthma, emphysema, gastritis, ulcer, hemafecia, anorexia, diarrhea, Crohn's disease, constipation, hemorrhoid, hepatitis c, autoimmune hepatitis, cirrhosis, mononucleosis, hyperthyroidism, hypothyroidism, goiter, diabetes, nephropyelitis, urinary tract infection, renal insufficiency, hematuria, anemia, headache, dizziness, vertigo, Meniere's disease, chronic fatigue syndrome, depression, Alzheimer's disease, Pick's disease, arthritis, systemic lupus erythematosus (SLE), dermotomyositis, muscle atrophy, limb numbness, impotence, irregular menstruation, menopausal syndrome, adnexitis, tinnitus, acute/chronic sinusitis, blurred vision, over-weight/obesity, sleep apnea, severe snoring, eczema, herpes, quit-smoking syndrome, steroid withdrawal syndrome, Evans syndrome, allergy, hay fever, cancers, HIV/AIDS, etc. 4. Class B Diseases Definition: Class B Diseases are the diseases not listed in Class A Diseases, but are within the professional practice of CHM by CMD. Because the ACMA Coding is designed to cover all the diseases treated in the professional practice of CHM by CMD, it is applicable to Class B Diseases. List of Class B Diseases: Because CHM and Western Medicine (WM) are completely different medicines, they classify diseases very differently. As a result, usually there is no exact match of diseases between the two medicines. Generally speaking, the professional practice of CHM by CMD covers all diseases available in WM. The major difference is that CHM usually uses different disease names. CHM also cover some diseases that are not defined in WM. CHM vs. Dietary Supplement
Herbs The professional practice of CHM by CMD is very different from the dietary supplement use or public use of herbs by non-CMD. The former is a professional medicine. The latter is the over-the-counter use of herbs. The ACMA Coding is designed for the professional practice of CHM by CMD only. The ACMA Coding is not designed for other use of herbs (e.g. dietary supplement use and the public use of herbs, etc). Therefore, the insurance coverage for the professional practice of CHM by CMD will not include insurance coverage for the dietary supplement use of herbs. Epilogue As a concluding remark, we would like to use an analogy to describe this coding issue. Western Medicine (WM) and Chinese Herbal Medicine (CHM) are similar to two different languages (e.g. English vs. Chinese). CPT Coding and ACMA Coding are similar to the English grammar and Chinese grammar. Using CPT coding for CHM is similar to using English grammar for Chinese language. It would be invalid. The Chinese language need to use the Chinese grammar -- ACMA Coding. More information on the ACMA Coding is available in the “ACMA Coding” section and the “Fees” section at http://www.americanchinesemedicineassociation.org References: [1]. Xu, B. Mathematical Herbal Medicine. ACMA Publication Issue May 2, 2005. http://www.americanchinesemedicineassociation.org [2]. Xu B, Molony D, Yuan C.S. Handbook of Chinese Medicine. The Haworth Medical Press. New York. To be published. [3]. Xu, B. Fundamental Characteristics of Chinese Medicine: Holism and Bian Zheng Lun Zhi. ACMA Publication Issue Feb 2003. ACMA Publications. http://www.americanchinesemedicineassociation.org
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