Volume 18, Number 5
October 2004

ABC Codes: A New Opportunity to Capture CNS Contributions to US Healthcare

Synthia Molina, BS, MBA

A specialized set of insurance-related codes for integrative healthcare will increase the national influence and patient-specific effectiveness of clinical nurse specialists (CNSs) and others in the US healthcare system because virtually every participant in the healthcare system uses codes for some critical purpose. Inadequate codes prevent decision makers from having essential health-related information at their fingertips. ABC codes improve business processes and health industry efficiencies in the same manner that universal product codes (UPCs/bar codes) improved the retail operations and the retail industry. The codes are essential to research, management, and commerce. In healthcare, the combination of ABC codes with older medical and dental code sets allows many essential business processes (such as forecasting, practice management, insurance billing, claims processing, and third-party reimbursement) to be fully automated. The codes also help digitize information to simplify data collection, analysis, and reporting. This improves the quality of data and accelerates the speed with which conclusions can be drawn from those data about what works in US healthcare and why. By offering CNSs more complete, accurate, and precise information on best practices, ABC codes help ensure that CNSs and others can generate better outcomes in addressing health-related challenges faced by patients/clients, nurses, and nursing practices, and the nation’s health-promoting organizations and systems.


AN INTRODUCTION TO ABC CODES, HIPAA, AND THE NHII

Clinical nurse specialists (CNSs) and other advanced practice nurses are benefiting from a new health-related data standard that helps document the value of nursing and other integrative healthcare professions. This data standard, called ABC codes, works with and fills gaps in older medical and dental code sets such as the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT® codes) and the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II (HCPCS II). ABC codes consist of 5-character alphabetic symbols accompanied by 2-character practitioner identifiers. The codes work in conjunction with CPT® and HCPCS II codes and fit into existing claim forms, data fields, software applications, information systems, and business processes. ABC codes are supported by relative value determinations called relative value units (RVUs) that are useful in establishing fair pricing and payment levels for delivered care. RVUs are mapped to the Resource- Based Relative Value System/Scale (RBRVS) to support assessments of the financial worth of various interventions using the government’s RBRVS methodology. ABC codes are also supported by legal practice guidelines that indicate whether the coded care is within the legal scope of practice of more than a dozen practitioner types in all 50 states and the District of Columbia, based on statutes, administrative regulations, and case law. More than 4000 ABC codes have already been developed and hundreds more are added each year through a formal ABC terminology and code request process. The existing ABC codes represent integrative healthcare products and services delivered by more than 3 million licensed healthcare practitioners. Of these codes, nearly 2000 reflect healthcare services and more than 2000 reflect healthcare products and supplies, including nutraceuticals and homeopathic preparations. In April of 2004, the National Association of Clinical Nurse Specialists (NACNS) announced its collaboration with ABC coding authorities to enhance terminologies and codes for at least 48 nursing specialties targeted by the ABC coding system. The refined and expanded ABC codes promise to provide even greater support to CNSs and will help document practice in all 3 spheres of influence: (1) patient and client interactions, (2) nursing and nursing practice development, and (3) organization and system improvements.

In the patient and client sphere, newly developed ABC codes are providing an even stronger foundation of data and evidence to support CNSs in initial assessments; diagnoses, planning, and identification of outcomes; and interventions and evaluations. That is, used in conjunction with CPT® and HCPCS II codes, ABC codes support the collection of better data on, and the drawing of better conclusions vis-ŕ-vis, nursing-responsive diagnoses and nursing- driven interventions used across the continuum of care. CPT® and HCPCS II codes are adequate to document certain types of delivered care (eg, HCPCS II J-codes that document the delivery of injectable pharmaceuticals). However, for many other interventions, the only CPT® and HCPCS II codes available are too generic (eg, codes ending in "99" and representing "not otherwise classified" interventions) or are designated as nonpayable measurement (eg, CPT® Category II) or investigational (CPT® Category III) codes. In these cases, ABC codes are used to better reflect delivered care and to support coverage and reimbursement, where available and appropriate. As better data are compiled on the conventional, complementary, and alternative care delivered in the course of diagnosing and treating patients, more meaningful analyses can be conducted to determine the economic, health, health-related quality-of-life, patient satisfaction, and other outcomes of care. This will result in the identification of best practices and lead to improvements in evidence- based care standards and programs of care.

In the nursing and nursing practice development sphere, as well as in the organization and system sphere, ABC codes are enhancing the ability of CNSs to identify and define professional and institutional problems and opportunities; develop diagnoses, identify outcomes, and develop corrective plans; develop and test solutions; and evaluate performance against plans. Specifically, ABC codes enhance the ability of CNSs to guide other nurses and the entire US healthcare system in diagnosing and treating individuals, families, groups, and communities to prevent, remediate, or alleviate illness and to promote health in defined specialty populations. For example, by using the codes to compile data on diagnoses and treatments and to analyze care delivery patterns, CNSs focused on community health and public health may find that certain minority or ethnic populations have better outcomes when their initial clinical evaluations are supported by medical translators or culturally competent caregivers. Such findings could support health policymakers in more effectively addressing disparities in ethnic and minority care. Similarly, if psychiatric/mental health CNSs found that highly educated women with anxiety disorders were experiencing adverse reactions from the combination of natural supplements (described in consumer health magazines) and pharmaceuticals (prescribed by psychiatrists), new guidelines for pharmacy educators, psychiatric specialties, and patient counseling could be developed. Finally, CNSs focused on family health, community health, public health, or education could compare the pregnancy rates in teenagers exposed to abstinence education versus sexual education to determine the most effective approach in curtailing unwanted pregnancies.

Essential to the nursing professions and nursing-influenced elements of the US healthcare system, ABC codes are also critical to a fully functioning national health information infrastructure (NHII). By reflecting care delivered in more than 1.4 billion outpatient encounters each year and even more inpatient encounters, ABC codes ensure data can be captured, evaluated, and communicated for all areas of healthcare in support of such essential initiatives as electronic health records and public health surveillance. Without documentation on practices of caregivers other than conventional physicians and dentists, the NHII provides an incomplete, inaccurate, and imprecise picture of the financing, administration, and delivery of care in the nation and leaves the US healthcare system vulnerable to special interest influence. This missing information can result in ineffective and even harmful health policy decision making. For example, health policymakers may outlaw care delivery by certain types of caregivers because of the lack of data on the safety and efficacy of the care they deliver (eg, nurse midwives). Within a specific health plan, patients who might benefit from psychiatric nursing care for stress-related cardiovascular disorders might be guided to high-risk drugs or surgical interventions on the basis of suboptimal treatment guidelines and coverage and reimbursement policies. Complete, accurate, and precise coding counters special interest influence and ensures that health policymakers and practitioners alike can rely on valid evidence to support health-related decision making.

ABC codes are rapidly gaining support from some of the biggest stakeholders in US healthcare because the codes can help improve the outcomes of care, reduce administrative and medical costs, minimize litigation risks, and detect fraud and abuse. ABC codes are already in use in pioneering health plans, where they support measurable advances in healthcare research, management, and commerce. For example, the MedicarePlus Choice (Medicare Advantage) plan in the State of New Mexico has been using ABC codes for more than 5 years in collaboration with Bridges in Medicine, an integrative healthcare provider organization.* Alaska Medicaid is using ABC codes in its Program for Behavioral Health, and Aetna is planning to use the codes in its Compassionate Care program. Ultimately, ABC codes are expected to generate significant advances in individual and public health, business and industry efficiencies, and socioeconomic development, as the identification of the nation’s best practices in healthcare leads both health policymakers and professionals (such as CNSs) to promote the most cost-effective care available.


DEVELOPING A CRITICAL CLINICAL AND BUSINESS MANAGEMENT TOOL: THE HISTORY OF ABC CODES

Melinna Giannini, an insurance agent and third-party administrator who designed and sold self-funded medical plans and monitored employer claim funds, conceptualized ABC codes. In 1995, Giannini recognized the need for an National Committee for Quality Assurance (NCQA) certified network of integrative healthcare practitioners, including acupuncturists, bodyworkers, chiropractors, holistic physicians, homeopaths, ethnic and minority healthcare professionals, massage therapists, midwives, naturopaths, nurses, oriental medicine practitioners, osteopaths, somatic educators, spiritual healers, and others. As she explored methods of contracting with such practitioners, Giannini discovered a critical and missing element of the NHII: codes that characterized integrative healthcare interventions. She knew these codes were essential to the financing, administration, and delivery of evidence-based healthcare, especially in areas other than conventional physician-driven medical practices. Incomplete, inaccurate, and imprecise coding was resulting in misleading data that sometimes led policymakers to make harmful health policy decisions. The gap in coding and the NHII was resulting in suboptimal healthcare access, quality, and cost management— and, tragically, lost lives. Through third parties, Giannini approached existing coding authorities and encouraged them to accelerate the development of effective codes for integrative healthcare. One such authority, the AMA, served "allopathic" physicians and focused on Western, or conventional, medical practices. The other coding authority, the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services), served the elderly, disabled, and impoverished. Neither coding authority would commit to the project of characterizing thousands of interventions in areas of alternative medicine, nursing, and other integrative healthcare practices, and then assigning unique codes (digitized information) to support more cost-effective healthcare research, management, and commerce. Giannini saw that some new coding authority would have to build integrative healthcare codes from scratch to meet existing industry needs. She viewed these codes as essential under new federal legislation— the Health Insurance Portability and Accountability Act (HIPAA) of 1996—that called for administrative simplification in healthcare through standardized transactions and code sets.

* Ardent Health Services’ Lovelace Sandia Health System in New Mexico has been paying ABC-coded claims since 1999, under its various corporate forms.

To fill NHII gaps, and build a HIPAA-compliant code set, Giannini assembled a research team, raised funding, and created a new coding authority. The resulting company, Alternative Link, had no special interests that might otherwise limit or unduly influence the direction or depth of code development. It assigned codes impartially, based on the official nomenclature of the integrative healthcare professions, not on the medical establishment’s acceptance or the national prevalence of the coded interventions. This open and impartial code development process resembled that of the Uniform Code Council, the group that assigned Universal Product Codes in the retail industry. That is, like UPCs, Alternative Link’s new ABC codes for integrative healthcare were assigned to reflect actual healthcare practices, not just those preferred in Western medicine or by conventional physicians.

Alternative Link’s code development process evolved over time. Initially, many practitioners of alternative medicine, nursing, and other integrative healthcare practices were wary of coding authorities. They had developed mistrust of mainstream approaches to financing, administration, and delivery of care because these practices were largely controlled by special interests that might have financial and political reasons to disenfranchise practitioners other than conventional medical doctors. Understanding this, Alternative Link operated using business models that would help it continue to behave as an independent and impartial organization.

Early on, Alternative Link relied on exploratory interviews, informal surveys, and case studies to characterize the unconventional and nonallopathic physician practices. With a baseline understanding of the fields of integrative healthcare, the company then designed a terminology and code development and management process to routinely secure nomenclature from the integrative healthcare professions (including nurses) and convert this nomenclature into coding that would completely, accurately, and precisely reflect their practices. The process included systematic research using more formal data collection instruments and the input of degree-granting academic institutions, practitioner associations, leading experts in each field, state licensing boards, and national testing and credentialing authorities. The company also sought industry input from subject matter experts in areas such as coding, billing, claims management, health plan design, utilization management, credentialing, pricing, contracting, clinical practice management, outcomes research, actuarial analyses, information management, supply chain management, healthcare administration, health law, health policy, and health industry evolution. The result was a set of codes, roughly half the size of the CPT® code set, that described a broad variety of integrative healthcare practices to support the financing, administration, and delivery of best practices among conventional, complementary, and alternative approaches to care.

Today, Alternative Link works with strategic collaborators and practitioner associations to update and expand the terminology behind ABC codes. This interactive process ensures the code set remains complete, accurate, and precise as healthcare practices evolve. The company also offers a variety of information products and consulting services essential to the efficient functioning of the NHII so that health industry stakeholders can more easily work together to ensure more Americans gain access to the right care in the right place at the right time, at a rational cost. Among these are coding manuals, legal practice guidelines, patient encounter forms, reference books for relative values, and integrative healthcare databases.


UNDERSTANDING WHY ABC CODES ARE ESSENTIAL

ABC codes reflect integrative healthcare rather than allopathic medicine or dentistry and help ensure data can be collected, analyzed, and communicated on the best approaches from conventional, complementary, and alternative care models. This broader perspective is critical because older medical and dental code sets have significant gaps. They do not adequately describe or reflect the care delivered by millions of licensed healthcare practitioners and other caregivers. Gaps in codes compromise the ability of the nation, the US healthcare system, healthcare organizations, and CNS and other practitioners to get better care to more people at a reasonable cost.

Used in conjunction with CPT® and HCPCS II codes, ABC codes were designed to help all participants in the healthcare system digitize information that is essential for critical business processes so that these processes would become more cost-effective and reliable. The codes were also designed to improve the NHII so that decision makers could have the information they need readily available to make good decisions or take appropriate actions. ABC codes provide more complete, accurate, and precise descriptions of integrative healthcare interventions and counter potential biases in coding that may not only prevent scientific comparisons of the economic and health outcomes of conventional, complementary, and alternative approaches to care but also disenfranchise caregivers other than allopathic physicians and dentists. Those familiar with coding know that older medical and, to a lesser extent, dental coding authorities still maintain prevalence requirements for assignment of payable codes. That is, the applicant for a new code that could be considered payable by health plans must prove that the intervention is already widely used, despite the fact that widespread use often depends on the preexistence of coding and third-party payment.

Older medical coding authorities require that care being considered for payable coding be subjected to "technology assessment" standards established by conventional Western physicians. While numerous integrative healthcare interventions are safe and effective, relatively few can be properly assessed using allopathic physician criteria alone and could therefore fail to meet Western physician-driven standards. This could result in Western and physician biases in coding that could limit the ability of entire categories of caregivers to participate in mainstream healthcare and prevent scientific comparisons of the economic and health outcomes of conventional, complementary, and alternative approaches to care. Further, older medical codes tend to be less precise in describing nonphysician interventions than ABC codes and medical codes typically lack corresponding RVUs, practitioner identifiers, and legal practice guidelines. Without connecting these data elements, these older medical codes can introduce more administrative inefficiencies into the healthcare system by making necessary manual checks to ensure the integrative healthcare that is financed, administered, and delivered is legal and appropriate. For example, without corresponding practitioner types, RVUs, and legal practice guidelines, codes for integrative healthcare would cause otherwise automated processes (such as insurance claims review for compliance with statutes, administrative regulations, and case law) to require costly manual checks.


DEPLOYING ABC CODES TO SOLVE A BROAD RANGE OF NURSING AND HEALTHCARE CHALLENGES

ABC codes are developed in an open and unbiased manner that reflects the official training, practices, and vocabularies of the integrative healthcare professions. ABC codes not only fill gaps in the HCPCS Level I and II codes but also replace many retiring HCPCS Level III codes (local codes) used by Medicaid programs. As noted above, ABC codes represent the practices of millions of caregivers and an estimated 1.4 billion episodes of outpatient care.* In contrast, CPT† and Current Dental Terminology (CDT)‡ codes—the medical and dental coding standards—represent the practices of an estimated 800,000 physicians and 150,000 dentists, an estimated 1.1 billion annual physician office visits, and a fraction as many dental office visits.§ Reflecting not only the administrative simplification provisions of HIPAA but also the need for a fully functioning NHII, ABC codes are supported by (1) practitioner identifiers that can be used as code modifiers, (2) RVUs/RBRVSs, and (3) legal practice guidelines (including special training requirements).

* This figure was derived from 629 million reported visits to complementary and alternative medicine (CAM) practitioners in 1997,1 and a compounded annual growth rate of 14.2%.
† CPT® is an acronym for the AMA’s Current Procedural Terminology, a code set named a national standard under HIPAA in the August 17, 2000, Final Rule published in the Federal Register.
‡ CDT is an acronym for the American Dental Association’s Current Dental Terminology, a code set based on the Code on Dental Nomenclature and named a national standard under HIPAA in the August 17, 2000, Final Rule published in the Federal Register.
§ These figures were derived from Alternative Link’s proprietary data, as well as from the Web sites www.ama-assn.org and www.bls.gov/oco/print/ocos072.htm.

Practitioner identifiers help establish legal scope of practice on a line-specific basis on insurance claim forms, as well as in contracting, credentialing, clinical practice design, and other applications. They are similar in function to provider taxonomy codes but are used on a codespecific basis. That is, each 2-character practitioner identifier is used to modify a 5-character ABC code to convey the type of practitioner who provided the corresponding care. The resulting 7-character "code + modifier" is used in the same data fields as older medical codes and their modifiers—except that the ABC code and identifier/ modifier can be linked to state-specific legal practice guidelines to help automatically ensure care was in compliance with statutes, administrative regulations, and case law. That is, practitioner identifiers/modifiers help identify who delivered care and, used in conjunction with ABC codes and legal practice guidelines, establish whether caregivers are legally authorized and properly trained to deliver a specific intervention.

RVUs establish the financial worth of healthcare interventions based on a variety of factors associated with delivered care: time, skill, risk to patient, risk to practitioner, and severity of the health condition. RVUs support health economics studies, health insurance benefit plan design, managed care and provider contracting, utilization and clinical practice management, claims processing, outcomes research, and a variety of actuarial analyses. RVUs are multiplied by conversion factors (CFs) to establish a dollar value for a specific intervention in a specific geographic area. For example, an RVU of 5.2 would be multiplied by a CF of $10.00 to establish a baseline value of $52.00 for the corresponding service. For another service, the RVU might be 12.4 and, with the same CF of $10.00, the baseline value would be $124.00. CFs are monetary multipliers that convert RVUs into payment amounts. CFs are reported as dollar figures. They reflect healthcare practice costs in a particular office, group practice, healthcare institution, or region. They take into account cost-drivers including current fees, prevailing area rates, and overhead costs such as malpractice insurance, rent, salaries, and the cost of doing business. For example, the CF in Anaheim, Calif, might be $40.00, while a CF in Little Rock, Ark, might be $28.00. CFs are multiplied by relative values to support cost accounting, resource allocation studies, pricing and fee schedule development, practitioner compensation analyses, utilization and case management, health economics studies, capitation cost analyses, and managed care contract analyses.

Legal practice guidelines establish the legality of delivered care based on the qualifications of the practitioner in relation to regional statutes, administrative regulations, and case law. In contrast to the laws for conventional physicians, the laws for integrative healthcare practitioners, such as CNSs, vary tremendously by state. Practitioners, provider organizations, and health plans need to know—on a per intervention, per practitioner, and per state basis—whether care delivered by a specific type of integrative healthcare practitioner is within that practitioner’s legal scope of practice and professional competencies/abilities. Practitioners can use legal practice guidelines to identify healthcare products and services they can legitimately provide to patients and avoid malpractice or fraudulent billing charges. Provider organizations and health plans can use the same legal practice guidelines for credentialing and contracting— and to avoid being named in malpractice or fraud cases.

Used in conjunction with practitioner identifiers/modifiers, RVUs, and legal practice guidelines, ABC codes offer unprecedented value in association with the older HIPAA code sets and the NHII—value that cannot be derived from the prior code sets alone. ABC codes can immediately fulfill the nation’s need to completely, accurately, and precisely document the financing, administration, and delivery of care to support best practices.²


SHEDDING LIGHT ON THE HIDDEN AREAS OF US HEALTHCARE

ABC codes reflect the vocabularies and professional training of healthcare practitioners whose practices are not adequately reflected in the older medical and dental HIPAA code sets. These practitioners include (but are not limited to) those listed in Table 1. Services not adequately reflected in older medical and dental HIPAA codes are listed in Table 2.


UNDERSTANDING WHAT’S IN IT FOR CNSS

CNSs represent 67,000 of the millions of licensed healthcare practitioners who were underserved by the older medical and dental code sets and are now supported by ABC codes. Complete, accurate, and precise ABC codes for CNS practices are particularly important because of the critical role CNSs have in the rapidly changing dynamics of healthcare, for example, shaping the national health agenda and modeling the most advanced and innovative nursing practices to improve outcomes up and down the healthcare vertical.







CNSs have demonstrated particular competencies in anticipating and evolving with changes in patient care needs across the continuum of care in response to shifts in factors as diverse as sociodemographics and models of healthcare financing, administration, and delivery. However, the ability of CNSs to effect favorable change has been limited by the paucity of data on the entire spectrum of care, especially nursing care and its outcomes. This lack of data has led to limitations in the advancement of evidence- based practice, nurse-sensitive outcomes, self-care, the wellness of families and communities (eg, through provision of aging adult and end-of-life care), and the quality of clinical practices. ABC codes support clinical expertise, the foundation of CNS competencies, by creating standardized vocabularies for describing integrative healthcare and, especially, nursing interventions.

The ABC code set already includes more than a thousand codes for nursing, derived from the Nursing Intervention Classification System (NIC), the Omaha System Intervention Scheme (Omaha), the Home Health Care Classification System (HHCC), and other nursing vocabularies. The ABC Coding Manual for Integrative Healthcare includes mappings or "crosswalks" to these vocabularies and explains the process for refining terminology and coding based on evolution of the integrative healthcare professions. With active involvement of NACNS, the codes will improve and expand over time, so that data collection, analysis, and communication more and more effectively reflect real-world practices and provide a basis for advancement of the profession and US healthcare system.

For example, the March/April issue of Clinical Nurse Specialist included an article titled "Nursing Considerations in Psychotropic Medication-induced Weight Gain."³ Today, the code for weight management counseling is BFBAJ for "weight management, group, each 15 minutes, management, nutrition, multispecialty interventions." To the extent that specific interventions evolve for delivering weight management programs to address the unique needs of mentally ill patients, these interventions will be reflected in new nursing terminologies and corresponding ABC codes. Such codes will ensure that the outcomes of these interventions are measured and, where cost-effective, potentially covered and reimbursed by health plans. More specifically, ABC codes will help document the outcomes and medical necessity of new areas of specialized nursing care, for example, lowered rates of obesity, physical complications, psychological consequences, and noncompliance with treatment in pharmacologically treated psychiatric patients.

A quick review of ABC code BFBAJ illustrates the use and implications of complete, accurate, and precise coding on the advancement of nursing practices and US healthcare. If a registered dietician provided a weight management service using this existing ABC code, the code would be followed by a practitioner identifier "1X" to form a "code + modifier" of BFBAJ-1X. If a CNS delivered the counseling, the code and modifier would be BFBAJ-1F, since 1F represents CNSs. Both codes and practitioneridentifying code modifiers could be used on any patient encounter form (eg, superbill), insurance claim form (eg, CMS-1450 or CMS-1500), or data field designed for a 5-character code plus 2-character modifier.

In running his practice, setting rates, and establishing managed care contracts, a registered dietician would refer to the RVU for this intervention, currently 1.0 and annually updated through surveys implemented by Relative Value Studies, Inc. (www.rvsdata.com). In comparison, code BFBAI, for weight management counseling in a oneon- one setting, would carry an RVU of 4.0. A CNS would refer to the same RVUs. If the CF in a city in Maryland was $5.39, a practitioner could theoretically justify a charge of $5.39 per patient for every 15 minutes of care in a group setting (RVU 1.0 x CF $5.39) and $21.56 for every 15 minutes in a one-on-one setting (RVU 4.0 x CF $5.39). If the CF in a city in California was $5.75, a CNS who practiced there could justify a charge of $5.75 per patient in a group setting and $23.00 for every 15 minutes spent counseling a patient in a one-on-one setting.

Prior to delivering care, however, to ensure compliance with their respective legal scopes of practice, the registered dietician and CNS would each secure a separate list of legally deliverable and billable care. That is, they could each get a list of ABC codes that had been "queried" by the practitioner type (registered dietician vs CNS) and relevant statutes, administrative regulations, and case law in the targeted state (Maryland vs California). The registered dietician would secure a "Practitioner’s Guide to Billable Interventions Using ABC Codes: Registered Dietician in the State of Maryland." The CNS would secure a "Practitioner’s Guide to Billable Interventions Using ABC Codes: Clinical Nurse Specialist in the State of California." If either practitioner wanted to "recommend a Western herb or botanical" (ABC code ADXAE) to enhance patient weight loss, a "Training Addendum" would alert each of the need to document additional training to substantiate the legality of care delivery.

In the credentialing and contracting processes, a preferred provider organization (PPO) that was considering including these practitioners in a national network would selectively query a database that included fields for ABC codes, hierarchic descriptions, expanded (clinical) definitions, RVUs, practitioner identifiers/modifiers, and legal practice guidelines. This would give the PPO the ability to

• verify the educational qualifications necessary to deliver different types of care,
• establish a rational and defensible fee schedule, and
• protect itself from legal exposure that might result if a "participating provider" delivered care beyond his or her legal scope of practice.

A clearinghouse or health plan would query the same database (looking at the ABC code, the practitioner identifier/ modifier, the state in which care was delivered, and legal logic) to automatically assess the legality of care on an insurance claim, such as a CMS-1500 form. The organization would then automatically connect each ABC code to the corresponding ICD-9 diagnostic code and clinical logic (eg, from monographs on integrative healthcare available from a national authority such as Natural Standard [www.naturalstandard.com]) to assess the medical necessity of care. Finally, the organization would compare the codespecific charges on the claim form to RVUs, RBRVS information, and/or usual, customary, and reasonable charges (UCR data) to determine what level of reimbursement was appropriate. In this manner, either organization could fully automate the processing of insurance claims that would have gone into manual review—were it not for the availability of ABC codes and corresponding practitioner identifiers/modifiers, RVUs, and legal practice guidelines.

By warehousing data from the insurance claims from these and all categories of caregivers, a health plan could compile a data set far superior to any currently available. The resulting data would reflect conventional, complementary, and alternative care and would document the relative economic and health outcomes of care delivered by physicians, dentists, advanced practice nurses, holistic caregivers, behavioral health professionals, allied health practitioners, public health professionals, etc. As a result, health plans could identify best practices and significantly improve health insurance benefit plan design, managed care and provider contracting, utilization and clinical practice management, claims processing, outcomes research, and actuarial analyses. As a result, more individuals would stand to gain access to higher quality care at a less draconian cost.


RECOGNIZING THE IMPLICATIONS FOR PATIENTS, THE NURSING PROFESSIONS, AND US HEALTHCARE

Today, ABC codes may be used by anyone in research, management, and manual commerce applications, such as insurance billing using paper-based insurance claim forms. These uses are unregulated and beyond the scope of HIPAA. For electronic commerce applications, such as electronic submission of insurance claims, ABC codes are recognized by the US Department of Health and Human Services (HHS) as a proposed modification to the HIPAA standards. The codes are HIPAA-compliant for registered code set users and their trading partners, in accordance with Title 45 of the Code of Federal Regulations, Section 162.940.

ABC codes are supported by (1) practitioner identifiers used as code modifiers that characterize caregivers on a per code basis, (2) RVUs that reflect the financial worth of interventions, and (3) legal practice guidelines that establish the legality of delivered care on a per intervention, per practitioner, and per state basis. Together, ABC codes, practitioner identifiers/modifiers, RVUs, and legal practice guidelines help health industry participants identify the best practices among conventional, complementary, and alternative approaches to care.

NACNS is working to develop new and refined terminology and codes to reflect the services and supplies delivered by CNSs. This will help ensure the best practices of nursing and integrative healthcare are made available to a greater number of Americans at a rational cost. CNSs should consider using ABC codes immediately (see Appendix). The codes can be used on standard CMS-1500 and CMS-1450 forms used for filing healthcare insurance claims. ABC codes fit in the procedure code sections of both forms. Supported by practitioner identifiers/modifiers, RVUs, and legal practice guidelines, ABC codes can help CNSs do a better job of (1) caring for patients and clients, (2) advancing nurses and the nursing practices, and (3) improving the US healthcare system and its healthpromoting organizations.

From the Alternative Link, Albuquerque, NM.
The author is the CEO of Alternative Link, the organization that first developed ABC codes.
Corresponding author: Synthia Molina, BS, MBA, Alternative Link, 6121 Indian School Rd NE, Suite 131, Albuquerque, NM 87110 (e-mail: Synthia.Molina@AlternativeLink.com).

References

1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997. JAMA. November 11, 1998;280:1569–1575.
2. White House Commission on Complementary and Alternative Medicine Policy. Final Report. March 2002.
3. Harrison B. Nursing considerations in psychotropic medicationinduced weight gain. Clin Nurse Spec. March/April 2004;18: 80–87.

APPENDIX

Anyone can use ABC codes for research, management, and manual or paper-based commerce. These uses of code sets are unregulated and fall outside of HIPAA. For electronic commerce, which is a federally regulated use of code sets under HIPAA, ABC codes may be used by any of more than 10,000 entities that registered to secure rights to use the codes under a section of the Code of Federal Regulations known as 45 CFR §162.940, as well as by millions of their contractual trading partners. Registrants included major employers with self-funded health plans; government and commercial health plans; integrative delivery networks, hospital systems, and community hospitals; subacute care facilities including skilled nursing facilities, rehabilitation centers, integrative healthcare clinics, and integrative healthcare practices; academic research centers and think tanks; healthcare information technology companies and consultancies; third-party administrators and claims management companies; holistic physicians; integrative, complementary, and alternative medicine practitioners; nurses and hundreds of other categories of health industry stakeholders. HIPAA is federal legislation, passed in 1996, that includes an “Administrative Simplification” section and requirements for development of standardized transactions and code sets to support electronic data interchange (EDI) in the US healthcare system. HIPAA empowered the US Department of HHS to establish (1) national standards for electronic healthcare transactions and (2) national identifiers for providers, health plans, and employers. The objective of the HIPAA transaction and code set standards is to improve the efficiency and effectiveness of the nation’s healthcare system by encouraging the widespread use of EDI in healthcare. Organizations and individuals registered between January 16 and May 29 of 2003 to secure their rights to use ABC codes in electronic commerce beyond the October 16, 2003, HIPAA transaction and code set compliance date. The registration requirement was recommended by the Office of HIPAA Standards and was subsequently established by the Secretary of the US Department of HHS. HHS required registration for 2 reasons. First, in permitting use of ABC codes under HIPAA, HHS needed to comply with the section of the Code of Federal Regulations (45 CFR §162.940) that required identification of “trading partners” who planned to use ABC codes, as well as their geographic locations. Second, the registration gave HHS a way to make ABC codes quickly and broadly available under HIPAA. HHS authorized HIPAA-compliant use of ABC codes under 45 CFR §162.940 because—unlike the older medical code sets—ABC codes were relatively new to the US healthcare system, and no objective, transparent, and timely evaluation and naming process had been established for such innovations. 45 CFR §162.940 gave the Secretary of HHS power to establish HIPAA-compliant uses of proposed modifications to the HIPAA standards, while data was collected to support the necessity of those modifications. Under this section of the Code of Federal Regulations, the Secretary extended the uses of ABC codes from research, management, and manual commerce (which are unregulated) into electronic commerce (which is regulated under HIPAA). The secretary’s authorization of ABC codes under 45 CFR §162.940 ensures broad-based availability of ABC codes as an optional but not mandatory HIPAA-compliant code set. It also supports the collection of real-world data on the cost-benefit of ABC codes in electronic commerce. Industry experts anticipate ABC codes will become mandatory before the third quarter of 2005. The codes are likely to be named as a subset of a preexisting mandatory HIPAA code set (such as HCPCS II, which already incorporates code sets developed by outside entities) or as a freestanding and mandatory HIPAA code set.