Chairman Cohn, Vice Chairman Blair and members of the Subcommittee, thank you for the opportunity to address you this morning on behalf of the American Association of Naturopathic Physicians (AANP). My name is Bruce Milliman and I am a naturopathic physician in private practice in Seattle, Washington. My practice in Seattle is in a multidisciplinary office setting with one of the oldest integrated medical centers in the United States, and is comprised of practitioners of acupuncture and oriental medicine, medical (MD) and naturopathic (ND) physicians as well as other licensed healthcare professionals, all working together under one roof and frequently co-managing care when it is to the benefit of the patient. I am Chair of the Insurance and Reimbursement Committee for the AANP, an Associate Professor (currently adjunct faculty) at Bastyr University and am a member of the Integrated Healthcare Policy Consortium Coding Taskforce.
The AANP and its sister organization, the Canadian Naturopathic Association are the only national organizations in North America representing licensed naturopathic physicians.
We are pleased that the Secretary has authorized a pilot study of Alternative Links ABC code set. We also applaud the fact that the CPT Evaluation and Management Workgroup is currently assessing and making
recommendations for the physician work components of the E&M codes. These advances are encouraging, and it is hoped that the Subcommittee will work to ensure autonomy for the editorial panel process from undue influence by any single interest group, and plurality of representation on any code set editorial panel(s) and related advisory group(s).
Naturopathic medical services, as taught in the five accredited naturopathic medical colleges in North America and as practiced by licensed naturopathic physicians are generally describable via current procedural terminology (CPT), in terms of both the evaluation and management (E&M) as well as the procedural code components. Difficulties encountered in CPT coding by ND’s are similar to those encountered by MD’s. Naturopathic medical services are billed for by utilization of both ICD9 and CPT on a HCFA 1500 form. Most primary and specialty naturopathic medical services are reimbursed for by third party payers in jurisdictions where ND’s are contracted providers. ND’s would like to participate in the further revision of E&M codes as already undertaken by the CPT Evaluation and Management Workgroup. As the body of research mounts in support of nutritional counseling, lifestyle modification and exercise education as appropriate interventions for chronic dysfunction and disease and as alternatives to long-standing drug therapy, many of these interventions (perhaps formerly underutilized) are beginning to look more mainstream and now more than ever are showing their true value. The public is attuned to and embraces these therapies that are more safely available under licensed care.
Contemporary medical practices are thus beginning to include more interventions commonly used in naturopathic medicine. Many conventional physicians are recommending such interventions. For example, in light of the recent negative hormone replacement study for post-menopausal women, there is an increase in the recommendation of Black Cohosh (Cimicifuga racemosa) by MD’s. Only months ago, a recommendation to use an herb for the treatment of menopausal syndrome would have been strongly resisted, yet these types of interventions have been part of our professional practice for many decades. We would like to assist in reflecting these and other developments into the descriptors for physician work in E&M.
The existing components in E&M of history of present illness, physical examination and complexity may be inadequate to describe the emerging nature of physician work, especially as it relates to the following components increasingly common in clinical practice (for ND’s and MD’s in primary and specialty care): Patient advocacy through shared decision making and condition-specific education via interpretation of laboratory and other reports, records and studies; stress management counseling; exercise/physical education; spiritual and relationship counseling; nutritional evaluation and counseling, and the increasing use of electronic communication as a frequent mechanism of patient follow-up care. The foregoing is illustrative of the importance of reexamining and possibly redefining the components of E&M in light of the evolving nature of physician work.
Multiple system diseases, chronic pain and fatigue, epidemic obesity and diabetes are but a few of emerging trends in the health of our citizens. These and other conditions did not have the prevalence and demographic dominance when current CPT descriptors were developed for E&M. The resulting complexity of medical decision-making and coordination of care with new and emerging modalities of management are accompanied by new coding challenges. Naturopathic medical education, perhaps more so than any other discipline, includes familiarization with, training in and appropriate utilization of all of the specific therapies, modalities and complete medical systems currently defined as complementary and alternative medicine (“CAM”) (botanical medicine, homeopathy, hydrotherapy, therapeutic nutrition, acupuncture, manipulation, massage therapy, natural childbirth). We would like to aid in the development of parameters to help code for the coordination and delivery of care that may utilize these therapies, modalities and systems of healthcare. The exact definitions of the components of such care must come from the naturopathic profession as well as each of the other relevant professions.
The AANP supports the planned pilot study of the Alternative Link’s ABC code set, as well as the CPT update of the descriptors for documenting physician work in E&M coding. Our profession regards it as critical that autonomy for the editorial process (code development, management, evaluation and retirement) be encouraged by the Subcommittee to the greatest extent possible. We believe that it is equally important that representation on advisory committees and editorial panels become more truly representative of the provider groups affected by the codes, including naturopathic physicians, and needs your fullest attention and action.
Our profession has participated and is participating in numerous studies, both on outcomes and utilization. Some of these are supported by grants from NIH National Center for Complementary and Alternative Medicine and are carried out by the naturopathic medical schools; others have been completed or are underway at conventional medical institutions. Some ND’s enlist the aid of medical students and recent graduates from naturopathic medical schools to aid in the gathering of data for office-based research. Much of this research is published in peer-reviewed journals.
We hope that this information is helpful to the Subcommittee in its deliberations and recommendations to the Secretary, and we thank you for the invitation to submit testimony.