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Chiropractic’s Next Battle: AMA Ownership of the CPT Codes

Chiropractic’s Next Battle: AMA Ownership of the CPT Codes

The Chiro.Org Blog


SOURCE: Dynamic Chiropractic ~ Dec 16, 2010

By Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher


As 2010 comes to a close, it is important to look ahead to see what we can do as a profession to brighten the future of chiropractic. Among the many bits of information that have come across my computer monitor of late is a very interesting article by John Weeks of The Integrator Blog, “an organizer-writer in the emerging fields of complementary, alternative and integrative medicine since 1983.” [1] The article points out that the American Medical Association (AMA) has owned the current procedural terminology (CPT) codes for more than 40 years.

The benefits of this ownership are probably much greater than you realize. Basically, they amount to the following:

  • Control:   By owning the CPT codes, the AMA effectively keeps a lid on what doctors of chiropractic (not to mention nurses, optometrists, acupuncturists, doctors of naturopathy, etc.) can be reimbursed for. None of the other health care professions is able to create new codes that are more reflective of what they do (and should be reimbursed for) without saying “AMA, may I?”
  • Influence:   By controlling the CPT codes, the AMA is able to influence health care policy decisions on a national level through its relationship with the U.S. Department of Health and Human Services, particularly with the Centers for Medicare & Medicaid Services. This ultimately translates into undue influence with third-party payers who are unlikely to jump over the CPT code barrier to explore more efficient care options from non-medical providers.
  • Money:   Weeks estimates that the AMA’s CPT-related income is approximately $71 million per year. Not a small chunk of change considering that their membership dues (from less than 20 percent of licensed MDs) is less than $44 million. Here is AMA’s income breakdown for 2009 [2] (unfortunately, the CPT-related income is not able to be broken out): membership dues $42.3 million; advertising $23.4 million; periodical subscription revenues $12.7 million; other publishing revenue $19.3 million; books, newsletters and online product sales $50.0 million; royalties and credentialing products $66.4 million; insurance commissions $34.0 million; investment income $9.6 million; grants and other income $10.6 million; and other $0.5 million.

The most important point to all this is what the AMA does with the $71 million of CPT-related income each year. The AMA typically spends between $15 million and $22 million in direct lobbying each year, something it refers to as “advocacy.” Much of that lobbying money is spent to keep chiropractic and other non-medical professions in their place. Add to that “marketing and communications” spending that runs between $13 million and $27 million each year, and almost $50 million is spent each year to advance the AMA agenda.

Other probable uses for the money include the Scope of Practice Partnership (SOPP) campaign that began in 2006 and continues today. [3] The Scope of Practice Partnership is designed to oppose any effort by any other health care profession to expand their scope into areas where the AMA doesn’t want them.

Interestingly enough, the genesis of Weeks’ article was a question from integrative nursing leader Mary Jo Kreitzer, RN, PhD, who founded and directs the Center for Spirituality and Healing at the University of Minnesota. What makes this interesting is that chiropractic is not the only profession looking at the unfair advantage the AMA has established with its continued ownership of the CPT codes. This battle could help us build some exciting alliances with a number of professions, particularly the nurses.

To close, I would like to offer the “recap” from Weeks’ article, as it does an excellent job of presenting the important points. In the article, he refers to the various health care professions as “guilds”:

  • “All guilds must use the CPT if they want to participate in 3rd party payment.
  • To do so, they must pay one guild, the AMA.
  • This guild is pitted against their efforts to expand their practice scopes.
  • In addition, this guild is apparently opposed to multidisciplinary recommendations from the brains of US medicine about the future of healthcare in the United States.
  • As is clear in the IOM report, many medical doctors are not aligned with the AMA position. In fact, the AMA that received these $71-million+ each year presently counts only 15%-20% of MDs as dues-paying members.”

As I look at our horizon, I can see no better opportunity for this profession to break the bonds of the AMA’s hold on the chiropractic profession (and all other health care professions) than through breaking their grasp on the CPT codes.

References

1.   Weeks J. “The AMA’s $70-Million Taxation Without Representation: Is It Time for a ‘CPT Party’ Royalty Revolt?
The Integrator Blog ~ Wed, Oct 20, 2010

2.   American Medical Association Annual Report, 2009

3.   “AMA Scope of Practice Partnership Tightens Its Grip
Dynamic Chiropractic, Jan. 15, 2007

19 comments to Chiropractic’s Next Battle: AMA Ownership of the CPT Codes

  • Fascinating article. I imagine that this control over the CPT codes reflects the AMA’s future-thinking at the dawn of the insurance age. There would be no need for standardized codes without insurance companies. If my chiropractic history is correct, our profession was still too young and disorganized at the time to seize the opportunity.

    As a recent chiropractic graduate, I remember being told in school about the suits vs. the AMA and the long legal history between our professions. I would hope that healing professions could find mutual ground in each other’s wellbeing, and see the others not as competitors but as cooperators in the health of our patients. But, when there’s strife and struggles as mentioned in the article, it usually comes back to one thing: control. Here’s hoping for a brighter future for all of us, where money doesn’t have to be wasted on CPT lobbying.


    RESPONSE from Frank

    I applaud your sentiments. In a perfect would, we’d all be lovingly doing our jobs in a conflict-free world. I look forwards to it! Meanwhile we need to continue to fight the good fight (like the Wilk Case did) to “even” the playing field. The AMA is very tenacious, and they won’t yield an inch without our concerted efforts.

    With or without Insurance, there’s a lot of benefit for having codes that identify specific services provided. Most of the retrospective reviews that demonstrated chiropractic’s cost-effectiveness would have never been possible if there were no diagnosis (ICD) and service (CPT) codes to identify and compare similar cases and their management, outcomes and overall cost.

  • [...] Continued here: Chiropractic's Next Battle: The AMA and CPT Codes [...]

  • Jerry

    Very interesting article.

    Didn’t the UCA have a concerted effort to produce a set of codes specific to the chiropractic profession back in the mid 1990′s?

    What ever came of that effort?


    RESPONSE from Frank

    Those (ABC) codes only relate to alternative/complementary treatments. Because CPT had just accepted the 4 CMT codes, I don’t think any National Associations paid it much mind. That’s too bad. Have you ever looked at the tiered levels of coding that DOs use for their SMT?

  • Jerry

    p.s.

    Typo: I meant ICA !

  • Maine Chiropractor

    If the codes were more comprehensive then maybe we could spend more time with our patients and spend less time worrying about whether or not we will be paid for our services (most of us provide them regardless).

  • Since 1996, the American Chiropractic Association (ACA) has been the voice of chiropractors in the collaborative maintenance of the AMA’s Current Procedural Terminology (CPT) codes. By working with CPT, the ACA helped develop a range of specific codes for reporting chiropractic manipulative services (98940-98943). The inclusive nature of the ACA’s full participation in the CPT process stands in stark contrast to the article’s call for confrontation.

    CPT is maintained by a broad collaborative process that not only involves chiropractors, but also includes input from physicians and other health professionals, insurers, government agencies, and organizations representing more than 100 health care fields.

    CPT is one of several code sets used to report procedures. Another example includes Current Dental Terminology (CDT) codes developed by the American Dental Association. Nothing prevents the chiropractic profession from following in the foot steps of the medical and dental professions and developing a unique code set.

    Creating a set of reporting codes will not guarantee payments from insurers. There is no truth to the claim that a procedure will be covered by insurers just because a CPT code has been assigned to it. Only the government and private insurers decide payment policies, and not all CPT codes are accepted as covered procedures. Insurers alone bear responsibility for these payment policies.

    It is a gross mischaracterization to claim that CPT generates $71 million in AMA revenue. This reckless estimate is a based on a distortion of the transparent information the AMA voluntarily offers about its finances. The AMA has publicly reported this figure represents income from its complete line of books and products, which include more than 100 items, not just CPT.

    The AMA alone paid for the 44-year development of CPT, and it invests millions of dollars annually to ensure CPT accurately reflects contemporary patient care. This precision is responsible for CPTs wide use throughout the health system. A universal language for reporting procedures benefits all health professionals by making it more efficient to communicate vital information to hospitals, insurers, and government agencies.

  • Maine Chiropractor

    The problem I have with the current CPT codes is that I do more than 98940-98943. The codes as written pidgeon hole our profession into manipulation only. If we develop more codes, we may get paid, we may not. If we DO NOT develop more codes then there is a 100% certainty that we will not be paid for the additional services that we provide. Doing SOMETHING is always a better option than doing nothing.

  • The CPT codes developed for CMT were designed to help report a unique procedure and do not pigeon hole chiropractors. According to the American Chiropractic Association, a few dozen CPT codes are utilized by chiropractors on a daily basis. It’s up to each health care professional to choose the CPT codes that accurately reflect the services provided to patients. Only insurers, however, decided if they’ll pay for services that have been accurately reported. Insurer payment policies are as much of a challenge for physicians as they are for chiropractors.

  • AMA,

    Thank you for your astute comments. I appreciate your monitoring this thread.

    I’m not clear what service Maine Chiropractor is referring to which is “more than 98940-98943″, that could not be described by other physical medicine codes (the 97000 series).

    I was miffed when CPT eliminated the myofacial release code (97250) because no other code accurately reflects the work involved. The “supposed” replacement MT code (97140) code is poorly defined, and because of the confusing inclusion of the word “manipulation”, has caused nothing but havoc when it is billed with a CMT code.

    Myofascial release is a unique (and intensive) process, and really should have it’s own unique code again.

  • Maine Chiropractor

    Frank you nailed it. We need separate codes for myofacial release in addition to a slew of other techniques that we use that have no accurate codes under the current system. Many just lump these under “Manual Therapy” which insurers love to deny. If you are working with a patient on say, a Bosu Ball in order to improve balance and strengthen the muscles in the lower leg, how do you accurately bill for it under the current system?

  • Maine Chiropractor brings up a good point. Insurers can unilaterally manipulate CPT codes and guidelines so they are not applied as intended by health professionals.

    When the HIPAA law was enacted, lawmakers allowed insurers to implement and interpret the CPT code set as they see fit. This sweetheart deal for insurers allows each company to manipulate CPT to best fit their bottom line rules for processing and paying medical claims. The resulting confusion and inconsistency in claims processing necessitates that all health professionals must maintain a costly claims management system for each health insurer.

    Not even the insurers themselves can keep their own payment policies straight. One in five medical claims is processed inaccurately by commercial health insurers, according to the AMA’s National Health Insurer Report Card. A 20 percent error rate represents an intolerable level of inefficiency that wastes an estimated $15.5 billion annually.

    As long as each insurer uses different rules for processing and paying medical claims, the system will be hampered by complexity, confusion and waste. Eliminating this variability with a single transparent set of processing and payment rules for our multi-payer system would create huge savings and allow health professionals to direct time and resources to patient care and away from excessive paperwork.

  • Maine

    When I do rehab work (as you mentioned above) I use this prescription form:

    Rehabilitation Prescription

    Mr./Ms. has been diagnosed with biomechanical and structural instabilities that directly contribute to his/her symptoms. A prescription for a managed care rehabilitative exercise program, utilizing resistance tubing devices and other equipment, has been made. The purpose of this program is to provide a low resistance and high repetition workout, leading to gradual strengthening of the (___) region’s muscles and ligaments. This program is specifically designed to relieve pain, increase capillary action, loosen adhesions, and to increase the structural strength and stability of the region of complaint. This program involves Kinetic Activity (97530) and Therapeutic Exercises (97110), both for 15 minutes under direct supervision of the Doctor.

    97530 Kinetic Activity This is the beginning of our rehabilitation process. We do active and/or passive range of motion (ROM), active muscle stretches and/or resisted isometric stretches for 15 minutes. The purpose of this is to stretch the collagen tissue which is being laid down during the healing process. This will improve the strength and elasticity of the new “scar” tissue and improves functional performance.

    97110 Therapeutic Exercises The patient does resistive exercises to develop strength and endurance, range of motion and flexibility, which all lead to stability of the spine. This program is specific to the injured tissues, as well as to the regional musculature. This is a 15 minute program.

    As for proprioceptive work, as on a ball for balance and increasing the speed of muscle response to perturbations in the environment, I use the Kinetic Activity code, as it’s the closest in description.

    As AMA mentioned, creating a slew of new codes would not guarantee that 3rd parties would adopt (or pay) for them.

  • Frank is correct. The CPT code for myofacial release (97250) was deleted and replaced in 1999. It is of paramount importance to the AMA that CPT reflects contemporary patient care. CPT relies on coding change proposals to keep it up to date with advances in clinical care. Anyone can submit a coding change proposal at:

    http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/applying-cpt-codes.shtml

    The American Chiropractic Association’s full participation in review of additions, revisions, or deletions to CPT ensures chiropractors have a voice. The ACA’s years of experience in the CPT process can be very helpful to any chiropractor who is interested in submitting a coding change proposal.

  • AMA

    Thanks for the link to submit a CPT code for consideration. The only drawback would be the vested interests of those who deleted (or should I say combined) 5 different codes into the poorly received MT code. Assuming they are still involved in a decision making role, they might resist a submission for a new Myofascial Release code out of a vested interest (EGO) to protect their previous actions.

    Considering the formidable time I would have to invest in preparing a submission, I’d like to get some background on why *they* chose to cram 5 distinct procedures into one little code?

    The replaced codes were:

    97250 ~ Myofascial Release
    97122 ~ Manual Traction
    97265 ~ Joint Mobilization
    97260 ~ Manipulation, and
    97261 ~ Manipulation (for each additional Area)

    The last 2 codes (The old Medicare codes chiropractors were required to use to describe CMT) were replaced by the new CMT codes, and it made sense to remove them.

    However, the rest of these removed codes all suggested that the *new* Manual Therapy (97140) code was the appropriate replacement code for traction, soft tissue release of TrPs, and joint mobilizations.

    This was a rather transparent way to remove 3 separately billable codes which described vastly different treatment procedures, cramming them all into one code. These codes were not removed because they lacked validity….they were merely crammed into one code to reduce payment options.

  • Maine Chiropractor

    Exactly. It boils down to dollars and cents every time. If you perform all three of the services mentioned (97250, 97122 and 97265) shouldn’t you be reimbursed accordingly (in addition to 9894X)?

  • Frank,

    The following background come from the Journal of the American Chiropractic Association, March 1999…

    “The new code, 97140, was developed to replace codes 97122, 97250, 97260, 97261, and 97265 to describe both joint and soft tissue manual techniques, inclusive of manipulation or mobilization. The American Physical Therapy Association (APTA) wanted the services deleted to obtain a manipulation code similar to the Chiropractic Manipulative Treatment (CMT) and the Osteopathic Manipulative Treatment (OMT) procedures (CPT 98925 – 98929 and 98940 98943). APTA proposed creating a code set identical to the CMT and OMT codes that would be used to describe four codes for mobilization/manipulation.

    “CPT 97122 (traction, manual, each 15 minutes) was deleted because the code describing this procedure would be considered a fragmentation of another service described in CPT 97140. The rationale is that manual traction is a form of joint mobilization, and the relative value for this service is inherent in the relative value of more comprehensive services already existing in CPT.

    “The Health Care Financing Administration (HCFA) recommended the deletion of CPT codes 97260 and 97261 because the codes were defined as a “separate procedure,” and there were more appropriate ways to describe physician-level services for manipulation with the CMT and OMT codes, which include an evaluation and management component.”

  • Excellent thread! AMA, thanks for chiming in. It seems you are doing much – if even in this small space – to bridge some gaps between chiropractors and the AMA. DCs are in a tough spot, because although we know we are filling a huge gap in the health care community, we have been completely spanked by the AMA and MDs in regard to national leadership and business savvy. Traditional medicine owns the system, and that is frustrating for DCs. I thoroughly enjoyed the conversation. Thanks for all the info.

  • AMA

    That’s rather circular logic isn’t it? You suggest they got rid of 97122 (traction, manual, each 15 minutes) because is *could* be a portion of the Manual Therapy code (97140), when in fact, they crushed 3 very different codes into one code, simply to reduce the options for billing. I believe the proper term is referred to as bundling.

    Now, if the relative value units assigned to the new code actually reflected the training, time of application, and professional art and skill involved in doing the procedure(s) I wouldn’t complain, BUT, in fact the RVU is lower than for kinetic activity (97530) at .63, and is actually closer to unattended therapy (97014) at .40, which I take as a real insult!

  • Wow, what an interesting thread! Surprising to see an AMA rep here responding. The professional courtesy of a response in this dialogue is nice. Regarding the distinction between myofacial release techniques versus manipulative maneuvers…Frank is right, in that they really are intensive, can be time consuming, and a whole ‘nother ball of wax.

    In a perfect chiropractic world, I’d like to see the same distinctions drawn between adjustments codes based on the system of analysis. Because adjusting a 98940 after a half hour film analysis is different than adjusting after 3 minutes of joint palpation and passive range of motion. If we could control these codes we might actually get to describe the diversity of approaches we’re actually using.


    RESPONSE from Frank

    There already is a distinction for adjusting after a lengthy review of films…it’s an E&M code (99212-3) associated with the assessment that led you to take the films.

    Whenever you spend significantly more time than the *usual* pre- and post- assessment (for example, a change in symptoms or diagnosis) you should use an E&M code with the modifier -25, to advise the 3rd party that a separate E&M was required in addition to the adjustment. Your documentation must also substantiate the level of care you provide.

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