Part B Insider (Multispecialty) Coding Alert

Consumer choice doesn't extend to extra codes, critics charge

The American Medical Association-s monopoly on physician codes may be restricting patients- ability to choose alternative treatments, critics charge.

On Oct. 16, 2006, the Centers for Medicare & Medicaid Services (CMS) killed a project that Health & Human Services Secretary Tommy Thompson, initiated before his resignation at the end of President Bush-s first term. Thompson had authorized Alternative Link, the parent company of ABC Coding Solutions, to use its own code set for billing purposes in Alaska and New Mexico.

For Alaska's 4,000 patients and 500 paraprofessionals who participated in the program, ABC codes created 50 percent savings in bush and rural communities versus using only CPT codes, according to Tim Bolen, a crisis management consultant for Jurimed.

New Mexico also demonstrated the potential benefits of alternative billing methods. Insurance companies participating in the pilot program concluded after three years that services for seniors who participated in the program cost less than for those who did not, Bolen said in a statement.

Despite the trial's apparent achievements, CMS denied ABC's October 2006 request for a continuation of its right to use ABC codes in electronic claims transactions. Individuals using ABC billing codes must now file claims using manual transactions; this reversion to labor-intensive paper filing comes even as HHS officials tout the cost-saving potential of advances in health IT.

Melinna Giannini, president of ABC, wrote a letter to Daniel Levinson, HHS Inspector General, requesting an investigation into CMS- refusal to extend ABC's ability to file electronically. That decision could cost the United States $51 billion in health IT savings, Giannini alleges--a steep price to pay for the privilege of restricting competition in the medical billing field.

Bolen insists the AMA has used its monopoly on billing codes to restrict the growth and practice of health care providers not licensed by the AMA. AMA-licensed MDs have more than -8,000 codes to use for billing while the government and the AMA dole out a few token codes to osteopathic surgeons, nurses, chiropractors, acupuncturists, massage therapists- and other non-traditional health care providers, Bolen said in a statement.

Even though concerns over the legality of this monopoly prompted the AMA and CMS to remove the exclusivity clause from their agreement a few years ago, alternative coding systems have remained irrelevant at least in part because of governmental inaction, as in the case of ABC, argued Sen. Trent Lott (R-MS).

In its defense, the AMA claims to offer every medical treatment the opportunity to qualify for a CPT code upon demonstrating its clinical success.