Editor's Note: To read Part 1 of this article, visit www.acupuncturetoday.com/mpacms/at/article.php?id=33137.
ICD (International Statistical Classification of Diseases and Related Health Problems) is a numbered list of codes managed by the World Health Organization (WHO), for Western Diseases, Symptoms and Medical Conditions, designed to measure mortality and morbidity data. Traditional Chinese Medicine (TCM) has yet to be officially given ICD codes for Pattern Differentiation. This affects access to TCM care, reimbursements and data collection (including efficacy and safety). The next version of ICD-11 has plans to change all of this. The future may be more inclusive than you thought!
For more than five years, International Classification of Traditional Medicine (ICTM) experts have worked in a Technical Advisory Group (TAG) representing several countries, to build TCM ICD codes. This was motivated by the findings that showed that a great number of the worlds population was not using medicine coded by pre-existing ICD diagnosis codes (potentially as much as 80%), therefore, mortality and morbidity data were lacking for a great many people world wide. The WHO has released 10 versions of ICD; each country decides when, and how to implement updated versions. The United States made ICD coding mandatory for mortality data in 1999. Over the past 17 years, hospitals have been adopting and maintaining ICD implementations, with each updated version (the last ICD-10 required for inpatient hospital procedures was October 1, 2015). Hospital systems are skilled with ICD coding within electronic medical records, insurance billing and data management. In this interview, I speak with Galina Roofener, LAc at Cleveland Clinic's Wellness Institute, about how medical codes affect her TCM practice in a mainstream hospital, what the inclusion of TCM in the next ICD-11 codes mean to her and how TCM practitioners can help bring them forward.
Galina: Not many TCM schools teach students standard ways to deal with charting for a real multidisciplinary clinical setting, where notes can be shared amongst healthcare professionals. Understanding ICD codes and their relationship to the practice of TCM is essential. Unless the patient was referred by an MD for particular diagnosis, TCM practitioners must use symptoms/syndromes such as cough for ICD coding, rather than using a Western Medical Diagnosis such as pneumonia, in order to remain within the TCM scope practice of medicine. Some practitioners think ICD limits my treatment options. The reality is, it doesn't limit my style of acupuncture or herbal formulary, but it determines content of my notes, which must support both my TCM and ICD-10 diagnosis.
Shellie: Can you give our readers an example of how ICD codes affect your patient charts?
Galina: For my TCM practice, diagnosis of disease is incomplete without pattern differentiation. To be compliant with hospital charting, ICD billing requirements, as well as with documentation to support my Chinese herbal formulation, I use both TCM syndrome diagnosis and ICD codes. Currently, there is no ICD-10 diagnosis that really tells the TCM story. An example of how I blend these together reflecting necessary minimum of detailed information may look like this.
Subjective: For 8 years, patient complains of migraine headache located in the right temple area. Quality of pain is throbbing, severity of pain ranges from 4 to 9 on the scale 1 to 10 (10 being unbearable). There is no aura preceding an onset. Patient wakes up with migraines 2 to 3 times per week that may be accompanied by nausea and irritability. Patient denies any dizziness. Was treated by multiple medications without success. No other complains.
Objective: On 03/26/2015 had brain MRI that reveled no brain abnormalities.
TCM pulse: string-like.*
TCM tongue: dusky, thin white coat.*
If my patient is seeking an acupuncture treatment, in my notes I will write down a TCM diagnosis that I may select based on Channel Pattern Identification/Syndrome Differentiation. Migraine due to obstruction of lesser yang meridian.* If my patient is seeking an herbal treatment, in my notes I will write down a TCM diagnosis that I may select based on Visceral Pattern Identification/Syndrome Differentiation. Migraine due to ascendant hyperactivity of liver yang.*
For both acupuncture and/or herbal treatment, my billing ICD-10 diagnosis is: (the most close matching) intractable chronic migraine without aura and without status migrainosus G43.719** (Migraine is a syndrome/neural condition characterized by a severe recurrent vascular headache, usually on one side of the head, often accompanied by nausea, vomiting, and photophobia, sometimes preceded by sensory disturbances. Intractable means stubborn, non-responsive to standard treatment. Chronic means longer than 3 months. Status migrainosus is severe type of migraine that can last more than 72 hours.
Shellie: The WHO is actively working on ICD-11 to include TCM terms and coding. How do you see the environment changing in mainstream medicine when this inclusive TCM terminology arrives?
Galina: It will be the most important step in the development of traditional medicine. Acquiring a set of diagnostic codes along with the incorporation of a Doctorate degree as a professional entry-level requirement in the U.S., will pave the ground for TCM practitioners. We are heading down the same road that fairly recently, Doctors of Chiropractic traveled. An example of a chiropractic diagnosis with a code is: Nonallopathic lesion of cervical region M99.01** Our own set of diagnostic codes will bring us another step closer to recognition, as well as a higher acceptance among the medical community. There will be no more questions of if we are a technician, or a licensed independent practitioner like an MD. I do the work of the physician and I want to be recognized accordingly.
Shellie: Marilyn Allen has been working hard to fund the campaign for the inclusion of TCM into ICD-11. You are donating a portion of your courses to the effort. How can practitioners learn more and get involved in bringing ICD-11 forward?
Galina: The WHO manual of International Standard Terminologies on Traditional Medicine in the Western Pacific Region is the source for ICD-11. You can download the manual at www.wpro.who.int/publications/PUB_9789290612483/en/
TCM practitioners need to get involved. How soon ICD-11 arrives depends on our support. The United States TCM community is behind the rest of the world due to a financial shortage. I encourage all of us to donate money to the effort. If every practitioner gave $10, the project could reach its' goal. You can find more information on the ICD-11 project and download a donation form provided by Marilyn Allen on my website www.asiantherapies.org/academy. Learn more about what it is and share the information with others.
Standardization of terminology is a keystone as TCM is being built into the Western medical system. I'm excited for the ability to collect research using ICD-11 TCM codes. The potential safety and efficacy data of TCM could lead to reimbursement by insurance companies as it occurs in Taiwan.
For decades, Taiwan has collected data based on the practice of herbal medicine, and their insurance systems pay for herbs. Galina, thank you for your thoughts, as well as your clinical procedures and practices. In future conversations, we will discuss the role of standardization and EMR recording of traditional Chinese herb prescriptions.
Click here for more information about Shellie Rosen, DOM, LAc.