Documentation in the Alternative Care Setting
Cover Story
Documentation in the Alternative Care Setting
Everybody knows that treatment options are different in this environment. Are records kept differently as well?
Guided imagery. Therapeutic touch. Herbal remedies. In the past, these alternative treatment options have been placed in the same category as sorcery, witchcraft and supernatural powers by many Americans—medical practitioners and patients alike.
But before dismissing this branch of medicine as quackery, take a closer look—it’s a field that has been gaining ground (and respect) in the United States in recent years. In fact, various estimates show that Americans are spending $25 billion to $40 billion per year on alternative therapies—mostly out of their own pockets. And many traditional practitioners of Western medicine (although by no means a majority) are beginning to investigate, learn and utilize some of these age-old remedies.
While these recent developments may be very beneficial to patients, they do raise a few issues for health information management (HIM) professionals. For example, how are these new patient care options being documented in alternative care settings? Does this information also get recorded in the patient’s traditional medical record—and if not, should it? If the details of alternative visits aren’t being made available to a patient’s traditional doctors, does this “knowledge gap” pose any problems or health risks for patients?
ADVANCE investigated the situation and found that yes, there is a knowledge gap created by having two separate patient care realms; and indeed, it could be potentially harmful to patients. Because these therapies are becoming more pervasive, it’s important for HIM professionals to become familiar with the techniques and terminologies used in alternative medicine.
Can’t We All Get Along?
Although alternative medicine is steadily inching into the mainstream, its progression has been slow. Despite the fact that some techniques currently described as “alternative” are thousands of years old, have been extensively studied in Europe and elsewhere, and are regularly used in other cultures, a majority of physicians in the United States consider them scientifically undocumented and unreliable.
In fact, such a stigma has been attached to alternative health care that many patients who seek such treatments for their symptoms are reluctant to tell their traditional physicians and other caregivers. “Medical studies have documented the fact that patients do not tell their mainstream physicians about their alternative care visits,” noted Dr. Richard Clofine, DO, FACOOG, an obstetrician/gynecologist practicing at Complementary Obstetrics and Gynecology in Lilburn, GA. “Patients don’t want to risk angering their doctor, nor do they want their doctors to ‘look down’ on them for trying something that is viewed by much of the medical community as quackery.”
Sound like an overdramatization? Apparently it isn’t. “I know people who have told their regular doctors about the positive results they’ve had with alternative treatments, and their doctors reacted with a combination of disbelief, horror and anger,” added JoAnn McCurdy, vice president for medical services at the American Centers for Health & Medicine (ACHM) in Phoenix. “Patients definitely weigh the pros and cons before confiding in their doctor. If they try a certain treatment and it doesn’t work, they’ll figure, ‘Why bother telling my doctor about this when it didn’t work?’ In the back of their minds, these patients know that they still have to continue a relationship with their regular doctors; and in that relationship, it is important that they be taken seriously.”
But this selective disclosure of medical details creates a wall between doctor and patient—a wall that can negatively impact patient care. “This ‘knowledge gap’ is a major problem,” Dr. Clofine asserted. “A lack of honesty and a feeling of distrust between doctor and patient cannot possibly be good for any patient’s long-term care.”
In addition, what doctors don’t know can in some cases actually hurt patients. Herbal remedies that are fine for some people could cause harm in others or could conflict with or counteract the effects of traditional medicines (licorice root, for example, should not be taken by patients with high blood pressure). “Patients who are medicating themselves and not telling their doctors are handicapping their own medical care,” McCurdy affirmed. “To serve you best, your doctor must be made aware of all of the treatment options you’ve explored—whether they are over-the-counter or alternative.”
Bridging the Gap
Fortunately, the tide is beginning to turn; alternative medicine is slowly gaining the respect of the United States medical community. In fact, many health care practitioners working in the field no longer refer to these therapies as “alternative” at all—rather, they prefer the terms “complementary” or “integrative,” to imply that such treatments are to be used in addition to or in conjunction with traditional Western medical treatments.
“This is definitely not a matter of ‘us vs. them.’ The philosophy behind alternative medicine is to treat each patient as a whole individual—not just treat the medical symptoms,” explained Margaret Cary, MD, MBA, MPH, who, as regional director of the United States Department of Health and Human Services (HHS), oversees approximately 350 federal employees in Colorado, Montana, Utah, Wyoming and North and South Dakota. “Medical practitioners who are turning to alternative medicine are doing so to add to, not replace, the treatment options in their repertoire.”
Dr. Clofine agreed. “No one is suggesting that we substitute alternative therapies for traditional medicine,” he stated. “But it can be very beneficial to add certain alternative therapies into a traditional care regime. This is why the term ‘complementary’ is a more accurate way to describe how these therapies should be used.”
ACHM is one example of an integrated care facility. “Our MDs and DOs work in tandem with the center’s licensed massage therapists, acupuncturists and herbal therapists,” McCurdy noted. “Many of our physicians have also received training in one or more of these complementary areas. Because we are a physician-driven care venue, our center manages to garner an unusually high level of respect in the local medical community.”
Indeed, the surest way into the mainstream medical community’s heart might just be through its best and brightest practitioners, who lend their credibility to the endeavors they support. According to a recent article in Hospitals & Health Networks, most successful complementary medicine programs usually credit a highly respected doctor who championed the cause.
Documenting Care
“The way that complementary services are being documented can differ widely from one site to the next,” said Dr. Clofine. “Furthermore, practitioners in alternative settings do not have a commonly accepted vocabulary of terms and language to apply to patient treatments and services. So even if two different practitioners are describing the same course of therapy, there is still a lot of room for variation.”
McCurdy reported that at ACHM, patient care documentation and medical records upkeep is basically on par with that of the traditional domain. “Because our centers are physician-oriented and driven, we have a standard, extensive and thorough medical record. We are also licensed by the state of Arizona, so we have to meet the same documentation and record-keeping standards as any other outpatient treatment center in the state.”
In addition to traditional medical documentation—history and physicals (H&Ps), progress notes, medication sheets, etc.—medical records at ACHM also might contain special forms. Each type of complementary therapy has its own, unique form designed to document the course of that particular treatment. For example, the form for acupuncture prompts doctors to record which circuits or meridians were needled and in which areas of the body. “All of these forms are then integrated into the one, complete medical record that exists for each patient,” McCurdy explained.
McCurdy also noted that ACHM has developed special, internal codes to signify the complementary therapies being utilized at the centers. “We’ve developed a rather unique superbill to use at the facility,” she explained. “We want to track our complementary services for outcomes and research purposes. We are working with insurers to track costs, utilization and patient satisfaction.”
Furthermore, McCurdy reported that sometimes ACHM even receives reimbursement from Medicare for some of the complementary services rendered to patients (subject to certain restrictions). “Some of the integrated services performed at the centers do fit into ordinary CPT categories and are reimbursable if they have been performed by licensed physicians or certified counselors,” McCurdy explained. “The common term in the industry is called ‘crosswalking’—the service isn’t explicitly listed under a code, but it’s similar enough to crosswalk into that category of services.”
Guided imagery, for example, is a type of counseling; and this service can be “crosswalked” into standard CPT codes for counseling if the person performing the service is a credentialled, certified counselor. Feldenkrais®, the use of non-intrusive touch to release painful neuromuscular patterns that build up after an injury, can be crosswalked into standard physical therapy CPT codes, but only if a licensed physical therapist performed the service.
“Other things, like acupuncture, just don’t crosswalk,” McCurdy commented. “We advise all of our patients when they begin treatment that some of our services are not reimbursable. They know up front the costs they will have to pay out of their own pocket.”
Winds of Change?
And how long will it be before complementary therapies are considered reimbursable across the board by insurance companies? Although it will probably take years or even decades for this to happen, some believe it’s already in the works. “Consumers are the ones demanding these services, so consumers will drive this change as well,” stated Dr. Clofine. “It’s not so much a question of ‘Will it happen?’ but rather a question of when and how.”
Consumers may be winning round one of the battle already. According to a recent report in Hospitals & Health Networks, a recent survey of 80 national health maintenance organizations (HMOs) by Landmark Healthcare, a Sacramento, CA-based firm that provides chiropractic and acupuncture services, found that 58 percent intend to cover alternative therapies by 1998.
“If patients believe that complementary therapies are helping them, you can bet your bottom dollar that eventually they will want to be reimbursed for these treatments by insurers,” Dr. Clofine assured. “But that could only be a good thing in terms of patient care. Not only would it force an acceptance of complementary medicines from traditional health care practitioners, it would also serve to bridge the knowledge gap that currently exists between the two worlds.”
Anne Miller is an assistant editor at ADVANCE.
