Putting the HIM in IM: Assimilating Integrative Medicine into Clinical Documentation

By Ruthann Russo, PhD, JD, MPH, MSAc, RHIT


As integrated medicine becomes more common, HIM professionals have a unique opportunity to improve its documentation.


With integrative medicine (IM) services now offered by 80 percent of hospitals and healthcare systems, it's safe to say that integrative medicine is no longer a niche practice.1 With integrative medicine providers proliferating and the number of services they offer increasing, it's more important than ever to ensure that everyone, including patients, can effectively use the clinical documentation of IM providers. As a result, HIM professionals have significant opportunities in this area.

Because IM services are often provided in an outpatient clinic, this subset of healthcare providers and their patients may fall outside of the scope of work of the typical HIM professional. Increasingly, however, IM services are being provided in inpatient settings as well. HIM professionals need to be aware of and assist these healthcare providers to understand the power of the health record. The aim: to educate healthcare systems to standardize the documentation of integrative medicine practitioners in a way that is meaningful for the practitioner, the healthcare facility, and the patient.

This article offers an introduction to integrative medicine services and the licensed integrative medicine professions and explains integrative medicine patients' opinions regarding their health records. It also offers some suggestions for how HIM professionals can get started assimilating IM documentation into the EHR and clinical documentation for coding.

Integrative Medicine Defined

"Integrative medicine" is the term used by most healthcare systems to identify their use of complementary and alternative therapies within the structure of traditional medical care. According to the Arizona Center for Integrative Medicine at the University of Arizona: "Integrative medicine makes use of all appropriate therapies, both conventional and alternative. Integrative medicine is a healing-oriented medicine that takes account of the individual as a unique and whole person, taking into account body, mind, and spirit."2

For example, a patient seeking an integrative medicine approach to treatment for back pain may visit an orthopedic surgeon to rule out the need for surgery, followed by acupuncture or chiropractic treatment and long-term massage therapy. Because this example involves both traditional and complementary and alternative medicine (CAM) treatments, it falls under the umbrella of integrative medicine.

Although the phrase "integrative medicine" has largely replaced the phrase "complementary and alternative medicine," the National Institute of Health's National Center for Complementary and Alternative Medicine uses the CAM acronym because the site is dedicated to providing resources about both complementary and integrative medicine. This site is an excellent resource for learning about all CAM therapies.

Patient Use of CAM in the US

Studies show the use of CAM as high as 90 percent for certain patient populations in the United States, and 38 percent for all adult Americans.3 Sixty-two percent of Americans reported using some form of CAM therapy within the 12 months preceding a recent survey. In 2010, American adults spent an estimated $36 to 47 billion on purchases of CAM services, a significant increase from $34 billion reported in 2007.

Up to 12 percent of patient out-of-pocket healthcare spending goes towards CAM, evidence of the growing patient demand for CAM services.4 About 35 cents of each CAM dollar is for visits to acupuncturists, chiropractors, and massage therapists, mostly for pain relief. This represents nearly $12 billion, or about one-quarter of what Americans spend on visits to physicians.5 Continued growth in patient demand for CAM services has caused most healthcare systems to offer some IM services.

Acupuncture is perceived to be effective by most patients who use it to treat a specific condition.6 And acupuncture has been considered to be both highly effective and highly safe by the American College of Physicians (ACP) for migraines and post-operative nausea and vomiting.

ACP has also found acupuncture to be highly safe and moderately effective for chemotherapy-induced nausea and vomiting, cancer pain, anxiety, pregnancy-induced nausea and vomiting, acute gastrointestinal pain, PMS, infertility, incontinence, low back pain, neck pain, and osteoarthritis of the knee.7

Licensed Integrative Medicine Practitioners

It is estimated that there are more than 350,000 licensed integrative medicine practitioners in the US.8 States differ on license requirements and eligibility. The five licensed integrative medicine practitioner categories are chiropractors, acupuncturists, massage therapists, naturopathic doctors, and direct entry midwives. (Note that direct entry midwives, or certified professional midwives, differ from traditional nurse midwives.)

Massage therapists comprise the largest number of integrative medicine practitioners (250,000), followed by chiropractors (75,000) and acupuncturists (25,000). Chiropractors were first licensed to practice in the US in 1963, followed by acupuncturists in 1985, naturopaths in 1986, and massage therapists and direct entry midwives in 1994.

CPT Codes for Acupuncture and Massage Therapy

HIM PROFESSIONALS MAy want to consider whether it would be a good practice to capture codes for certain integrative medicine services. Currently, CPT provides codes for acupuncture and massage therapy.

CPT Code

Description

97810

Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97811

Acupuncture, one or more needles, without electrical stimulation, Each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needles.*

97813

Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97814

Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles

97010

Modality; hot or cold packs, 15 minute increment

97124

Massage treatment-15 minute increment

97140

Myofascial release, manual therapy-15 minute increment

Practice in Hospitals and Healthcare Systems

Licensed IM practitioners most likely to be employed by hospitals and healthcare systems are acupuncturists and massage therapists. Forty-seven percent of hospitals in a recent survey said they were interested in expanding their IM services, and 62 percent plan to expand acupuncture services. In hospitals, acupuncture and massage therapies are used specifically in the management of cancer-related and post-stroke symptoms, arthritis, and all types of pain.

Approximately one-half of academic medical centers (AMCs) have an integrative medicine program in place.9 Eighty percent of non-AMC hospitals offer some type of integrative medicine services.10 Visits to integrative medicine providers (624 million) exceeded the total visits to all primary care physicians (386 million) for 2007.11 In fact, most physicians would refer a patient for IM services if an IM practitioner were available at their facility, and most physicians believe that incorporating IM therapies into hospital care would have a positive effect on patient satisfaction.12

Clinical Documentation Practices of Integrative Medicine Providers

Most integrative medicine providers have clinical documentation practices that are specific to their profession and may not be understood by other practitioners. Because the health record serves as the communication tool among all healthcare providers, any uncertainty may negatively impact the quality of patient care. As a result, a shared understanding of all documentation practices in the health record is essential.

Acupuncturists have a specific methodology for documenting care. The most common acupuncture treatment is the insertion of acupuncture needles at specific points along energetic lines on the surface of the patient's body, known as meridians. These meridians are named for major organs in the body such as the lung, liver, kidney, and bladder. Each meridian contains a different number of acupuncture points; there are more than 365 acupuncture points on the body.

The acupuncturist documents the insertion of each needle using the meridian acronym and the point number. For example, if a needle is inserted on the 67th point of the bladder meridian on both the left and right sides of the body, the acupuncturist will document B-BL67 in the patient's record. The first B represents "bilateral" and the BL represents the bladder meridian.

Even if a physician or other healthcare professional caring for a patient can interpret this information, it is still important for them to know where on the patient's body BL67 is located. The location for BL67 is on the outside of the pinky toe, near the nail, and it is one of the most powerful points on the body. BL67 is used, among other things, to turn a breech baby's position while in utero, and has been documented as an effective treatment for breech presentation.13

This is just one example of the need for some level of standardization of documentation for licensed acupuncturists providing services in hospital settings. As integrative medicine therapies continue to grow in healthcare systems, it is essential to develop a standard for documentation across all healthcare disciplines.

How HIM Can Help

many conditions may be treated effectively with integrative medicine. For each listed below, HIM professionals can play different roles in developing and standardizing documentation and coding.


Diagnosis or
Chief Complaint

Evidence-Based Support for Treatment of Diagnosis or Symptom

EHR Standardized Format Development

Documentation Guideline Development


Coding Guideline Development

Acute GI Pain

Acupuncture

X

X

X

Asthma symptoms

Yoga, breathing techniques

X

Cancer pain

Acupuncture, massage

X

X

X

Chemotherapy induced N&V

Acupuncture, relaxation training

X

X

X

Fibromyalgia

Massage therapy

X

X

X

Infertility

Acupuncture

X

X

X

Major depressive disorder

Aerobic exercise, yoga

X

X

Migraine

Acupuncture, massage, meditation, MBSR, biofeedback, relaxation training

X

X

X

Neck Pain

Acupuncture

X

X

X

Osteoarthritis of the knee

Acupuncture

X

X

X

CHD – Prevention

Transcendental meditation, yoga

X

Post-operative pain

Acupuncture

X

X

X

Pregnancy induced N&V

Acupuncture

X

X

X

Pre-operative anxiety

Ear acupuncture; acupuncture, meditation

X

X

X

Source for columns 1 and 2: The American College of Physicians' Evidence-Based Guide to Complementary & Alternative Medicine by Bradly Jacobs, MD, MPH, and Katherine Gundling, MD, FACP. Philadelphia: ACP Press, 2009.

Patient Use and Understanding of Integrative Health Information

Concerns around integrative medicine health records involve patients as well as practitioners. In a recent study, acupuncture patients were found to be less knowledgeable about their health records and less confident about asking their practitioner for copies of their records than patients visiting their physician.14 In addition, only 27 percent of patients treated with acupuncture have a copy of their medical record while almost half of patients treated by physicians have a copy of their medical record.

Most acupuncture patients feel "somewhat" confident about asking their acupuncturist for a copy of their health records, while patients feel "very" confident asking their physician for their records. All patients appeared to be equally interested in the information kept in their health records. However, acupuncture patients were more interested in finding out how to obtain copies of their health records than patients of physicians. These findings support the need to educate both integrative medicine practitioners and patients about their rights and responsibilities with regard to their health information.

The Roles for HIM Professionals

HIM professionals can play several key roles in the standardization of clinical documentation in healthcare systems that impact patient care, research, coding, EHR implementation, and healthcare planning. HIM professionals can begin by learning which integrative medicine therapies are provided in the organizations where they work, as well as where the services are provided. The HIM professional can determine how IM providers are documenting in health records as well as how other healthcare practitioners who care for the same patients are using the IM documentation. Once HIM professionals have gathered this basic information about the healthcare systems where they work, they can take some or all of the five following recommended actions:

Educate. HIM professionals can educate physicians, clinicians, and administrators about the importance of standardizing all clinical documentation, including documentation provided by integrative medicine practitioners. There is a need to develop formats for integrative medicine documentation that are understandable to all healthcare practitioners as well as useful to the IM practitioner. These standards should be incorporated into all electronic health record templates.

Rethink practices. Documentation from an integrative practitioner may change some coding practices. For example, is it legitimate to query a physician based upon clinical documentation provided by a chiropractor, acupuncturist, or naturopathic doctor? Currently, these opportunities are likely to be more prevalent in the outpatient setting. However, current research has shown that IM practices are continuing to be integrated into inpatient care as well.

Consider capturing codes. HIM professionals may also want to consider whether it may be a good practice to capture codes for certain integrative medicine services. Currently CPT provides codes for acupuncture and massage therapy, shown in the table on above. But as research in the area of CAM continues to be funded by the National Institutes of Health, the need for more reliable coded data will grow. In addition, ICD-10 will provide additional opportunities to capture relevant data in both inpatient and outpatient settings that may involve integrative medicine therapies. Given the amount of revenue generated by integrative medicine services, these data are important for both patient care and healthcare system strategic and budget plans.

Educate patients. One of the HITECH Act's meaningful use criteria requires healthcare providers to make electronic copies of patient health information available to patients upon request. Should these records include documentation from integrative medicine professionals, the healthcare system will need to ensure that both physicians and patients will understand the documentation. Under HIPAA, patients have the right to ask for clarification of their health information. That responsibility often falls to the HIM professional. This is another reason why standardizing the documentation of these practices is so important.

Look for new roles. In addition to opportunities within current healthcare systems, HIM professionals may find possibilities for employment with independent IM practitioners. There are about half as many IM practitioners as there are physicians in the US, but these IM practitioners have not been trained in the clinical documentation practices common to most healthcare systems. Most have their own methodology for documentation that may not be understood by other practitioners. It is clear that integrative medicine professionals are in need of HIM resources. In addition, patients of IM practitioners are in need of education about their health information rights. There are 54 acupuncture and oriental medicine schools and 97 massage therapy schools in the US. All of these schools have one or more clinics where students, under the supervision of licensed practitioners, treat hundreds to thousands of patients weekly. These schools are a great opportunity for health information professionals to educate and inform the growing cadre of IM practitioners. The school clinics may also be an opportunity for HIM professionals to provide consultative services.

HIM professionals may want to research integrative medicine treatments for themselves. With up to 92 percent of the US population receiving some form of IM therapy, it appears to be worthwhile. Many IM therapies are backed by evidence-based support, as illustrated in the tables. In general, patients feel that IM gives them a sense of empowerment, and it appeals to their holistic approach to health where mind, body, and spirit are interconnected.

Notes

    *

    This article has been revised to reflect a correction to the description for CPT code 97811 for acupuncture.

  1. SIMUS Survey, State of Integrative Medicine in the U.S. CIMEx Health, 2009. See also the National Center for Complementary and Alternative Medicine housed within the National Institutes of Health at www.nccam.nih.gov.
  2. "What is Integrative Medicine?" University of Arizona Medical Center. http://integrativemedicine.arizona.edu/about/definition.html.
  3. Neiberg, R.H., et al. "Occurrence and Co-Occurrence of Types of Complementary and Alternative Medicine Use by Age, Gender, Ethnicity, and Education Among Adults in the United States." The Journal of Alternative and Complementary Medicine 17, no. 4 (2011): 363–70.
  4. Samueli Institute and American Hospital Association. "2010 Complementary and Alternative Medicine Survey of Hospitals, Survey of Results." www.siib.org/news/2468SIIB/version/default/part/AttachmentData/data/CAM%20Survey%20FINAL.pdf. See also Callahan, L.F., et al. "Use of Complementary and Alternative Medicine among Patients with Arthritis." Preventing Chronic Disease 6, no. 2 (2009). www.cdc.gov/pcd/issues/2009/apr/08_0070.htm.
  5. Nahin, R.L., et al. "Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007." National Health Statistics Reports 18, 2009. Hyattsville, MD: National Center for Health Statistics.
  6. Barnes, P.M., B. Bloom, and R. Nahin. "Complementary and Alternative Medicine Use among Adults and Children: United States, 2007." National Health Statistics Report 12, 2008. www.cdc.gov/nchs/data/nhsr/nhsr012.pdf.
  7. Jacobs, B.P., and K. Gundling. The ACP Evidence-Based Guide to Complementary & Alternative Medicine. Philadelphia, PA: ACP Press, 2009.
  8. Based upon membership in the Academic Consortium for Complementary and Alternative Health Care (ACCAH), www.accahc.org.
  9. ACCAH. Clinicians' and Educators' Desk Reference on the Licensed Complementary and Alternative Healthcare Professions. Seattle, WA: 2009.
  10. SIMUS Survey, State of Integrative Medicine in the U.S. CIMEx Health, 2009.
  11. Nahin, R.L., et al. "Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007."
  12. Dietlind, L., et al. "Physicians' Attitudes Toward Complementary and Alternative Medicine and Their Knowledge of Specific Therapies: A Survey at an Academic Medical Center." Evidence-based Complementary and Alternative Medicine (eCAM) 3, no. 4 (2006): 495–501.
  13. Cardini, F., and H. Weixin. "Moxibustion for Correction of Breech Presentation: A Randomized Controlled Trial." Journal of the American Medical Association 280, no. 18 (1998): 1580–84.
  14. Russo, R., and I. Diener. TSCA Survey of Acupuncture Patients. Presented at AAAOMC Annual Conference, 2011.

Ruthann Russo (ruthannrusso@gmail.com) is assistant professor, health information technology, at City University of New York/Borough of Manhattan Community College, and faculty member, complementary and integrative medicine, at Tri-State College of Acupuncture.


Article citation:
Russo, Ruthann. "Putting the HIM in IM: Assimilating Integrative Medicine into Clinical Documentation" Journal of AHIMA 83, no.5 (May 2012): 32-36.