Full title: “The International Classification of Traditional Medicine: ICD-11 Codes in Practice”
Abstract
The integration of medicine across disciplines has motivated dialogue between patients and their providers, insurance companies and practitioners, and even between continents. As these relationships have increased in number and complexity, the importance for clear language has become essential. For over five years, International Classification of Traditional Medicine (ICTM) experts have worked in a Technical Advisory Group (TAG) representing several countries, to build traditional Chinese medicine (TCM) specific codes. This was encouraged by findings that showed nearly 80% of the world’s population did not have access to diagnosis codes to fit their needs. The codes are part of the ‘International Statistical Classification of Diseases and Related Health Problems,’ or ICD version 11(‘11’ represents the numerical version of the codes) for Western diseases, symptoms and medical conditions. The codes help measure mortality and morbidity data to clarify human health globally. These codes have been circulating within Western medicine for two decades, and hospitals have adopted and maintained Western medical ICD implementations for over 17 years. Before ICD-11 Traditional Medicine -TM pattern differentiations for TCM were not considered a part of any formal health reporting system. The primary method for TCM practitioners to enter clinical findings into national databases in the United States is through insurance billing procedure codes. These codes detail methods of Chinese medical practice and the duration of application, not pattern differentiation. Ultimately, the lack of data collection (including efficacy and safety data) leads to limited access to TCM treatments and restrictions on insurance reimbursements. Standardized terminology allows for beneficial outcomes research (especially meta-analyses) to be conducted more efficiently. The subject matter experts who chose inclusive TM terms in ICD-11 faced a monumental task of pleasing the varied East Asian medicine practitioners throughout the world including China, Japan, South Korea, United States, Europe, Australia, Singapore, and Canada. ICD-11 TM Codes are new to most practitioners and have not been taught in universities. However, integrative medical practitioners familiar with the codes may better avoid institutional jargon and communicate with more formality in their clinical reporting. In this conversation practitioners Shellie L. Rosen, Dipl. OM (NCCAOM)®, DOM (NM), and Galina Roofener, Dipl. OM (NCCAOM)®, L.Ac., lead TCM herbalist at Cleveland Clinic’s Integrative & Lifestyle Medicine Department, discuss the inclusion of ICD-11 for TCM practitioners considering it for their practice.
Discussion
Shellie: Galina, as an integrative medical practitioner of Chinese Medicine at a major hospital, you have been trained to understand Western Medical ICD-10 codes. Given this experience, do you feel prepared to apply ICD-11 TM specific codes?
Galina: The creation of the ICD-11 TM manual has been a significant international focus for traditional Chinese medicine (TCM). However, it has not been of much interest to academic leaders in the United States. TCM schools have struggled with standardized teaching material. Many schools reference a variety of TCM textbooks producing a confusing ratatouille cocktail of terminology. My first reaction to the WHO ICD-11 manual was: “I need to go back to school and re-study the terminology!” The new WHO terms are very different from what I learned in my TCM program. I strongly recommend that others study the terms before they become a clinical necessity.
Shellie: Despite the differences in TCM diagnosis terminology, can you expand on why you think the ICD-11 TM descriptions might be a positive guide moving forward as TCM is included in the integrative environment?
Galina: For mainstream medicine to consider accepting TCM in integrative settings, a standard terminology must be in place. There is no other way to discuss the evidence of safety and efficacy without consistent terms. Standardized language is fundamental to design a study. Terms used within research are also used to share findings with medical peers learning about medicine. When there is a discrepancy in terminology, the research design is compromised. In the hospital setting, I am expected to support my statements with research. Recently, I was asked to offer a presentation to my colleagues, illustrating TCM therapies for insomnia. It became a challenging task because I could not locate quality sources with consistent terminology to correlate my clinical findings. I was also unable to find well-designed research with language that would stand up to the scrutiny of my colleagues. I found an astounding 78 TCM diagnosis for insomnia! A majority of the differences were rooted in language descriptors, not in meanings. Indeed, we can expect that many potential presentations of a single symptom like insomnia may exist, but 78 is far too many for analysis. ICD-11 helps narrow this mess down significantly. A part of the complication in seeking quality data or research is in the way computer search terms are used.
Shellie: TCM’s lack of consensus may be a factor in the medicine’s ability to gain more considerable momentum on the integrative stage. Perhaps there is fear that standardizing terminology could result in prohibitive limits upon the medicine. However, some beneficial research can be nearly impossible without standardized terms. Grouping studies with shared diagnostic values and treatment principles (meta-analyses) rely upon accurate terminology. Practitioners may be pleased to find a great diversity of East Asian medical expression presented in the many codes available in ICD-11 TM. Overall, it appears to be a deeply considered body of language that encompasses several philosophies. Galina, what is your experience of the ICD-11 TM (Beta version currently as of September 2019) website? Do you expect changes from the Beta version?
Galina: The Beta version will likely stay the same until the release and implementation in 2022. I have learned a lot already from familiarizing myself with the way the codes are laid out and by learning the website. I recommend that practitioner’s take time to understand these features and to understand the “Coding Tool.” (Do this by clicking the ‘coding tool’ tab.) Also, it is essential to practice entering a TCM diagnosis (ex: ‘Liver Qi Stagnation’) in the search box. (Click the Traditional Medicine box in the Chapter distribution section to filter the list with TCM terms.) A list of options appears that make sorting data very accessible. Patterns containing keywords will appear, such as ‘SF 57 Liver qi stagnation pattern (TM1).’ I have already started using standard terminology codes in my clinical practice and recommend others consider it too.
Shellie: How are ICD-11 TM codes showing up in academia or symposia? Do you see a wave of adoption thus far?
Galina: It has not been a common practice for TCM schools to focus upon standard charting processes in real-life multidisciplinary clinical settings. Schools do not often illustrate environments where patient files are shared amongst integrative healthcare professionals. In these settings, patient files are audited for billing requirements and compliance under more strict requirements. Understanding ICD codes and their relationship to the practice of TCM is expected in the integrative medical setting. This has been the case with the previous versions of ICD (such as ICD-10) and will continue to be the standard until ICD-11 TM adoption. For example, TCM practitioners must use symptoms such as Cough for ICD coding, rather than using a Western Medical Diagnosis such as Pneumonia, to remain within the TCM scope practice of medicine (unless the patient was referred by MD/DO with a particular diagnosis -see example below). Some practitioners think ICD limits treatment options. The reality is, it does not restrict my style of acupuncture or herbal formulary, but it determines the content of my notes, which must support both my TCM and ICD-10 diagnosis.
Shellie: Some practitioners in private practice may be working with paper files in a cash exchange system without a working knowledge of codes for diagnosis and billing. These practitioners may detail clinical notes; however, the records might not contain language that a patient’s Western medical team can decipher. Private practice practitioners that file for insurance reimbursement are required to have an understanding of diagnosis and billing codes to submit a Health Care Financing Administration (HCFA) 1500 form. Going through this process prepares practitioners to communicate their treatment notes in terms and language that can be understood by a variety of care providers. Lastly, practitioners that work in environments with large referral networks adopt creative methods for communicating their findings with the Western medical doctor, osteopath, chiropractor, and other health care agents. One thing that often gets lost along the way in the current ICD-10 notes and HCFA form systems is the ability to discuss and register TCM Pattern Differentiation. How do you deal with this in your records?
Galina: In TCM practice, diagnosis of Disease is incomplete without Pattern Differentiation. To be compliant with hospital charting and ICD billing documentation that supports the treatment prescription is required for both acupuncture points and herbal formulae. I use the TCM syndrome diagnosis from the Beta ICD-11 along with the necessary ICD-10 codes. An example might look like the following: Billing ICD-10 diagnosis: (ex.) G43.719 Intractable chronic migraine without aura and without status migrainosus (Intractable means stubborn, non-responsive to standard treatment; chronic means longer than three months; status migrainosus is a severe type of migraine that can last more than 72 hours)
In my notes: Migraine due to SF52 Liver yang ascendant hyperactivity pattern (TM1)
Shellie: The East Asian medical profession has fought for inclusion in the Western medical paradigm. The hope has been to increase integrative settings in insurance reimbursement for patients. It looks as though great strides are possible but not without changes for the practitioner. Do you see changes such as ICD-11 TM as a gain for East Asian medicine? Will it be too much change for practitioners?
Galina: Thanks to NCCAOM efforts, TCM has achieved federal recognition as a legitimate profession and will be expected to comply with legal documentation requirements. It could be that with ICD-11 implementation, even practitioners who do not bill insurance could be mandated to switch to Electronic Medical Record (EMR) keeping. This switch may be difficult for some folks, understandably! However, with a little adjustment, clinical records keeping can be quite manageable.
Conclusion
Consistent terminology is critical for TCM practitioners to work together and with peers from other medical systems. ICD-11 TM codes may lead to higher reimbursement from insurance companies in the United States. However, using standardized terms and tools may not be the best fit for every patient or every practitioner. For those East Asian medical practitioners looking to adopt ICD-11 TM codes, perhaps Taiwan’s insurance system is an encouraging model in which to aspire towards. In Taiwan, insurance pays for herb prescriptions based on disease classification and outcome data. Perhaps this could be the future for the United States. Familiarity with ICD-11 TM terms and website user experience takes time. Perhaps TCM universities may adopt ICD-11 TM terminology training in future classrooms to help the process along. It is crucial to remember that ICD-11 TM is an international movement in alignment with many variations of how TCM philosophy is articulated. To best appreciate this contribution, including the diversity of options, one must take a look. To view the current Beta version of the ICD-11 Traditional Medicine Conditions Diagnostic Codes visit: https://icd.who.int/en/. The home page offers a “Use ICD-11” box with an “ICD-11 Browser” link. Click this ‘browser’ link and then scroll to Chapter 26. The chapter headings expand by clicking the arrow to the left of each subsection. Practitioners can download the manual at: http://www.wpro.who.int/publications/who_istrm_file.pdf
