There has been much discussion and speculation recently among chaplains about the advent of ICD-10 and the fact that it contains codes for some spiritual interventions which chaplains do.
ICD-10[i] is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO).[ii] It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. It is widely considered the gold standard used for billing for any kind of medical services. Chaplains have correctly noted that ICD-10 has codes for some spiritual interventions. They have also noted that the Centers for Medicare and Medicaid (CMS)[iii] will now start to pay for patients having end of life conversations. Lastly, it has been noted that social workers can bill.
All of this has led some chaplains to assume/hope that ICD-10 will allow chaplains in the United States to bill for spiritual interventions which now have codes and the CMS regulations will allow chaplains to bill for end of life conversations. Unfortunately, this is incorrect on all counts.
Social Work billing is limited to Licensed Clinical Social Workers (LCSW) who are functioning as psychotherapists, a level of functioning that most chaplains are not trained for or disposed to embrace. The National Association of Social Workers (NASW)[iv] does not appear to promote any other reimbursement strategy at this time. The "end of life conversations” that are cited are reimbursement codes for physicians (and secondarily for Advanced Practice Nurses (APN) and Physician Assistants (PA) under the direction of the physicians). Those who were responsible for lobbying for these new codes agree that, eventually, chaplains and social workers need to be included. However, if that discussion is opened now, the whole proposal would at least be held up for a long time and probably scuttled altogether.
There is also a prior issue for chaplains. In order to be reimbursed for medical services in the US as an individual provider, the provider needs to be able to bill under a billing code assigned by the National Uniform Billing Committee (NUBC)[v]. Chaplains do not have such a code. The process is complicated. At least one attempt has been made to obtain such a code in the past and that request was denied. The rationale was that there were no current payers for chaplaincy services, yet payers cannot be approached for reimbursement without a valid NUBC code. Efforts continue to address this conundrum. However, the general opinion is that, politically in this time when cutting medical expenses is the goal, there is probably no support for adding a whole new class of providers to the payment mix even if the problem above can be addressed.
An alternative is to be part of a bundled service like hospice where chaplaincy and social work costs can be included in the bill for the bundle. At least in that case, spiritual care is required but, as we all know, service provided is often minimal and sometimes skipped altogether. And again, even a bundled strategy is not likely to succeed if it adds costs to the system. To qualify for CMS’s recognition as a billing party in Medicare reimbursement would require that we seriously redefine what chaplains do clinically in healthcare and redefine how chaplains are educated and trained to provide clinical services that are recognized as medical in nature.
So what’s to be done for chaplain reimbursement? Continued attempts to obtain an NUBC code are warranted and continue to be in process. Conversations need to be initiated with payers about reimbursement for chaplaincy services so that the documentation needed to apply for a NUBC code can be obtained. Another road is regulatory such as the Joint Commission[vi] requiring a trained chaplain in order for a hospital to be certified in palliative care.
Chaplains can contribute to this effort by adding to the evidence-based literature of the work they do and the outcomes obtained for patients, staff, and the organization especially if that research shows cost savings to the institution. Research isn’t simply a good thing to do; it is necessary to move the profession ahead, including in its goal to seek reimbursement for chaplains
The Rev. George Handzo, M.Div, BCC, CSSBB
Director of Health Services Research & Quality
Health Care Chaplaincy Network
The Reverend Lerrill J. White, M.S., M.Div., BCC, ACPE Supervisor
Manager, the Center for CPE
Vidant Medical Center
The Rev. Susan Wintz, BCC
Director, Professional & Community Education
HealthCare Chaplaincy Network