Chiropractic Telehealth 101

“rendering written or oral opinions concerning diagnosis or treatment of a patient in a different location than the patient …by telephonic, electronic, or other means of communication.”

“the application of secure videoconferencing or store-and-forward technology to provide/support healthcare delivery by replicating the interaction of a traditional encounter in person between a provider and a patient.”

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Mechanisms

Synchronous/ Real-time• Live video• Audio/ telephone

Asynchronous/ Store & forward• Email• Text• Fax

Utility• Consultations• ROM assessments• Diagnostic impressions•Management options and

recommendations• Exercise prescription• ADL instruction• Nutritional

recommendations• Risk factor reduction

CPT “Counseling” Discussions

• Diagnostic results, impressions, and/or recommended diagnostic studies• Prognosis• Risks and benefits of management options• Instructions for management and follow up• Importance of compliance with chosen

management options• Risk factor reduction• Patient and family education

Considerations

• Federal law- HIPAA compliance, CMS guidelines• State/ regional law-

options, reimbursable, scope of practice• Liability- Standard of care,

coverage• Documentation• Billing and coding• Mechanism of delivery

1. Confirm Telehealth Laws

• Is telemedicine allowed within your licensing act? Yes• Does the law require synchronous/ real time audio &

video communication, i.e. Zoom web meeting vs telephone? Either is allowed• Are there laws governing payor reimbursement? Not

allowed for Medicaid• Does our state have reimbursement parity, i.e.,

payors are required to reimburse at the face-to-face rate for CPT codes that can be performed remotely? Yes• Can telemedicine be utilized for new patient

encounters? No Current restrictions- Could Change

How are telemedicine services reimbursed?A service delivered via telehealth is reimbursed at the same rate as the same service delivered in a face-to-face setting. For example, Alaska Medicaid currently reimburses for services provided through one of these three telemedicine modes:

•Interactive method: Provider and patient interact in “real time” using video/camera and/or dedicated audio conference equipment.•Store-and-forward method: The provider sends digital images, sounds, or previously recorded video to a distant site provider at a different location. The distant site provider reviews the information and reports back his or her analysis.•Self-monitoring method: The patient is monitored in his or her home via a telehealth application, with the provider indirectly involved from another location.

From- Telehealth and Telemedicine in Alaskahttp://dhss.alaska.gov/dph/HealthPlanning/Pages/telehealth/default.aspx#about

Foley & Lardner LLPDecember 2019

https://www.foley.com/-/media/files/insights/health-care-law-today/19mc21487-50state-survey-of-

telehealth-commercial.pdf

Coverage Law

Store & Forward

Reimbursement Law

Parity Law

2. Define Carrier Policy

• Is a -95 modifier required?• Can telemedicine be utilized for new patient

encounters?• Do you require synchronous/ real time

audio & video communication, i.e. Zoomweb meeting vs telephone?•What are the reimbursement levels for each

telehealth code.• Is telehealth reimbursed at the same level as

face-to-face for common codes

Coding Telemedicine

Code Description

99441 Physician /Qualified Health Professional telephone evaluation 5-10 min

99442 Physician /Qualified Health Professional telephone evaluation 11-20 min

99443 Physician/Qualified Health Professional telephone evaluation 21-30 min

99421 Physician/Qualified Health Professional online digital evaluation 5-10 min

99422 Physician/Qualified Health Professional online digital evaluation 11-20 min

99423 Physician/Qualified Health Professional online digital evaluation 21-30 min

Telephone Consult99441 Physician /Qualified Health Professional telephone evaluation 5-10 min99442 Physician /Qualified Health Professional telephone evaluation 11-20 min99443 Physician /Qualified Health Professional telephone evaluation 21-30 min

Online web meeting (i.e., Zoom)99421 Physician/Qualified Health Professional online digital evaluation 5-10 min99422 Physician/Qualified Health Professional online digital evaluation 11-20 min99423 Physician/Qualified Health Professional online digital evaluation 21-30 min

Established E&M (Counseling & Coordinating care time override)99212 – 10 minutes99213 – 15 minutes99214 – 25 minutes99215 – 40 minutes

New Patient E & M (Counseling & Coordinating care time override)99202 – 20 minutes99203 – 30 minutes99204– 45 minutes99205– 60 minutes

Therapeutic Exercise97110 Therapeutic Exercise

3. Confirm Liability Coverage

• Check with your professional liability insurer to determine whether you are covered for those activities.

• Obtain and document informed consent

NCMIC StatementMarch 20, 2020

“Our guidance is that based on your clinical judgment and in the interest of continuity of care, please use alternative methods such as telephone and video conferencing as available. For video conferencing, please work with the vendor to ensure the software includes encryption and HIPAA compliance.”

4. Stay HIPAA Compliant

Secure & HIPAA CompliantHIPAA-compliant video communication products:

• Skype for Business• Updox• VSee• Zoom for Healthcare• Doxy.me• Google G Suite Hangouts Meet

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

HHS TemporaryCompliance Exceptions

“During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies. Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules. OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. This notification is effective immediately.”

Under this Notice, covered health care providers may use popular applications that allow for video chats, including:• Apple FaceTime• Facebook Messenger video chat• Google Hangouts video• Skype• Whatsapp

Under this Notice, however video communication applications [that] are public facing, should not be used in the provision of telehealth by covered health care providers.• Facebook Live• Twitch• TikTok

HIPAA Compliance

• Have the vendor sign a BAA• Enable all

available encryption and privacy modes• Protect PHI: No

Speakerphones

5. Schedule Telehealth Calls

Define Call Length

Timed codes cannot be performed simultaneously

99212 10 min97110 8-15 min

Regional/ State Laws

The Law Of The State Where The Patient Is Located

Controls The Regulation Of Physicians And Telemedicine

Scheduling Telehealth Visits

• Reach out to all patients• Questions?•We’re open with a safe environment and

taking precautions (a,b,c)

and/or

• Offering a telehealth consult to minimize unnecessary risk

Scheduling

• Schedule the visit in your EHR with a different color or other identifier that designates a telehealth consult

• Confirm the telehealth consult with your patient by sending an email with a meeting link and details

Hi (patient), This is (staff) from (clinic). I’m calling to confirm your online appointment with (provider) at (time) on (day). Did you receive my email with log-in instructions? (Resend if necessary.)

Confirm the Call

6. Perform The Telehealth Visit

Standard of Care

Ensure that those services are within your scope of practice.

Comply with the appropriate standard of care for the services being provided.

Scope of Practice

Visit Dialogue

“Hi (patient), this is (provider). I don’t want the inability to meet in person to interfere with your health. So, we scheduled this visit to make sure you’re able to stay as healthy as possible during challenging times. Our lives and tasks have changed, so have our physical and emotional demands. I wanted to check in to see how you’re doing and help develop a plan to keep you healthy until we can return to a normal life. I have a few questions.

“To stay on track and to respect your time, we have a “hard stop” at the scheduled end of the call (i.e. 12:15 pm), but if we don’t get a chance to cover everything, I’ll be happy to call back.”

Topics of Discussion

• Are you having any MSK issues?•What’s your new workstation look like?• Are you staying physically active?• How’s your diet?•What is your Coronavirus defense strategy?•What are you doing to manage stress?

Potential Evaluation

• ROM• Posture evaluation• Functional evaluation• Hip abductor weakness• Breathing dysfunction

Deliver Substance

• ADL advice• Workstations• Sleep

• Rehab exercise prescription• Activity modifications or enhancements• Nutrition recommendations• General health advice • Infection control• Stress management

Pertinent Infographics

• Coronavirus FAQ’s• Stop the Spread of

Germs•Workstation

recommendations• Basic nutrition advice• Healthy sleep•Mind body best

practices

The typical diet is high in foods that cause increased tissue acidity and have high levels of free radicals

which may initiate and/or amplify pain and many other conditions, including cancer, heart disease,

decreased immunity, diabetes and arthritis. The foods we eat have a dramatic impact on how we feel and

our bodies will perform best with quality foods.

Routinely eating products that contain sugar leads to a vicious sugar-craving cycle.

Decrease consumption of red meat & refined carbohydrates like sugar and white flour.

These are easily converted to fat and the byproduct of this breakdown is

arachidonic acid. Arachidonic acid and prostaglandins (formed when animal

fats and proteins are broken down in the body) are highly pro-inflammatory

and intensify pain and initiate disease throughout the body.

When possible, substitute darker whole grains for refined white grains. Examples

include: 100% whole grain bread made without hydrogenated oil, brown rice, whole

grain pastas, couscous and others.

Red meat should be limited and may be replaced by fish, especially the

cold-water fish such as salmon, mackerel, tuna or herring. These fish also

contain a chemical called DHA, which has been shown to increase brain

circulation and function.

Sugar in the brain releases a chemical

called serotonin that produces a sense

of happiness and well-being.

As our sugar blood levels fall due to insulin production and

sugar absorption, we move from a hyperactive state to more

of a tired, irritable and weak state.

Sugars are absorbed into our blood

and travel to the brain.

1

2

3

Concentration levels fall, and our

cells begin to become acidic.

Our brain then once again sends a

message that we need more sugar,

and the cycle begins again.

4

5

The Sugar Cycle

BASIC NUTRITION ADVICE

Keep your hips and knees at

90 degrees.

MAINTAIN PROPER

BODY POSITION & ALIGNMENT

WHILE SITTING AT YOUR DESK

Relax your shoulders and bend

your elbows 90 degrees, then

position your mouse and

keyboard so that you don’t

need to move your arms or

bend your wrists to reach them.

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Use a lumber roll for lower back

support.

The top line of type on your screen

should be 15 degrees below eye

level.Use audio equipment that keeps

you from bending your neck (i.e.,

Bluetooth, speakerphones,

headsets).

Monitors should be close enough

to avoid leaning forward or

straining.

Exercises

• Forward a written exercise plan• Demonstrate exercises• Assess patient performance

Schedule a Follow-Up

• Reviewing health status• New issues• Earlier concerns

• Assess prescribed exercises•Modify and update • Exercises• Activity• ADL’s

7. Document the Visit

• Date of service • Provider name and location• Patient name and location• Any additional parties involved•Mechanism of telemedicine service • Start and end times• Subjective, Objective, Assessment, and Plan

8. Bill Patients & Carriers

Use “02” as the place of service code (item Number 24b)

Utilize the -95 modifier if directed by the insurer

Setting Your FeesCode Description

99441Physician /Qualified Health Professional telephone evaluation 5-10 min

99442Physician /Qualified Health Professional telephone evaluation 11-20 min

99443Physician/Qualified Health Professional telephone evaluation 21-30 min

99421 Physician/Qualified Health Professional online digital evaluation 5-10 min

99422 Physician/Qualified Health Professional online digital evaluation 11-20 min

99423 Physician/Qualified Health Professional online digital evaluation 21-30 min

Medicare Reimbursement

Medicare still only covers 3 codes for chiropractors

CMS has required that the patient must travel to a qualified originating site (not home) for synchronous, or live video encounters.

Medicare ABN ?A. Notifier:

B . Patient Name: C. Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn’t pay for D. below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. below.

D. E. Reason Medicare May Not Pay: F. Estimated Cost

WHAT YOU NEED TO DO NOW: • Read this notice, so you can make an informed decision about your care. • Ask us any questions that you may have after you finish reading. • Choose an option below about whether to receive the D. listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.

� OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. � OPTION 2. I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. � OPTION 3. I don’t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature: J. Date:

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No. 0938-0566

Notice of Non-covered Services

Points of Order

1. Be professional, dress, location, etc.2. Private location with reasonable

safeguards- no speakerphone

Telehealth Checklist

1. Confirm your state or regional telemedicine laws 2. Confirm carrier reimbursement3. Confirm liability coverage4. Install a compliant, real-time platform5. Schedule telemedicine visits6. Deliver substance- advice and exercises7. Document visits8. Bill patients and carriers

Download the complete Telehealth Guide at ChiroUp.com

• Step-by-step manual• Sample messaging & scripts • Rx and email exercises• Infographics