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.
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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: [email protected].
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