Telehealth – Coding, Documenting and Compliance of Telehealth

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Hello to all my friends. This is Samuel Collins, your coding and billing expert for chiropractic, specifically the HTA Ross Company, and of course, our forensic Chiro Secure. We’re here to make sure that your practice continues to thrive during this time. I wanted to go over some issues on telemedicine and staying open during this time. Without further ado and the wasting time, let’s get to the slides and let’s talk about telemedicine.

Telemedicine, of course, as we’re all aware of, is becoming more prominent due to what’s occurring now. I’ll start with a little something light to say. I’m not always required to see patients online, but when I do, it’s 99423. Of course that’s the code for a telemedicine for 21-31, 21-30 minutes of time. Again, it’s being a little bit of a joke with that. Certainly, it’s something that’s important because of course, if you’re not aware, here are the codes for the coronavirus . For ICV10, use 07.1, and if it’s something that’s suspicious of it, Z03.818.

Now, these won’t help you much. Obviously a doctor of chiropractic is not going to use or be paid for these codes, but in a certainly something to reason that of course we’re all being, not quarantine but isolated. I’m in California, which we’re on a work order now to not be in the office unless you’re essential. Let’s understand what essential means because a lot of people have misinterpreted for chiropractic offices, what this actually entails.

The definition of a health care operation that can stay open during these periods is, healthcare operations include hospitals, clinics, dentists, pharmacies, pharmaceutical and biotechnology companies, other healthcare facilities, healthcare suppliers, home healthcare services providers, mental health providers, public health, and of course for us, any related or ancillary healthcare services. Realize that you are included. You may remain open.

Obviously, you want to observe some tactics that protect you and your patients, certainly. I’m going to recommend following at least these eight types of things. I’m going to recommend that you likely should take the temperature of all incoming patients and staff on each day, someone that has a high temperature or shows signs of potential virus are recommend to self quarantine and get tested a lot. Of course now, getting tested is a bit easier so long as you have symptomatology, but that’s one way of assuring your patients what’s going on. Number three, place a notice on your office door that all surfaces in your office and clinic are regularly and thoroughly cleaned throughout the day between each patient. Of course, no more just rolling table paper. Now you’ve got to really thoroughly clean.

When a patient enters your office, make sure that you have available hand sanitizer immediately. Make sure they go wash your hands and of course, that’s why hand sanitizer has to be available. Not always is it going to be available to wash your hands and of course, by the time you go to the restroom to wash your hands, you’ve touched multiple surfaces. I would recommend also removing several of your chairs in the reception room to assure appropriate social distancing. In addition, I’d suggest the staff probably should wear gloves. It’s optional, but some doctors may not feel comfortable wearing gloves, but that certainly might be something you do.

I would also try to spread appointments to avoid crowded waiting rooms and reassure your patients, ultimately, that unless they’re in a high risk group or elderly with comorbidities, their risk of morbidity is low. Again, even though it’s only 3%, that’s still a lot of people if a lot of people catch it, so we do want to have some practices there.

Now let’s get into, what about telemedicine? What do we mean by that? This means a visit with a patient that is not taking place face to face in the office, but essentially face to face, online, face to face via Skype or FaceTime or similar types. Even a phone call for that matter, but please note it says patient initiated services with physicians or other health, other qualified healthcare professionals, and this is where chiropractors fall in. Certainly that is something that you may have a patient that is in an acute problem or a chronic problem for pain. They’re not coming in for a visit. You’re going to arrange with them on what things they can do at home to help themselves. We’ll give more details there. Notice this is not intended for non evaluative electronic communication of test results. If they just got X rays and you give them, “Oh your x-rays came back negative,” it doesn’t include that.

In other words, you want to really think of this as an evaluation and management visit where there’s no treatment but just counseling. This is an essentially evaluation management done non-direct face to face, basically history, evaluation, medical decision making and counseling. Documentation should include what you would normally document. Please document accordingly everything and the amount of minutes of the visit.

Patients under your care for acute or chronic pain, obviously you’re going to need to still help. Many should still be encouraged to come in, but at the same token, many may not want to go out. Therefore, you’re going to manage it without direct treatment. Here’s what we’re going to like we do, and this was just taken from Blue Cross Blue Shield’s protocol for self management of low back pain and notice what it says that we would be doing: rest and reduce strenuous activities, ergonomics, postural advice, exercises, appropriate exercise and stress management, joint protection, weight loss, massage meaning self massage, hot or cold packs if needed.

Educate the patient about causes, what things to avoid and of course maybe even potentially brief use of support. In other words, these are. likely the types of things you’re going to go over, but you’re all going to get over how the patient is doing, how they’ve managed it, how they’re going to continue to manage it. This may occur more than one time per week. It’s just going to be a cumulative visit.

For telemedicine, the problem may be a new problem to the provider, but it must be an established patients. I’m going to make very clear, you cannot see a patient you’ve never seen before for telemedicine. Telemedicine for our purposes, must be an established patient. It can be for a new problem, but it must be an established patient and typically it must be initiated on a HIPAA compliant protocol, but because of the recent COVID issues, they’ve completely scrapped that and you are allowed to use Skype, FaceTime.

In fact, it was encouraged from the head of CMS that doctors can encourage their patients to have their children, grandchildren or otherwise come with them to help them use a simple home portion. Again, do not worry about it being on a secure platform at this time, but again, do document what went on during the visit. We have three codes for the digital. This is the online, the Skype, the FaceTime, there is a 99421, a 422, and a 423, and they’re pretty straight forward. They’re for time: 5-10 minutes, 11-20 minutes, or 21 minutes or more. The key issue here is that it’s cumulative for up to seven days. If you are on the phone five minutes, three times in a week, that would make it a 15 minute call total, if you will. That will be a 99422. It’s not per call but cumulative within seven days so you’re not limited to a one-time.

Certainly, it may not be as many as most might think, but certain patients and acute problems may need, require, more management, may have more issues with you, so I would certainly encourage patients that you are available for these types of consults. All they have to do is set up a particular time with you and then of course you bill accordingly with these codes. Again, pretty straight forward.

Again, it must be patient initiated. It’s for the assessment of the patient. Again, I want to emphasize it’s literally just an ENM, but instead of the patient sitting in front of you, they’re on the screen. Within that, you could have the patient stand up, you can have them do a range of motion. Certainly you can have them do certain exercises to make sure it’s done safely. You can discuss with them about weight loss.

You can discuss with them many things or counsel the patient. That’s what this is intended for. In many ways. You might just be reassuring the patient. Now again, if the patient had an ENM within the last seven days, they may not be reported. If you saw a patient a day or two ago, it doesn’t count until there’s been seven days from the previous visit. I would also encourage if this telephone consult or the video results in the patient, just simply [inaudible 00:08:42] that it would not be recorded, as well.

This is something for patients who are not going to come in. It’s not going to be the result of the appointment. Don’t be afraid of making appointments for patients, but these are ones who are at high risk or just simply are too afraid to come out that you can certainly these. Again, the inquiry is about a new problem that can be addressed. That’s certainly no problem. It may be billed.

Let’s say you saw the patient yesterday for neck pain, but today they want to do a video conference because, “Oh my God, I hurt my low back last night.” Then again, it can be used. If it’s for the same problem within seven days, the answer is no. Again, I think we’re going to have set up for people because we have a two or three week hiatus in many places that this is going to be viable in a way to give a patient some self-assurance and to probably help them get through the problem. In other words, it becomes a visit where you’re helping the patient.

Now remember, you cannot bill for any treatment for these types of calls. If you’re teaching the patient exercises and so forth, it cannot be built as exercise. You are simply going to bill for the phone call time or the face to face time via the video consult. To count these times towards the start of the seven day clock when the physician or qualified health provider first performs personal view of the patient’s question, add in the time for the review of relevant patient records. Notice they’re saying that there’s a little bit of time you can use that you have to review the patient records before the interaction.

What you need to do is to make sure you’re documenting all the time and I’ll follow up in the last three here it just says it’s going to fall under any other ENM code including decision making, assessment management, and it could be within the same group practice, if you have one provider that’s doing these, that certainly can be done as well from someone else. For the medical records, the guidelines instruct you to keep a permanent documentation. Well, of course, this is just the patient visit online. I’m going to emphasize, document like you would any other ENM visit while the patient was in the office: put the date, the time, what was discussed, just like you would if they were sitting there. You do not have to record the call.

Now, what about telephone calls? Well, telephone calls can work as well, but they’re a little bit different. Telephone evaluation management service provided by a physician to an established patient, parent or guardian, not originating from an original ENM service provided within the previous seven days. It’s a little bit more complicated here. This one doesn’t allow you to do it if you had a visit with the patient within seven days. Clearly a video consult would be more likely the one to be paid because the phone call is a bit more different, if you billed a treatment within seven days. Notice also, it says it cannot lead to an appointment within 24 hours or the soonest available. Essentially, when you’re doing these and the patient is just simply coming in on the next appointment, it’s just going to be considered part of that visit, if you will.

Now, the phone call codes are very similar: 99441, 442, 443. These, again just are simple. They’re time: 5-10, 11-20, and 21-30 minutes. Essentially, what I want our offices to do is to encourage your patients that yes, they still need healthcare. More than likely, they should come in the office and receive treatment. In fact, I would argue a lot of people, under the stress of the situation, may need the care more than other times because this stress often exacerbates acute and chronic problems.

However, again, there could be times that only a phone call or a video will work, and so we have an option for that so the patient doesn’t feel abandoned or lost. Now you may wonder, “What can I charge for these?” Now, again, I can’t give you fees per se, but I would certainly say take a look at worker’s compensation in your state or look at your Medicare fee schedule, but I’ll make it real simple.

You’ll notice the RVU or relative value unit for an adjustment:99421-2 regions is 0.8 and then if you notice the values of these codes go to the point where 3.86 and what these are, are ratios. If you just do a simple comparison, you’ll notice the two mid-level codes, 99422 for the video, 99441 or excuse me, 442, for the phone call, fall about the same price as your adjustment codes, so if you just think in that range. Assume you’re charging say $40 or $50 for an adjustment, well, that mid-level time code would fall within that and then you notice the other codes are about half, so it at least gives you a little bit of a ratio of where this would be paid. Certainly don’t be afraid, again to take a look at the Medicare rates for these as well.

One other special note, when billing these codes, the place of service to indicate that it was a telemedicine visit is 02. I’m sure you’re aware the typical places serve as is 11 because the patient’s in the office, but because it’s a telemedicine it’s going to be 02. I would also encourage that you may also add modifier 95 to the codes. Modifier 95 indicates that it is a telemedicine visit as well. That’s probably not required, but to be on the safe side prior to the implementation of these codes that was required. Realize last year, offices would often build just the simple ENM with modifier GT, G as in George, T as in Tom, but with the implementation of these new codes for telemedicine, that is not required. Simply just bill place of service to and you can throw in the modifier 95. The good news is insurance companies have essentially been mandated to cover these.

I want to encourage you to make sure to stay on top of all the information. Go to our website, HJ Ross company. I have posted about five things on this since this last Thursday, so all the members of my network, if you’re out there as seminar attendees, please take a look. I’ve posted all the issues on what’s changed, what’s going on. I think you want to mostly stay on top of it with your patients, but also we’re here for you. Chiro Secure, the HJ Ross Company, are your partners. We want to make sure that your practice survives during this time and more importantly, we’re helping our patients and we’re helping you. Take a look at our website or Facebook page. Please note all our programs, until further will be online. If you’re registered for a seminar with us or any of the products, certainly it will still be online. Of course, network members. You’re always welcome to just give me a quick call or an email.

I wish you all the very best, and I’m sure I’ll be back in touch you, but continue being good to your patients. This is the Sam Collins, the coding billing expert for HJ Ross. Best wishes.

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