Telehealth Opportunities for Chiropractic during COVID-19 – Mike Miscoe

Hello everyone. My name is Michael Miscoe of Miscoe Health Law and welcome today’s ChiroSecure Facebook Live presentation. Our topic today is telehealth in amidst the COVID issues that are being presented. I’ve been surprised that I’ve gotten a number of questions relating to what opportunities chiropractors have to engage in telehealth or telemedicine services. At first blush, you would think obviously none. However, you have to understand telehealth is limited to evaluation management type services, and when you really think about it, there are some limited opportunities for chiropractors to potentially provide telehealth services to their patients.

I can see two scenarios where this likely is possible. The first being an initial evaluation of a patient with new complaints where you could reasonably justify providing self-care recommendations and mitigate the need for in-office treatment. Now, that doesn’t seem to be too advantageous to you, however, it could just as equally result in an evaluation where you believe that in-office treatment is necessary, and depending on the rules in your state relative to whether you can keep your practice open or not, for example here in Pennsylvania chiropractor practices can be open but they can not provide elective care. So, they’re pretty much limited to acute care management, people with active conditions. All maintenance, palliative, preventive, corrective, those types of care types have to be deferred at the present time.

The other scenario is a post-discharge followup. For example, you treat a patient through a restorative course of care. They’re dismissed. They’re given self-care recommendations and maybe including maintenance care, which given the present pandemic, you cannot have those kind of patients come to your office because their care is considered elective. You can, however, followup with those patients relative to any home management, home exercise, self-care, activity restrictions, whatnot, see how they’re doing. And while that would be normal followup where you could bill an ENM if the patient was coming to the office, most chiropractic practices don’t get the ability to take advantage of that because they go ahead and they provide a maintenance manipulation or treatment at that encounter, which swallows up that evaluation management service. But given that if the patient can’t come to the office, then there’s … and there’s no maintenance treatment to swallow the ENM where the ENM would bundle into that you can’t bill then, you could do that post acute care follow up I think via telehealth.

Now, there’s a couple of issues with telehealth when you’re talking about evaluation management services that we have to address. For new patients, I think you need to consider, as a precursor, and we’ll get into the mechanics of what telehealth is and what it’s not, but you need to think about some informed consent issues to mitigate potential risk. When you’re evaluating a new patient remotely, there’s limited examination that you can perform. You can go through all the history of present illness, review of systems, past family social history, receive and record that data. When it comes to examination, you’re going to be somewhat limited because you can visually assess range of motion, mood and effect, alert and oriented times three, get reported height and weight, things of that nature. But you’re ability to physically examine a patient is obviously compromised because you don’t have the ability to touch the patient. So, a lot of the provocative orthopedic tests that you might perform that would help you confirm or rule out a diagnosis are not going to be available to you, and as such, the potential to misdiagnose a patient is significant. So, I think before you engage in any telehealth related to certainly a new patient, you need to warn the patient of the risk of misdiagnosis because of your inability to perform a physical examination.

Certainly if anything comes up during the encounter that is a little weird, patient was in an auto accident, they don’t recall losing consciousness, but they’ve got neck pain and severe headaches, they’re seeing spots, double vision, nausea, you might be thinking concussion and sending them to the ER. So, you have to use your judgment but your inability to effectively diagnose a patient, use your imaging to the extent that you have it, is going to limit your ability to accurately diagnose the patient’s condition. And I think you need to disclose that to the patient before they engage in a telehealth encounter. For people that you’re going to evaluate for nutritional guidance, maybe you need lab data, that’s going to be compromised so, whatever recommendations or the purpose of your visit wherever you’re trying to lead the patient, your inability to do certain things is going to create some risk for misdiagnosis, and that should be disclosed.

Let’s talk a little bit about what telehealth is and more importantly what it’s not. Most commercial payers obviously, you have no telehealth opportunities for Medicare because Medicare does not reimburse a chiropractic for evaluation management services under any circumstances because it’s statutorily excluded from coverage. Since there’s very unlikely that you’re going to be able to do a remote manipulation, which is the only thing that’s covered when it’s done of the spine, there’s no opportunity for telehealth under Medicare or Medicaid.

But for commercial payers, where you can get paid for evaluation management services, there are telehealth opportunities, and we’ll talk about what the requirements are and some of the billing considerations. First and foremost, you need to make sure that you’re licensed to provide the telehealth service, and usually you have to evaluate whether the patient, where the patient is. So, if you’re in California and I’m in Pennsylvania, and you’re not licensed to practice chiropractic in Pennsylvania, I can’t call you up on the phone for a telehealth encounter because you’re not licensed to provide a service where I am at. Now, I know you’re licensed where you’re at, but the way the rules work is, is they look at the state where the patient is located because you’re reaching out to them to determine whether you’re licensed to provide that service. So, first and foremost, you can only do telehealth for patients who reside in or are physically located at the time of the service in a state where you’re licensed to practiced.

There’s two locations to consider. There’s what’s called the distance site, and that’s where you are. The originating site is where the patient is, and the originating site is where you need to be licensed. Once you’ve got that issue addressed, then you have to consider how are you communicating with the patient? There is what’s called asynchronous, which means, kind of think of walkie-talkies. They talk, you listen, then you talk, they listen. Those are what are called asynchronous forms of communication where it’s unidirectional at one time. Unfortunately, asynchronous communication is not permissibly billed as a telehealth service. You have to have synchronous, meaning bidirectional at the same time audio and visual communication.

Now, to the extent that you think that you’re going to FaceTime or use Zoom or Skype to do these services, think again. Not only does that create a potential for a breach because those are unsecure forms of communication where patient health information is going to be conveyed, and therefore not appropriate under HIPAA. Most payers require secure platforms designed for telehealth services. There’s a number of them out there. I’m not going to promote any one over another, but you need to locate and appropriately qualify telehealth platform before you engage in this and whatever they charge, they charge to use their system.

When you’re providing telehealth services, you’re billing regular evaluation management codes and you need to consider that the payer needs to know that the service that you’re providing was via telehealth. You do that with a place of service code. It’s usually 02, but check with your payer to see how they want you to report it. And then there’s modifiers that you put on. There’s a GQ modifier, which means asynchronous telecommunications, which basically means you’re not getting paid. GT means interactive audio and video telecommunication systems. And 95 is for synchronous telemedicine service rendered via realtime interactive audio and video. Now, what the difference between a GT and a 95 is I really can’t articulate. The descriptions are a little bit different but they effectively mean the same thing. GT doesn’t include the word synchronous, but interactive audio/video is effectively the same thing as synchronous. So, most payers will permit payment under either GT or 95. 95 seems to be the more accurate if you’re using a synchronous secure platform with synchronous audio/video.

The second thing you’ve got to be concerned with, with a new patient visit, the encounter is generally scored based upon the amount of history, examination and medical decision making. Given the limitations of even synchronous audio/video communication, visual observation, things like mood and effect, I mentioned, gait station, possibly range of motion, the patient’s ability to respond to questions. Their mood and effect, maybe their basic body type, those are things that you can see and appreciate without necessarily touching the patient. But that’s pretty much all you’re going to be able to do, which means problem focused analysis is potentially, maybe expanded problem focus is what your exam is going to score when you’re limited to just visual means of analysis.

To the extent that as you get through the patient’s subjective complaint, systems review, past family social, your limited examination, you get into the assessment, and maybe you move into providing counseling, which is addressing risk benefits, prognosis, potential diagnosis, self management activities, risk reduction strategies, all of those things are counseling elements that if properly documented would permit you to score your evaluation management service on the basis of time. And while you’re certainly record whatever history and examination, potential diagnosis and suggestions that you’re going to make, you need to be, if you’re scoring on the basis of time, the rule is, is that, the total time of the encounter is the first thing that you have to understand. If the counseling piece of it takes more than 50% of the total time, then you have to bill the ENM on the basis of time.

The documentation has to represent the total ENM time, the total counseling time, and then you need to be somewhat verbose about what you counseled the patient on. You just can’t say, “I counseled him on diagnosis, prognosis, risk and benefits, self-care instructions, tic-tic-tic.” And hit the elements. You need to go into some degree of detail as to what that counseling involved, especially with respect to any potential risk and recommendations for either followup in-office care or referral to appropriate medical management, either at an urgent care or an ER. If it’s diet and nutrition, be very, very cautious there because in many cases weight loss programs are not covered by commercial payers, and if the focus of the evaluation is to set up a nutrition and exercise plan for the purpose of losing weight and it’s not tied to some other condition for which the patient’s weight is a comorbid factor, basically you’re doing an evaluation management service associated with non-covered forms of treatment, which makes the ENM non-covered. So doing it telemed would not justify you sending in a claim for payment. You’d just end up paying it back later.

With those things in mind, you have to think about how you’re going to document your ENM work to get the appropriate ENM level. Don’t forget about your place of service or your modifiers to alert the payer that it’s telemed. And of course, before you do this, look at your individual payer policies and find out what they are doing specific to telemed. On the backend, if you’re doing patient care followups, people who have been dismissed from active care and you’re doing followups via telemed, I think the risk, the informed consent is a lesser concern. Some states require informed consent; many do not. But I still think it’s a good idea to alert the patient of your limitations to properly evaluate how they’re doing given the limitations of asynchronous audio/video communication.

If something comes up that seems weird, of course, you’re either going to recommend the patient to come into the office for followup physical evaluation and decision making where that’s permissible under your state’s COVID business closure rules, or recommend that they see or head to the ER.

Hopefully that gives you a quick little pressie on what might be possible with telemed. I would not set up and bill 1000 telemed visits this week. Make sure you’re on a legitimate platform. Check your payer policies. See what they permit. And where possible, I think integration of some telemed during this pandemic might help offset some of your income loss because patients just aren’t showing up to the practice. But be smart about it, and if you have any questions, certainly follow up and we’ll try to get those answered. Everybody have a great day. Stay safe.

I guess before we leave, I see a question that’s come up. You can’t pick and choose when you’re functioning as a doctor versus a health consultant. We’re not going to do that. You’re operating according to your highest credential on your license? That is true. If you’re a doctor, you’re a doctor, and you can’t stop being a doctor unless you’re operating an ice cream stand.

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