What is Telehealth?
The terms telehealth and telemedicine are used interchangeably and are the all-encompassing administration of healthcare services via required real-time telephone or video conferencing. The patient must consent to the service before or at the time it takes place.
Given today’s healthcare environment and evolving patient preferences, telehealth is quickly becoming a household term and is soon expected to be part of most healthcare practices. With advancing technology and ongoing familiarity with video communication, patients find that it is more convenient and beneficial to discuss their wellness and health concerns with their providers via secure video-based platforms. There are many concerns and conditions that chiropractors can help manage or provide advice for without having to see prospective or current patients in person. Further, diversification of your practice is beneficial and will allow you to be more flexible and serve patients who may be seeking advice while on vacation or traveling when you would otherwise not be able to see them.
What Codes Can I Use?
State regulations and insurance panels will provide the most specific information applicable to your practice since it varies considerably from state to state and payer to payer. It is important to note that Medicare does not cover telehealth services provided by chiropractors.
There are appropriate codes for conducting a clinical conversation with the patient on the phone. Most chiropractic coverage does not include this, but it can be a part of the fee schedule so that patients can contact you. Chiropractors can use the following Evaluation and Management (E/M) code types for established patients.
- 99441-Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 5-10 minutes of medical discussion
- 99442-(same description): 11-20 minutes of medical discussion
- 99443-(same description): 21-30 minutes of medical discussion
Documentation should include all the details of why the phone appointment was initiated, why it was necessary, and all other aspects of clinical documentation as required. Be sure to carefully document the discussion time.
Online Digital Codes
Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs). Online digital E/M services require a physician or other QHP’s evaluation, assessment, and management of the patient. These services are not for the nonevaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M. While the patient’s problem may be new to the physician or other QHP, the patient is an established patient. Patients initiate these services through the Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications that allow digital communication with the physician or other QHP. The CPT® codes are as follows:
- 99421 - Online digital evaluation and management service for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
- 99422-(same description); 11 to 20 min
- 99423-(same description); 21 to 30 min
How Can I Keep Track of the Rules?
Most importantly, check with all payers to determine whether there will be coverage, and if not, get an advanced acknowledgement to self-pay from the patient. Although some payers agreed to pay with more latitude during the pandemic, check medical review policies and coverage guidelines before attempting to bill a payer. And if it is requested by the patient, be sure you know the rules of your provider agreement, so that you know whether an advance notice waiver is required for the patient to be charged.
As of 2019, 42 states maintain telehealth commercial payer statutes. However, these laws vary widely from state to state. Currently, Florida, Illinois, Massachusetts, and Michigan do not mandate health plans to cover telehealth services. States with true payment parity laws include Arkansas, Delaware, Georgia, Hawaii, Kentucky, Minnesota, Missouri, New Mexico, Utah, and Virginia. It is best to consult with your state chiropractic association or state board to determine what coverage laws exist in your specific state.
How Do I Stay Compliant?
During crises such as the Covid 19 pandemic in, the flexibility not only extends to patients but the providers as well since telehealth allows providers to work from home. Whether working from home or in the clinic, stringent guidelines and procedures need to be in place to ensure HIPAA compliance and the security of Protected Health Information (PHI). Below are a few guidelines to consider when utilizing telehealth to interact with your patients.
- Avoid using a device that is shared by family members.
- Confirm that antivirus software is present and up to date.
- Create a password and username specifically for the device being used.
- Always log off your device when not in use.
- Encrypt the device.
- Utilize compliant encrypted email services.
- Do not leave PHI in plain sight.
- PHI documents must be secured and disposed of appropriately if working remotely.
- Conversations and meetings must be held in private spaces.
- For video conferencing applications, obtain a Business Associate Agreement, and use only HIPAA compliant versions.
While telehealth services may not be common for Doctor of Chiropractic, there are circumstances in which it makes sense to offer these services. Be aware of the rules and check with your Certified Compliance Specialist to assist with the implementation of proper policy and procedure before you begin this process.
Dr. Jess Brower is board certified by the American Chiropractic Rehabilitation Board, and a designated Certified Chiropractic Sports Physician® with an interest and expertise in the rehabilitation and functional restoration of spinal and extremity related injuries and conditions. He has been in private practice since 2010 upon graduation from Logan University.