With the advent of the Covid-19 pandemic, many offices are seeing an increase in cancelled appointments and some are even facing temporary closure. What are your options? Most of your patients still need the care and as a small business owner, you need to still pay the bills. Hopefully the information below can help you get a better sense of the issues surrounding your practice and telehealth. Keep in mind that circumstances are constantly changing and this information is current as of the above date.

Telehealth

Though it may have limited application in a chiropractic setting, telehealth could be a way to keep patients and providers safe while still hopefully generating a little revenue from delivering healthcare from a good social distance. It could also actually improve patient compliance by enabling patients to interact with providers when it may be difficult or impractical to see them in person.

To that end, and in response to the Covid-19 pandemic, the HHS Office for Civil Rights (OCR) announced on March 17, 2020, that it will waive potential HIPAA penalties for good faith use of telehealth during the nationwide public health emergency. Normally, Providers would have to use a secure means of communication. However, with this announcement, non-HIPAA approved technologies like Skype and FaceTime can be used. (Facebook Live, TikTok, and similar video communication applications are public facing, and should not be used in the provision of telehealth by covered health care providers). See HHS Notice for HIPAA for more details, also remember that these are temporary measures and providers should keep in mind that non-HIPAA approved technologies will not be allowed when emergency ends.

Additionally, the Trump administration lifted national restrictions this week on the use of telehealth which had previously limited Medicare telehealth programs largely to rural areas. It appears that the relaxed rules are to stay in effect as long as the pandemic lasts. Coverage is to be retroactive to March 6, the date Congress passed, and President Trump signed an emergency $8.3 billion Covid-19 spending bill.

Many private payers recognize the potential cost savings and improved health outcomes that telehealth can help achieve, therefore they are often willing to cover it. However, not every state has enacted parity laws which require private payers to cover telehealth to the same extent as face-to-face services, and the rules about how it is enforced vary from state to state. For example, Pennsylvania remains one of only a few states that does not require private insurers to cover telehealth programs. However, in neighboring New Jersey, it appears insurers must provide coverage and payment for health services delivered through telehealth or telehealth on the same basis as when the services are delivered through in-person contact and consultation (see NJ Statute C.26:2S-29 for full rules and requirements). You can visit Current State Telehealth Laws from the Center for Connected Health Policy to see if your state is included and check with. Remember things are changing daily in response to the pandemic.

It appears that all states with parity laws require private payer reimbursement for live video encounters, while only some require coverage for asynchronous, or store-and-forward encounters. Note that typically audio-only interaction is not covered. This includes:

• A text only email message
• A fax transmission
• An audio-only telephone consultation

Some states leave the rules up to the payers, therefore we encourage you to check with your state and the health plan before attempting to bill for telehealth.

Notably on January 1, 2020 the AMA released a new set of CPT codes for online digital Evaluation and Management (E/M) services. They vary in value from $16 to about $55 based on Medicare’s fee schedule and it’s likely that private payer reimbursement will be higher. These are patient-initiated digital communications that require a clinical decision that otherwise would have been typically provided in the office. The codes for physicians 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 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
• 99423 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

For non-physician practitioners such as physical therapists and occupational therapists the codes are as follows:

• 98970 – Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
• 98971 – Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
• 98972 – Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

*According to the AMA, CMS disagreed with the CPT Editorial Panel that codes 98970, 98971, and 98972 could be performed by qualified nonphysician health care professionals based on statutory requirements that govern the Medicare benefit and do not allow nonphysicians to report E/M services. CMS created parallel HCPCS G-codes with descriptors that refer to the performance of an “assessment” rather than an “evaluation.” For 2020, CMS will provide separate payment for the nonphysician online digital assessments with HCPCS G-codes G2061, G2062, and G2063.

The complete guidelines can be found in the AMA CPT codebook. However, the key requirements for these codes for both Physicians and Non-Physicians are as follows:

1. The patient must initiate the service.
2. The services must be medically necessary.
3. These codes can only be reported once per 7-day period.
4. Do not report online digital E/M services for cumulative time less than 5 minutes.
5. Do not report these codes on a day when other Evaluation and Management services are performed.
6. These services are not for the non-evaluative electronic communication of test results, scheduling of appointments, etc.

While these services must be “patient initiated,” Providers could send out a notice letting all patients know that these services are offered by your practice.

In addition to the above guidelines, when billing for telehealth, the place of service code that goes in box 24b on the 1500 claim form should be “02” to indicate “The location where health services and health related services are provided or received, through a telecommunication system”. Additionally, modifier -95 (Synchronous Telehealth Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System) should also be appended to the CPT code.

Medicare has two of their own modifiers, depending on the type of telehealth and some private payers may also recognize/require these. The options are:

• Modifier GQ: Via an asynchronous telecommunications system
• Modifier GT: Via Interactive Audio and Video Telecommunications systems

The AMA has created a list of what they call “telehealth-eligible codes” and unfortunately Chiropractic Manipulative Treatment (98940-98943) and other physical medicine codes (from the 97000s) are not on the list. (See Appendix P of the CPT code book for AMA’s full list of telehealth-eligible codes.)

The common established office evaluation and management codes (99212-99215) are found in Appendix P and can also be billed via telemedicine. It appears that these might be an option instead of the online evaluation codes (99421-99423) when the service meets the criteria for two of the three key components (history, exam, medical decision making), such as what might be required at the onset of a new condition. Or they might be used for a counseling encounter with a time override. CPT specifically states: “When counseling and/or coordination of care dominates more than 50% or the total time spent face to face with the patient, time may be the controlling factor in determining the level of service.” Counseling is defined in the CPT book as discussion with the patient and/or family concerning one or more of the following areas:

• 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

If using the time override, these things would need to be documented in the encounter as well as time. The current time requirements for these E/M codes are as follows:

• 99212 – 10 minutes
• 99213 – 15 minutes
• 99214 – 25 minutes
• 99215 – 40 minutes

For an in office encounter the face-to-face time must equal at least half of the total time. For telemedicine, it seems that it would represent the entire encounter since the provider and patient would be video conferencing. The online evaluation codes (99421-99423) might then be reported for encounters that occur later.

While there are no specific physical medicine CPT codes for telehealth services provided by chiropractors or physical therapists and occupational therapists, it is possible that some payers might allow billing a therapy code such as 97110 with the 95 modifier and the 02 place of service code. A provider might watch a patient via Skype and provide guidance while they perform stretching exercises for fifteen minutes. This assumes that the same criteria for medical necessity have been satisfied as at a live encounter and the documentation is complete.

If this applies to the services you provide, you might consider reporting them. Though it may seem like it has limited application in a chiropractic setting, patients could be better served, and the provider may be able to generate additional revenue by following the scenario outlined above. Check with private payers and your state board to make sure you can bill for these services via telehealth.

For more information on telehealth Providers can review this Guide on billing for telehealth encounters from the Center for Connected Health Policy to get the comprehensive overview on billing.

Steps to get going with telehealth:

1. Review all the links in this article.
2. Check to see if your state has parity rules in place.
3. Contact your state board to make sure you can perform telehealth as part of your licensure. Please note that over the weekend, Pennsylvania updated who can provide Telehealth, see Pennsylvania Telehealth Update
4. Contact the payers you plan to bill and ask if they allow you to use the 02 place of service code and the 95 modifier.
5. Set up a video conferencing tool, such as Skype or FaceTime and make sure you record your sessions.
6. Email your patients and let them know you have telehealth available.
7. When providing the service document all the things you normally would, but add a line that says something like “services provided via telehealth”.

Home Care

The concept of home health is one that has not disappeared from healthcare and is employed when a patient’s circumstances require treatment in the home. With the Covid-19 pandemic this may be a viable way for Providers to help patient’s in need.

CPT does have Home Evaluation and Management services that Providers can use. These codes follow the evaluation and management rules, however they are provided in a private residence, as follows (see CPT for full description):

New Patients

• 99341 -Home visit new patient low severity 20 minutes
• 99342 -Home visit new patient moderate severity 30 minutes
• 99343 -Home visit new patient moderate to high severity 45 minutes
• 99344 – Home visit new patient high severity 60 minutes
• 99345 – Home visit new patient unstable/significant new problem 75 minutes

Established Patients

• 99347 – Home visit established patient self-limited/minor problem 15 minutes
• 99348 – Home visit established patient low to moderate severity 25 minutes
• 99349 – Home visit established patient moderate to high severity 40 minutes
• 99350 – Home visit established patient unstable/significant new problem 60 minutes

Providers can also bill for other services that they provide in the home like CMT, modalities and certain therapeutic procedures. Providers would need to make sure and use place of service “12” to indicate “location other than a hospital or other facility, where the patient receives care in a private residence.” Providers are strongly encouraged to check with their malpractice carrier to ensure they are covered to provide services in a patient’s home.

In addition to the regular service provided, CPT code 99056 – Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service could also be billed.

As stated in the Instructions for Use of the CPT codebook, “Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional.” However, third-party payers may request that you report these services differently. It is recommended that you check with the payors in your area to determine the variations in reporting of these services.

Medicare has created a CMS Fact Sheet that describes regulatory flexibilities and other actions CMS has implemented to help health care providers and states respond to and contain COVID-19. Unfortunately, the actions did not include expanding Medicare coverage to include telehealth services furnished by Chiropractors or Physical Therapists but stay tuned.

Regardless of the payer or policy, all Providers must ensure that when providing telehealth services and home care, they are practicing legally and ethically. Providers must also be aware of state and federal practice guidelines and payer agreements.

Hopefully, some of the information above will help you and your Practice continue to serve your patients and provide for your family and staff.

This article was created in order to help health care professionals, medical billing personnel, coders and other support personnel to better understand the rapidly changing medical/healthcare environment. Documentation, billing and coding decisions should not be solely based upon information contained in this article. It was co-written by David Klein CPC, CPMA, CHC and Evan Gwilliam DC, MBA, CPC, CPMA. Both work for PayDC/Advanced Provider Solutions www.paydc.com, a web-based EHR/Practice Management system that focuses on documentation, compliance and reimbursement. Both are certified professional coders and auditors through the American Academy of Professional Coders (AAPC) They can be reached at dave@paydc.com and evan.gwilliam@paydc.com respectively.