Billing for Telemedicine in Chiropractic

Twenty percent of Americans live in rural areas, but they are only served by nine percent of healthcare providers. Telemedicine is a way for patients to interact with providers when it is difficult or impractical to see them in person. Evan Gwilliam, DC, shares how telemedicine could offer providers more revenue and better patient compliance while it reduces patient transportation expenses.

Posted in Risk Management on Wednesday, October 30, 2019

Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve; therefore, they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.

Currently, 37 states have parity laws in place that require payers to cover telemedicine to the same extent as face-to-face services. Fourteen states have special licenses for practicing telemedicine across state lines, but the rules vary from state to state.

It appears that all of the 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 some interactions typically are not covered including:

• Text-only email messages
• Fax transmissions
• Audio-only telephone consultations

For the most part, the parity laws require that the reimbursement for telemedicine is mandated to be the same amount as if the service were provided in person. However, some states leave it up to the payers. And, in some cases, small group or workers compensation plans have the option to opt out. Be sure to check with your state and the health plan before attempting to bill for telemedicine.

Medicare (CMS) has specified that they cover asynchronous, store-and-forward telemedicine in only Alaska and Hawaii as part of a special program. And CMS has required that the patient must travel to a qualified originating site (where the patient is at the time of the encounter) for synchronous or live video encounters.

For Medicare, these sites do not include the patient's residence, which would greatly limit telemedicine's application in a chiropractic setting. Fortunately, parity laws in most states remove this cumbersome requirement, but it is still best to check with each health plan.

Currently, CMS only reimburses for chiropractic manipulation, and that cannot be performed via telemedicine. However, some payers may follow the CMS standard, so it is important to be familiar with Medicare policies.   

The most likely type of encounter that a chiropractor might bill via telemedicine would be an established patient evaluation and management (E/M) counseling encounter from the codes for 99212 thru 99215. This type of encounter requires documentation of a time override rather than the typical E/M encounter that requires documentation of the three key components: history, exam and medical decision making. “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

These things would need to be documented in the encounter, as well as time. CPT rules tell us that to qualify for the time override at least 50 percent of the encounter time must be spent face to face. The counseling elements listed here are examples of what should be documented for that time:

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

Additional documentation requirements may vary by payer or state generally should include:

• Date of service (DOS)
• Location of provider (distant site)
• Location of the patient (originating site)
• Names of all participants with individual roles identified
• Type of telemedicine service (real time, asynchronous)
• Start and end times
• The above criteria met for the CPT code reported
• Diagnosis or symptoms to support high-specificity ICD-10-CM code selection

When billing for telemedicine, the place of service code that goes in 24b on the 1500 claim form should be 02 to indicate telehealth. Typically the 95 modifier should also be attached to the CPT code. (See Appendix P of the CPT code book for AMA’s full list of telemedicine-eligible codes.)

The options for modifiers include two for Medicare and are as follows:

• Modifier GQ: Via an asynchronous telecommunications system (for Medicare)
• Modifier GT: Via Interactive Audio and Video Telecommunications systems (for Medicare)
• Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System (reported with codes from CPT Appendix P, including E/M codes 99212-99215)

Some people think telemedicine has limited application in a chiropractic setting. However, it may allow patients to be better served and providers to generate additional revenue. Therefore, telemedicine will likely be worth considering for DCs in the future.