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Insurance Company/Plans That Pay Telehealth Services

Telemedicine History Management Form

Informed Consent for Telemedicine Services

 

Blue Cross Blue Shield, United HealthCare, Cigna, Aetna, and Humana all offer some form of coverage for telehealth services. However, telehealth is often still listed as a ‘policy-dependent’ service. That means, a patient who has a BCBS Gold Plan could have telemedicine included benefit under their plan, while a patient with a similar, (usually, less expensive) BCBS Plan might not. Each of these five insurers have a multitude of health plans in play and the only way to be certain your patients plan covers telemedicine is to put a verification protocol in place. 

 

Verifying Coverage of Telehealth vs. Telemedicine Services

 

Either your staff or the patient should call the patients insurer or administrator if self-insured, and ask if telemedicine or telehealth services are covered under their specific policy. So, what is the difference between telemedicine and telehealth? In short, telemedicine refers to clinical patient care, while telehealth refers to a broader collection of, administrative, and other non-clinical healthcare activities. Their definitions are as follows: 

  

Telemedicine- is “a two-way, real- time interactive communication between a patient and a physician or practitioner at a distant site through telecommunications equipment that includes, at a minimum, audio and visual equipment. Telemedicine is a form of telehealth.

 

Telehealth- is “the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration.

 

Depending on how you include telehealth services in your practice, you may want patients to verify their benefits themselves. Whether you assign this task to a staff member or ask you patients to provide the information you need make sure you create a form with a list of questions to ask, so that the insurance representative’s answers are documented and confusion is avoided. The following is a list of questions to consider. 

 

• Can you tell me the call reference number? (very important)
• Does the plan cover telehealth services?
• How do you define telehealth services?
• Does it have to be live video?
• What services are included?
• Are there a specific billing codes that should be used?
• Which modifier(s) do you required to be appended to which service code? (or you can make a list of codes)
• Are there any specific restrictions around the service, such as coverage is limited to 12 annually?
• Does the telemedicine service require any special or addition documentation?

 

The rep should be able to answer these questions and clarify any issues surrounding coverage. It's crucial that you document all of this, along with the ‘call reference number’. The call reference number will be essential should there be any disparities regarding payment of a claim down the road. If a claim is denied and you can cite your reference number (which will reference the recorded discussion), to say that it should be covered - the insurer must cover the service.

 

Telemedicine Services Chiropractors Can Provide

 

Chiropractors can provide any service within the scope of their practice, that they would ordinarily provide in their office using a telemedicine platform. The exception of course would be any manual or manipulative therapy procedure which requires direct one-on-one provider contact with a qualified/skilled professional. For example, spinal manipulation, the mainstay service of every chiropractic practice, cannot be done remotely, nonetheless there are other services that can and should be provided to maintain public health during this time. 

 

Evaluations, examinations, counseling, and co-ordination of care as well as chronic care, and pain management assessments, wellness visits, and a number of modalities and procedures, are all services that can be provided interactively using telecommunications technology. What is more, if the service is ordinarily performed in your office and is a covered benefit that qualifies for reimbursement, according to government officials, if it is performed remotely, it will also be paid by the insurer. 

 

Documentation Required to Bill Telemedicine 

 

Whatever platform Chiropractors choose to electronically communicate, the level of documentation remains the same and should be commensurate with the level of service being reported. As long as you perform and clearly document the context and detail of the service you are providing i.e. the elements of an E/M service { history, exam and decision-making, or time spent counseling}, the same as you would if you were physically with the patient -and meet the basic conditions of a telemedicine visit - you will have a billable telemedicine visit. Assign the proper code and append the required modifier. Any further billing instructions would be determined by the payer.

 

Determining the Level of Service to Report

 

Examinations, diagnostic evaluations, treatment assessments as well as counseling and conferences with or concerning patients, necessitate a wide variety of skills, effort, time, responsibility, and clinical knowledge to diagnosis and treat disease, disorders. All Physicians are expected to have a clear understanding the amount of documentation and work that is inherent to the codes they use to report the level of service they provide. To facilitate this understanding and ensure proper code assignment, I have developed a form, that if used correctly, will reveal the level of service a provider has achieved once a patient’s history, and examination findings are recorded and providers clinical decision-making process has been documented. CPT recognizes six levels of service which can be matched to five Evaluation and Management codes. 

1. Minimal Level of Service: A level of service supervised by a physician but not necessarily requiring his presence. (99201 and 99211)

1.Brief Level of Service: A level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and examination. (99202 and 99212)

1. Limited Level of Service:: A level of service pertaining to the evaluation of a circumscribed acute illness or to the periodic re-evaluation of a problem including an interval history and examination, the review of effectiveness of past management, the ordering and evaluation of appropriate management as indicated, and the discussion of findings and/or care management. (99213)

 

Clarification: Limited level of service requiring limited effort or judgment. This level of service would be applicable to uncomplicated cases.

1. Intermediate Level of Service: A level of service pertaining to the evaluation of a new or existing condition, complicated with a new diagnostic, or management problem. May or may not relate to the primary diagnosis, but which necessitates obtaining a pertinent history, evaluating the patients’ physical or mental status, the results of diagnostics as well as other procedures tried and ordering of appropriate therapeutic management; formal conference regarding patient medical management and progress. (99203- 99214) 

Clarification: This procedure is applicable in three situations:

1. A new condition that requires those things noted in definition.
2. An existing condition complicated with a new diagnostic or management problem, which would also require those things noted in the definition.
3. An exacerbation of a condition being treated or flare-up of an existing condition

 

5. Extended Level of Service: A level of service requiring an unusual amount of effort or judgment including a detailed history, review of medical records, examination, and a formal conference with patient, family, staff, or a complete diagnostic and/or therapeutic service. (99204 99215)

 

6.  Comprehensive Level of Service: A level of service providing an in-depth evaluation of a patient with a new or existing problem requiring the development or complete re-evaluation of medical data. This procedure includes the recording of chief complaint(s), and present illness, family history, past medical history, personal history, system review, a complete physical examination, and/or the ordering of appropriate diagnostic tests and procedures. The amount of data to be reviewed is extensive; there are several diagnoses and/or management options to consider and the risk of complications and/or morbidity or mortality is high. (99205)

  

Certain key words and phrases are used throughout the E/M section of CPT. The following definitions are intended to reduce the potential for differing interpretations and to increase the consistency of reporting by physicians in differing specialties. 

 

• New Patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

 

•  Established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

 

NOTE: “In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the first physician who is not available. “

 

Coding to Report Telemedicine Services 

 

The following is a list of CPT codes which represent modalities, therapeutic procedures and other services that can be provide using audio and video telecommunications systems. For full descriptions look to your Current Procedural Terminology Book.

 

G2061 Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes

G2062: Qualified non-physician healthcare professional online assessment and management service, for an 

       established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes

G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an 

        established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.

G0506: Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services (add-on code) 

G0438: Annual Wellness Visit, includes a personalized prevention plan of service (PPPS)first visit

G0439: Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit 

G2063: Qualified nonphysician qualified health care professional assessment and management service, for an established patient, for up to seven days; cumulative time during the 7 days, 21 or more minutes

 

97110, 97112, 97116 -Therapeutic Procedures 

97750, 97755 -Performance testing

97161- 97168 -Physical therapy evaluations 

97530 -97535       -Therapeutic activities 

97760, 97761 -Orthotics management

98960, 98961, 98962   -Education and training for patient self-management by a qualified,  

nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes 

99241-99245  -Office consultation 

99421-99423  -Online digital evaluation and management service, for an established  

                       patient, for up to 7 days, cumulative time during the 7 days; 5-10 min.

9495, 99496           -Transitional care management services (usually DC cannot meet the level of complex decision-making)

 

There are a few codes that are specific to telemedicine, although they do not have to be used to bill telemedicine. CPT codes 99441 through 99444 can be used to bill telephone consultations provided by a physician. For example CPT® 99441 can be used to bill a telephone evaluation and management service provided by a physician 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. The problem is that very few if any insurers include these services as a benefit, hence these codes are often denied for reimbursement. 

   

Billing Telemedicine Services

 

In most cases, billing for telemedicine will be the same as billing a for face to face or in-office services The difference is that you will need to append either a -GT, -GQ or -95 modifier to the service code, this will earmark a claim as telemedicine.

 

According to the American Medical Association the GT modifier is appended when the services are provided “via interactive audio and video telecommunications systems”. You can append -GT to any CPT code for services that were provided via telemedicine. It is most often used for codes like 99201-05, and 99211-15, behavioral health codes and other services that are medically appropriate for telemedicine.

  

Modifier 95 is similar to GT in use but, unlike GT, there are limits to the codes that it can be appended to. Modifier 95 is one of the newest additions to the telemedicine billing landscape. Per the AMA, modifier 95 means, “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.” Modifier 95 is only for codes that are listed in Appendix P of the CPT manual. There is considerable overlap between situations for using GT and 95. Codes listed in Appendix ‘P’. The specific codes include:

 

• Consults- 99241-99245
• E/M for Established Patients- 99211-15
• New Patient Evaluation and E/M- 99201-05
• Most behavioral health codes

  

So, when do you append -GT and when do you append -95 and to what codes? The answer is simple- query the payers you are submitting claims to. Rules vary from payer to payer. Medicare requires the GT modifier. Some payers will insist you use modifier -95 while others will prefer the GT modifier. Payers have no one standard and there is no way to know unless you ask. Reimbursement should be the same regardless of the modifier, but that might be a good question to ask as well when you verify benefits.

 

The GQ modifier is an option for certain situations where asynchronous telemedicine would be appropriate. Per the AMA, GQ is appropriately appended to services provided, “via an asynchronous telecommunications system”. Asynchronous telemedicine means that care was provided via image and video that was not provided in real-time. A patient will undergo a service that is recorded as video or captured as an image, and the provider will evaluate it later. Usually, the evaluation is completed within the same day, but there may be situations where that is not the case. GQ is reimbursed by some payers, but the reimbursement is not as common as the GT modifier. Most uses for asynchronous telemedicine are situations where patients undergo a service and the information captured is reviewed later. It’s frequent with imaging studies, but there are many other uses.

 

A final comment on the use of modifiers. If you are billing physical therapy modalities and or procedures. Payers may require modifiers be appended when certain combinations of those CPT codes are performed at the same encounter. Additionally, these PT codes unlike the spinal manipulation codes, do not inherently include an evaluation and management service component. Therefore, when both the E/M service and the PT service are performed at the same encounter the E/M code does not require a -25 modifier be appended (‘to indicate a separate and distinct service’). Always check with the payer policy for requirements on the use of modifiers for physical therapy services. 

 

Changing The ‘Place of Service Code’ on The Claim Form 

 

A frequent area of confusion for billing telemedicine CPT codes was whether the place of service changes. If the provider is at the facility but the patient is at home, is the place of service still 11? As of January 1, 2017, the recommended Place of Service for telemedicine was ‘02’. This references a location where the service is received through telemedicine technology. Not all payers require the 02 place of service to bill a telemedicine claim, but it’s good information to have if you receive remittance advice indicating that the ‘Place of service is incorrect’.

  

Summarily stated, appending either the modifier 95 or QT to CPT Evaluation and Management codes 99201-99204 for new patients, and 99211–99215 for established patients will indicate the encounter was telecommunicated. When billing these codes be sure to change the POS to ‘02’(https://www.cms.gov/Medicare/Medicare-Fee-for-Servicepayment/PhysicianFeeSched/Downloads/Website-POS-database.pdf). 

 

Angela Giordano Powell 

National speaker, author, and expert witness, Angela Powell has spent the last 35 years as a highly respected consultant to both the chiropractic and legal communities. As a facilitator of knowledge, she has presented to SID’s of Blue Cross Blue Shield, the FBI, and the US Department of Justice to expand their understanding of the practice of chiropractic, and continues to serve as ambassador to two of the leading chiropractic consulting firms in the US. Ms. Powell’s knowledge base extends from record keeping, & documentation, to coding, diagnosing, Medicare billing and all areas of legal compliance. She has seen doctors through some of the most challenging Medicare and private payer audits. Her experience is unparalleled. 

 

Angela Powell

 

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COVID-19 (Corona Virus)

The elected leadership and staff of the Arizona Association of Chiropractic have been in communication with the Governor’s office regarding COVID-19. Through an exchange of letters and calls it is clear that chiropractic services are considered an essential service within the health care definitions included in the Governor’s Executive Order. We are continuing to stay in direct communications with the Governor’s office as the crisis continues.

This means you have the choice to remain open for business. As a profession we need to bond together and educate our patient base and the public that we are considered an Essential Profession and you are an Essential Health Care Provider that is open to deliver essential chiropractic care. 

We are proud to continue to provide essential healthcare services to maintain the maximum health condition of our patients. 

So we strongly recommend that we all please take this opportunity to educate our communities and our patients on the benefits of chiropractic care during this health care crisis.

The AAC has started a public Facebook group entitled “Arizona Chiropractic Offices Who Are Open During Corona Virus Outbreak.” You can find that group here:

https://www.facebook.com/groups/212127709871057/?ref=group_header  

Please join and post often. This Facebook Group was established to get public health information to your patients and the general public in case they are looking for a chiropractor in these troubling times.

There are several ways to post to this group. 

1. You can take a pic of your business card and load that up with a statement that you will remain open.

2. You can also post the same to your business page on FB and then share to the Facebook group.

3. Don’t be shy. Make a quick video (less than 1 minute) and upload to your FB business page. Then share that with the Group.

Share this new group to your business page and vice versa. We encourage you to post weekly, at a minimum. Don’t forget to state that your office remains open. The AAC will be posting general information from authority sites throughout this campaign. The AAC staff remains engaged with state and federal government agencies and organizations to monitor the situation as it unfolds.

Please post informative digital materials from authoritative resources only and refrain from posting lengthy medical peer reviewed studies. We want to keep this on a USA Today style of informational posts.

Also post to the AAC public page as described above. By doing so, you are doubling the educational effect. Again, please do not miss this opportunity to tell all of Arizona we are an essential profession and you are an essential business.

Dr. Penny

AAC President

Please click the links below for futther details from:

Arizona Department of Health Services:https://www.azdhs.gov/preparedness/epidemiology-disease-control/infectious-disease-epidemiology/index.php#novel-coronavirus-healthcare-providers

CANCELED!!Due to the COVID-19 uncertainties, the 2020 Annual Convention has been canceled. Please remember to cancel your reservatations made at the Hassayampa Inn.

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