Sam Collins for HJ Ross

Telehealth – Coding, Documenting and Compliance of Telehealth

Hi, everyone. This is Samuel Collins, your coding and billing expert for acupuncturists. Specifically, the American Acupuncture Council’s Insurance Information Network and Malpractice. Today’s program, as you’re probably aware, is going to be one that’s very important considering the crisis we’re going through right now, and on telemedicine. Is it something appropriate? Is it something we can code? And how do we do it? Well, of course we have to make sure, first of all, that we are getting ourselves together. Because of course our patients are changing, can they come into the office? So without further ado, let’s get to the slides. Let’s make sure we’re understanding what’s going on for telemedicine.

So you’ll see here on this first slide, I’ve got my email address and of course take a look at our website, the American Acupuncture Council Insurance Information Network, which is But here you can see a teleconference call. Now on the left side here you’ll notice this picture, a woman opening her tongue, doctor observing. So what can we do? Well before we get fully there, let’s talk a little bit about making it a little bit light. I’m not always required to see patients online, but when I do, it’s a 99243, that is the code of course for the 30 minute visit online. But it could be for of course the diagnosis of Z03.818, which is the encounter for observation for a suspected exposure to other biological agents to be ruled out, which of course could be COVID-19.

Now again, that’s not something you’re going to be treating for, but of course this is why now many patients can’t come in. So what are the diagnosis for COVID-19? Just to make sure everyone’s aware of the diagnosis under ICD10 is U07.1. And of course if it’s just for observation, Z03.818. Now of course we’re not going to be seeing patients for that, or you won’t be seeing patients for that, but likely for the conditions that you’re already treating for, but they cannot come into the office, maybe they’re in a high risk group. Certainly it’s not something that you have to close your office per se, if there’s a person in acute or severe pain. Certainly you should be helpful to them, but make sure of course you’re using all the safe practices.

That being said, let’s talk about telemedicine. It is a patient initiated service with a physician, or as I underlined here, or other qualified healthcare professional, which would fit an acupuncturist, for the evaluation, assessment and management of the patient. In other words, an ENM code. It’s not intended for the non evaluative electronic communication simply of test results, scheduling of appointments, or communication that doesn’t involve an ENM. In other words, consider it, it’s like an office visit but just done online. You would be doing all the same things of discussion with your patient: history, exam and so forth. So essentially this is an ENM visit, simply in a non-direct face to face manner, but through electronic communication. Basically doing the patient’s history, evaluation, medical decision making, and counseling.

Patients must be under your care and likely under your care for acute or chronic pain, and how to manage without direct treatment. You might have a patient that cannot come in but they’re having a severe episode of back pain. What are we going to do to help them? Well, this is the point. You can do it via the phone or virtual, meaning through your computer or tablet, to make sure to evaluate the patient and give them instructions how to help themselves.

What would this include? Well, here’s an example of a self management of a patient that you all likely do or would do face to face. Talking to the patient about how to rest and reduce strenuous activities; changing their ergonomics and posture; appropriate exercises including Tai Chi, Qi gong, yoga; stress management or meditation; joint protection; weight loss; self massage; self acupressure; maybe the use of hot or cold packs or relieve discomfort. Educate the patient about the causes, what things they can avoid, and then potentially about brief use of supports if necessary in the acute stages to limit motion. In other words, the same recommendations and things you would do face to face without care.

So in other words, simply put, this is a patient you are helping, just doing it online, doing it without physically touching or hands on the patient. So telemedicine, the patient must be an established patient. It can’t not be a new patient, someone you’ve never seen before, but it can be an established patient that has a new condition. So the problem may be new to the provider, but it must be an established patient. And it must be initiated on a HIPAA compliant secure platform, typically. That would be something where you’re going to use obviously some sort of secure platform. But however, due to this recent COVID issue, they have made a mandate that providers may use simple communication through phones or tablets with simple services like Skype or FaceTime. In fact, it was recommended by the centers of Medicaid and Medicare Services yesterday that patients that are of an older age probably should just get their grandchildren or children to come over and then use their phone or tablet for them. So don’t be afraid to initiate in that way as well.

Now what are the codes? Okay. So for online digital evaluation of a patient, which means you’re going to do some type of virtual visit, the first code is 99421, that is online digital evaluation management service for an established patient for up to seven days of cumulative time during a seven day period, for five to 10 minutes. So in other words, it’s the entire time up to a seven day period. So this might be several communications with a patient within seven days, and the time would be cumulative. But it certainly could be just for one, if it’s only one within that time. You’ll notice the codes are relatively simple, in that one is for five to 10 minutes, one is for 11 to 20 minutes, and one is for 21 minutes or more. So simply put, once you get over 21 minutes, then it’s just a 99423, and this would be again, the accumulative time for each patient. And again, it’s online, meaning through some type of virtual platform.

These are patient-initiated services for the assessment and management of the patient. They’re not intended for non-evaluative communication for test results. I want to be clear, it’s not for a patient where you’re calling and saying, “Hey, your test results came back,” but literally just like you would do on a regular visit. The patient had an ENM within the last seven days, these codes cannot be used for that problem. So if you saw a patient yesterday, this part of it would be counted as part of that visit. It’s not till after seven, which I believe we’ll see a lot of this because of the time that’s extending for patients that would’ve had an appointment, this certainly is going to fit, particularly if it’s just initiating here.

So certainly keep in mind if you saw the patient the day before and a phone call the day after, or a virtual visit, that would not count towards this. But for a patient within or after a seven day period, and again it’s cumulative time. If the inquiry is about a new problem, certainly if that’s no problem, and it can be sooner than seven days. So, so long as that is a new condition. And I would question, even though a patient may be initiating right now, they’re dealing with some new issues because they cannot come in. So certainly I think this is going to fit. And we might see a nonissue of that seven day period. The issue here is that it’s simply a visit with the patient that’s done on an online platform to address their concerns of how you may help them.

Obviously you’re not going to be able to do direct treatment, but the things you can do to help them, and maybe it might even be to get them in, and of course if it is to get them in within a 24 hour period again, that wouldn’t count because it goes towards a visit, but certainly for a patient that can’t be seen or a person in a high risk group, obviously that is mandated to stay home.

Now again, to count the times for these codes, start the seven day clock when the physician first performs a persona’ review of the patient’s question. Add the time for the review of the relevant patient records and data interactions or the clinical staff to the problem. So in other words, what this is including is the time you may take to review the records before that phone call starts. Now I would be careful, I would certainly say, don’t tell me you spent a half hour reviewing records, but certainly a few minutes would count. And this would include communication with the patient by digital means that doesn’t fall under another ENM code, meaning it’s not with a phone call. This is going to be the online. It includes decision-making, assessment, management by those in the same group practice as well. So again, if you’re in a group setting, that could work.

What I want to emphasize here though, is that it is simply the doctor doing an ENM. And when I say doctor, I mean the licensed acupuncturist doing an ENM with that patient just simply online. And that means the documentation would fall into the same way. So for the medical record, the guidelines just direct you to keep permanent documentation, either electronic or hard copy. And to make this simple, simply document like you would any other visit, as if the patient were in the office. Make notes, put the time down, obviously, the time you started and ended. You do not need to record the phone call, but you would record the visit in the same manner. So take the same type of copious notes you would as with any other visit.

Now what else can we do besides a virtual visit? Well there’s the telephone evaluation and management service, which certainly could be useful as well. And this is provided by the physician or established acupuncturist to an established patient. And again, I want to make sure that we see that’s established patients for this, not a new patient. Now it could be an established patient you have not seen in six months. And if they’re calling for a problem, then of course you can see them. It’s simply just not for the new patient. Now this services, again not within the previous seven days of the first visit, or the last visit, and it can’t lead to an appointment within 24 hours. So that’s something you’ll see kind of uniquely here for the telephone visit, is that it cannot be the result of the phone call is to come in for treatment. This is literally for the patient to manage at home, not come in within the next 24 hours or next available appointment.

So what are the codes here? 99441 is for five to 10 minutes, 99442 is 11 to 20 minutes, and 99443 is for 21 to 30 minutes of medical discussion. So again, this is going to be that discussion with the patient, essentially, again, an ENM visit where you’re discussing with them the history of the issue, evaluating their outcome, what can they do at home, this is what this is going to be used for.

Now, one thing about these codes though is that you have to document them properly in the sense that I want everyone to note here at the bottom, the place of service is not 11 as you normally would do on a claim. The place of service would be 02, which indicates a telemedicine visit. So again, if the patient’s in the office, it’s 11. If you go to a patient’s home to do a treatment the place of service is 12, but if you’re doing a telemedicine visit, the place of service is 02.

But now one thing I’m sure everyone’s concerned with is, what would be an appropriate charge for these codes? Well, I really can’t give you what your charge should be, because of course everyone’s going to vary as to the location. But what I can help you with is the relative value unit. The relative value unit is the value comparison of one code to the other, or a ratio. So what I put here at the top is the relative value of manual acupuncture, which has a relative value of 1.05. Now for our intents and purposes, let’s just say it’s approximately a value of 01. So now when you look at these other codes, you’ll notice all their RVUs are broken down to 0.43, 0.86 and so forth.

So in a simple term, think of it, it’s a ratio. If you were charging whatever you’re charging for acupuncture, roughly 99421 would be about 40% of that. 99422 would be about 86%, and so on. So again, just think of it as a simple ratio. So by example, if someone were charging probably $70 for manual acupuncture, the relative price for a 99421 would be 40% of that, or about $28. So again, just keep it really simple. We want to make sure, of course, that acupuncturists are available to patients who are managing their chronic pain, who are managing many issues that they otherwise would not get help for. You could be the person that really gives them a good sense of feeling of assuredness that you’re there for them to give them even just stretches, how to use hot packs, maybe it’s even dealing with some of the herbal consult that you’ve had.

What I want to make sure is that we’re doing a good job and continuing to help our patients in this time, and make sure they’re aware that you’re available. There would be nothing wrong with sending something out to your patients to let them know that you are available, potentially in the office for appointments, but also online and it will be covered by insurance. Ultimately, we want to make sure you’re doing well. The American Acupuncture Council is your resource, and I’m going to make sure that anyone that’s listening that’s of course a member of my network, you’re welcome to give me a direct call or email so I can help you with these.

Of course, if you’re not in the network, I apologize for that, but we do offer a service for it. You may want to see that we upcoming seminars that will allow you to, with some help, and the seminars will be virtual as well. But please take a look, we have more information on our website, to go to our Facebook page or to our Instagram account to take a look there. We’re here for you. The American acupuncture council is your partner. Your success is our success, and we’re your partner to make sure your practice continues to thrive even during this time. Next week’s post will be Virginia Duran. And until then, this is Sam Collins, the coding and billing expert for the American Acupuncture Council, and I wish you all well and be safe.

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