Telehealth Considerations for New Hampshire Chiropractors

Despite our essential business status, physical distancing strategies decrease demand for chiropractors’ hands-on treatment as people try to stay home more. However, we are able to apply our broad knowledge and skill sets to continue serving the people of NH, even when they aren’t able to reach our offices. Telehealth provides an opportunity to reach people in their homes.

screenshot from Doxy.me visit

Patient and provider connect by video in a telehealth appointment

There are a broad array of services available for telehealth consults. To hit the ground running, choose one that is affordable and simple to use for you and patients. Free options include Doxy.me, and other options ranging from Google Meet at $12/mo or VSee at $50/mo, to ExamMed and Zoom for Healthcare at $200/mo. The cloud-based EHR Jane, which is popular among chiropractors, integrated a telehealth feature in March in response to increased demand, and we will see this market continue to grow.

Each of the options listed above is HIPAA compliant. However, the US Department of Health and Human Services announced that during the emergency period they have relaxed HIPAA restrictions around remote consults. They are prioritizing getting care to patients, so they’ll honor our good-faith attempts to provide quality care, even if that means using more informal services like FaceTime, Skype, Messenger or Hangouts. In NH, emergency order #8 also interpreted the use of audio-only phone consults as valid telehealth service.

You should also know about billing and regulations. Medicare only covers manipulation codes, so we are excluded from telehealth reimbursement. NH Medicaid plans mostly exclude service from chiropractors, but plans that allow chiropractic are currently expected reimburse for telehealth under emergency order #8. Private insurance plans are expected to reimburse for telehealth consults and guided rehab at the same rate as in-office care, though this may vary. According to ChiroCode, E/M codes will be used most frequently, with level based on time and coded with a -95 modifier. You should brush up on this documentation and coding at the ChiroCode website. Additionally, VP Pence has also encouraged states to create temporary avenues for interstate telehealth, a situation we will continue to monitor.

COVID-19 Statement for Chiropractors

Dear NHCA Members,

As front line health care providers, we selflessly serve humanity. And from time to time we as doctors find ourselves amid a public health crisis. Today is such a time.

The outbreak of COVID-19 in the United States is affecting both the way you practice and the business side of practicing. The available information changes by the day and much of it influences our practices. And the available misinformation seems to change even faster. We at the NHCA will try to give you resources to benefit your practice and, of course, your patients.

SPREAD IN NEW HAMPSHIRE

The NH Dept of HHS’ most recent count is 55 confirmed cases in the state as of 3/20/20 at 9 am. Most of these cases are in Rockingham, Hillsborough and Grafton counties. The promised, more widespread, availability of testing may well make this number go up dramatically in the coming week. DHHS website for tracking coronavirus is: www.nh.gov/covid19/

ADVICE TO HEALTHCARE FACILITIES

Kentucky has ordered all DC offices to close, no other state has followed suit and many have declared all doctors’ offices to be essential. Advice from CDC to healthcare facilities can be broken down into two categories:

Screening patients pre-visit:

As of March 16, 2020 CDC recommends asking patients:

  • Have you traveled outside the state or country in the last 14 days?
  • Have you had contact with anyone with confirmed COVID-19 in the last 14 days?
  • Have you had: Fever over 100, Difficulty breathing or a Cough?

If the answer is no to all, then they may be scheduled for an appointment. However, if the answer is yes to the health questions, refer them for testing. If yes to contact or travel questions, then wait 14 days.

Sanitary procedures for healthcare facilities:

  • Clean tables, armrests and headrests esp. between each patient
  • Clean chair rails, doorknobs, toilet and sink handles and any other surface patients may touch regularly
  • Regularly clean those things staff touch regularly, such as keyboards, adding machines, copiers, etc.
  • Separate and/or remove chairs from reception area to maintain a 6-foot distance between patients (basic test: if two people sit in chairs and reach toward each other, they can’t touch if the chairs are 6 ft apart)
  • Wearing gloves is optional at this time and masks are generally ineffective unless you are a carrier.
  • Hand washing for at least 20 seconds is very effective, water temp. is unimportant, the use of soap is what gets rid of the virus.
  • Avoid face touching.

HIPAA REMINDER – COVID-19 FROM NCMIC

Original article here from NCMIC HIPAA has a special guidance section for what information and to whom that information can be released during an emergency situation. You can review these guidelines as release by US DHHS.

The 18 Protected Health Information (PHI) identifiers include: names, dates (except year), telephone numbers, geographic data, fax numbers, social security numbers, email addresses, medical record numbers, account numbers, health plan beneficiary numbers, certificate/license numbers, vehicle identifiers and serial numbers including license plates, web URLs, device identifiers and serial numbers, internet protocol addresses, full face photos and comparable images, biometric identifiers (i.e. retinal scan, fingerprints), any unique identifying number or code.

HELPFUL LINKS

For up to the minute information from CDC this is a good reference which is more chiro specific:

There is a great amount of fear and trepidation about the current situation so allow patients to cancel their appointments without judgment. Also, some insurers may reimburse for telehealth visits and all may be ordered to soon. A good article on these including coding information are available online.

Finally, if you find you need to lay off staff, they can take advantage of the unemployment guidelines and receive help earlier than usual through NH Employment Security.

Please know those of us at NHCA are here to help. If you have any questions or concerns, please don’t hesitate to contact us directly or via our social media channels. We wish you all the best of luck and hope you stay safe during these trying times.

Yours in health,

NHCA Board of Directors

Getting Insurance in Sync with Treatment

When his son, Sam, died of a heroin overdose after becoming addicted to opioids used in a sports injury, Greg McNeil started the non-profit Cover2 Resources to help other families like his. Now, Cover2 provides presentations, podcasts, and aggregates other help for people, families and organizations working toward non-opioid pain management.

In this podcast episode, Greg speaks with clinician/researcher Aaron McMichael, DC, and clinician/lobbyist Dr. Vern Saboe, DC, of Oregon. Their conversation focuses on what the research says about clinical best practices, how that matches up with the incentives provided by insurance coverage, and how doctors are affecting real change in regulation.

Study: Chiropractic Care May Lessen Drug Use

Dartmouth-Hitchcock primary care physician Dr. Louis Kazal, left, and D-H chiropractor Justin Goehl, second from left, step into the lobby of the Dartmouth-Hitchcock Heater Road clinic for a news conference after meeting with David Mara, N.H. Gov. Chris Sununu’s advisor on addiction and behavioral health, second from right, in Lebanon, N.H., Tuesday, June 26, 2018. Kazal and Goehl were part of a study in collaboration with Southern California University Health Sciences that showed patients receiving chiropractic care for non-cancer related back pain were less likely to use prescription opioid pain killers. At right is Dr. Mark Stagnone, president of the N.H. Chiropractic Association, and third from right is Dr. James Whedon, lead author of the study. (Valley News – James M. Patterson) Copyright Valley News. Reprinted with permission.


Valley News Staff Writer

Tuesday, June 26, 2018 (Valley News)

Lebanon — Researchers at Dartmouth-Hitchcock and the Geisel School of Medicine are highlighting a study that found that New Hampshire patients who received chiropractic care for lower back pain are significantly less likely to fill a prescription for an opioid than patients who didn’t see a chiropractor.

As a result, the Dartmouth researchers, among others, are pushing for expanding insurance coverage for chiropractic care.

The findings, which were published earlier this year in The Journal of Alternative and Complementary Medicine, further bolster guidelines from groups such as the American College of Physicians, which suggest that physicians should first treat patients suffering from lower back pain with therapies such as spinal manipulation, a common chiropractic treatment, before prescribing opioids.

Expanding access to such therapies — which are not always covered by health insurance — was the subject of a discussion some of the researchers had on Tuesday with David Mara, who serves as New Hampshire Gov. Chris Sununu’s adviser on addiction and behavioral health, at Dartmouth-Hitchcock Heater Road.

“I believe it’s all about access and if there are other options to pain medication it should be available to citizens of New Hampshire,” Mara said to reporters following the meeting.

He noted that some patients in New Hampshire have health insurance that covers chiropractic care, while others do not.

“We’re trying to do anything we can to stop more people from suffering from addiction,” Mara said.

Changing the way providers treat lower back pain has the potential to make a difference in overall opioid use, given that 59 percent of U.S. adults prescribed opioids reported having back pain, according to a 2008 study in the Journal of Pain and Symptom Management. (more…)

Chiropractic Better For Neck Pain

Bronfort et al. (2012), Annals of Internal Medicine
In a study funded by NIH’s National Center for Complementary and Alternative Medicine to test the effectiveness of different approaches for treating mechanical neck pain, 272 participants were divided into three groups that received either spinal manipulative therapy (SMT) from a doctor of chiropractic (DC), pain medication (over-the-counter pain relievers, narcotics and muscle relaxants) or exercise recommendations. After 12 weeks, about 57 percent of those who met with DCs and 48 percent who exercised reported at least a 75 percent reduction in pain, compared to 33 percent of the people in the medication group. After one year, approximately 53 percent of the drug-free groups continued to report at least a 75 percent reduction in pain; compared to just 38 percent pain reduction among those who took medication. (more…)

For Headaches

McCrory, Penzlen, Hasselblad, Gray (2001), Duke Evidence Report
“Cervical spine manipulation was associated with significant improvement in headache outcomes in trials involving patients with neck pain and/or neck dysfunction and headache.” (more…)