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New Acupuncture Specific Codes Effective 10-1-2016

The following codes have been added 10-1-2016 and are included in this list as the most likely to affect an acupuncture claims and/or conditions. They are listed in Alphabetic/ICD10 order. Codes are in the system and can be viewed by logging in and can be searched by “10-1-2016” in the search bar and it will be bring up all the new, updated and deleted codes.

Visits on or after 10-1-2016 require the updated codes.

  • E78.0 Pure hypercholesterolemia(deleted 10-1-2016)
  • E78.00 Pure hypercholesterolemia, unspecified
  • E78.01 Familial hypercholesterolemia
  • F32.81 Premenstrual dysphoric disorder
  • F32.89 Other specified depressive episodes
  • F34.81 Disruptive mood dysregulation disorder
  • F34.89 Other specified persistent mood disorders
  • F42 Obsessive-compulsive disorder(deleted 10-1-2016)
  • F42.2 Mixed obsessional thoughts and acts
  • F42.3 Hoarding disorder
  • F42.4 Excoriation (skin-picking) disorder
  • F42.8 Other obsessive-compulsive disorder
  • F42.9 Obsessive-compulsive disorder, unspecified
  • F50.8 Other eating disorders(deleted 10-1-2016)
  • F50.81 Binge eating disorder
  • F50.89 Other specified eating disorder
  • G56.03 Carpal tunnel syndrome, bilateral upper limbs
  • G56.13 Other lesions of median nerve, bilateral upper limbs
  • G56.23 Lesion of ulnar nerve, bilateral upper limbs
  • G56.33 Lesion of radial nerve, bilateral upper limbs
  • G56.43 Causalgia of bilateral upper limbs
  • G56.83 Other specified mononeuropathies of bilateral upper limbs
  • G56.93 Unspecified mononeuropathy of bilateral upper limbs
  • G57.03 Lesion of sciatic nerve, bilateral lower limbs
  • G57.13 Meralgia paresthetica, bilateral lower limbs
  • G57.23 Lesion of femoral nerve, bilateral lower limbs
  • G57.33 Lesion of lateral popliteal nerve, bilateral lower limbs
  • G57.43 Lesion of medial popliteal nerve, bilateral lower limbs
  • G57.53 Tarsal tunnel syndrome, bilateral lower limbs
  • G57.63 Lesion of plantar nerve, bilateral lower limbs
  • G57.73 Causalgia of bilateral lower limbs
  • G57.83 Other specified mononeuropathies of bilateral lower limbs
  • G57.93 Unspecified mononeuropathy of bilateral lower limbs
  • H93.A1 Pulsatile tinnitus, right ear
  • H93.A2 Pulsatile tinnitus, left ear
  • H93.A3 Pulsatile tinnitus, bilateral
  • H93.A9 Pulsatile tinnitus, unspecified ear
  • K52.29 Other allergic and dietetic gastroenteritis and colitis
  • K52.2 Allergic and dietetic gastroenteritis and colitis (deleted 10-1-2016)
  • K52.3 Indeterminate colitis
  • K52.831 Collagenous colitis
  • K52.832 Lymphocytic colitis
  • K52.838 Other microscopic colitis
  • K52.839 Microscopic colitis, unspecified
  • K90.41 Non-celiac gluten sensitivity
  • M21.611 Bunion of right foot
  • M21.612 Bunion of left foot
  • M21.619 Bunion of unspecified foot
  • M21.621 Bunionette of right foot
  • M21.622 Bunionette of left foot
  • M21.629 Bunionette of unspecified foot
  • M25.541 Pain in joints of right hand
  • M25.542 Pain in joints of left hand
  • M25.549 Pain in joints of unspecified hand
  • M26.601 Right temporomandibular joint disorder, unspecified
  • M26.602 Left temporomandibular joint disorder, unspecified
  • M26.603 Bilateral temporomandibular joint disorder, unspecified
  • M26.609 Unspecified temporomandibular joint disorder, unspecified side
  • M26.611 Adhesions and ankylosis of right temporomandibular joint
  • M26.612 Adhesions and ankylosis of left temporomandibular joint
  • M26.613 Adhesions and ankylosis of bilateral temporomandibular joint
  • M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side
  • M26.621 Arthralgia of right temporomandibular joint
  • M26.622 Arthralgia of left temporomandibular joint
  • M26.623 Arthralgia of bilateral temporomandibular joint
  • M26.629 Arthralgia of temporomandibular joint, unspecified side
  • M26.631 Articular disc disorder of right temporomandibular joint
  • M26.632 Articular disc disorder of left temporomandibular joint
  • M26.633 Articular disc disorder of bilateral temporomandibular joint
  • M26.639 Articular disc disorder of temporomandibular joint, unspecified side
  • M26.60 Temporomandibular joint disorder, unspecified (deleted 10-1-2016)
  • M26.61 Adhesions and ankylosis of temporomandibular joint (deleted 10-1-2016)
  • M26.62 Arthralgia of temporomandibular joint (deleted 10-1-2016)
  • M26.63 Articular disc disorder of temporomandibular joint (deleted 10-1-2016)
  • M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level
  • M50.021 Cervical disc disorder at C4-C5 level with myelopathy
  • M50.022 Cervical disc disorder at C5-C6 level with myelopathy
  • M50.023 Cervical disc disorder at C6-C7 level with myelopathy
  • M50.120 Mid-cervical disc disorder, unspecified
  • M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
  • M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
  • M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
  • M50.220 Other cervical disc displacement, mid-cervical region, unspecified level
  • M50.221 Other cervical disc displacement at C4-C5 level
  • M50.222 Other cervical disc displacement at C5-C6 level
  • M50.223 Other cervical disc displacement at C6-C7 level
  • M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level
  • M50.321 Other cervical disc degeneration at C4-C5 level
  • M50.322 Other cervical disc degeneration at C5-C6 level
  • M50.323 Other cervical disc degeneration at C6-C7 level
  • M50.820 Other cervical disc disorders, mid-cervical region, unspecified level
  • M50.821 Other cervical disc disorders at C4-C5 level
  • M50.822 Other cervical disc disorders at C5-C6 level
  • M50.823 Other cervical disc disorders at C6-C7 level
  • M50.920 Unspecified cervical disc disorder, mid-cervical region, unspecified level
  • M50.921 Unspecified cervical disc disorder at C4-C5 level
  • M50.922 Unspecified cervical disc disorder at C5-C6 level
  • M50.923 Unspecified cervical disc disorder at C6-C7 level
  • N50.811 Right testicular pain
  • N50.812 Left testicular pain
  • N50.819 Testicular pain, unspecified
  • N50.82 Scrotal pain
  • N50.89 Other specified disorders of the male genital organs
  • N50.8 Other specified disorders of male genital organs(deleted 10-1-2016)
  • N94.10 Unspecified dyspareunia
  • N94.11 Superficial (introital) dyspareunia
  • N94.12 Deep dyspareunia
  • N94.19 Other specified dyspareunia
  • N94.1 Dyspareunia(deleted 10-1-2016)
  • S03.40XA Sprain of jaw, unspecified side, initial encounter
  • S03.40XD Sprain of jaw, unspecified side, subsequent encounter
  • S03.40XS Sprain of jaw, unspecified side, sequela
  • S03.41XA Sprain of jaw, right side, initial encounter
  • S03.41XD Sprain of jaw, right side, subsequent encounter
  • S03.41XS Sprain of jaw, right side, sequela
  • S03.42XA Sprain of jaw, left side, initial encounter
  • S03.42XD Sprain of jaw, left side, subsequent encounter
  • S03.42XS Sprain of jaw, left side, sequela
  • S03.43XA Sprain of jaw, bilateral, initial encounter
  • S03.43XD Sprain of jaw, bilateral, subsequent encounter
  • S03.43XS Sprain of jaw, bilateral, sequela

How and when to use unspecified and other diagnosis codes in ICD10

I am confused when it comes to using codes that state unspecified. I see there are three codes for extremity pain codes. There is a code for right, left and unspecified. I have heard from some that I should never use the code unspecified, is that correct?

With the plethora of new codes available in ICD10, some of the language can be overwhelming or at best confusing to decipher. In fact, that statement is partially true. Indeed it is not likely you would ever use a code for an unspecified shoulder. However, let’s make a clarification of this meaning. M25.519 indicates pain in the unspecified shoulder, while M25.511 is pain in the right shoulder and M25.512 is pain in the right shoulder. When you physically examine the patient it would be clear that you could identify the pain being right, left or both shoulders. Therefore it would not be appropriate to indicate unspecified shoulder as you can identify if it is right, left or both. When bilateral simply use both codes. Unspecified when it comes to identifying an extremity as left or right would not appropriate assuming you physically see the patient and can identify it as left or right.

Please note do not infer that unspecified may or does mean both or bilateral. If both shoulders have pain the claim would indicate both the right and left codes. For pain in the extremities, there is no code that indicates bilateral and therefore when right and left are involved both codes would be utilized. Unspecified shoulder would likely only be used in a setting such as a hospital where emergency personnel contact the hospital indicating a shoulder injury and the initial documentation of the diagnosis would be unspecified until the person is examined.

However, there are many codes that indicate unspecified or other and are not referring to left, right or location. When using codes that state “other” or “unspecified” note these have special meanings. Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist. One obvious example is muscle spasm. There are three codes that indicate muscle spasm, muscle spasm of the back is M62.830 and muscle spasm of the calf is M62.831 which are specific to those 2 regions. But third code is M62.838 other muscle spasm. The “other” code, therefore, would be chosen when the spasm is not in the back or the calf but some “other” region.

Another example would be a patient where the history and exam findings lead you to a diagnosis of facet syndrome. When you search there is no specific code that states “facet syndrome.” In this case, you would use the codes M53.80 to M53.88 which are noted as “other specified dorsopathies” these codes defines and extends from the occipito-atlanto-axial region to the sacral and sacrococcygeal region.

This would be the proper code to use when specifying the condition as “facet syndrome” and therefore fits as “other specified dorsopathies.” This type of code is used when you can indicate or describe the specific diagnosis or causation of condition but there is no code that indicates that specific diagnosis directly.

 

In opposition when the pain or dorsopathy is determined as sciatica, you can indicate M54.31 to M54.32 for sciatic pain or M54.41 to M54.42 for lumbago with sciatic pain as there are codes that specifically indicate the diagnosis for sciatica or low back with sciatica.

 

Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. This means you have a patient with a dorsopathy (back pathology or pain) but cannot clearly determine a specific diagnosis or causation and therefore would use the code M53.9 which is for “dorsopathy unspecified” as there is no clear diagnostic conclusion.

 

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. This, in reality, takes the place when a provider has several potential diagnostic possibilities or suspicions and is wanting g to use a “rule out diagnosis.” For instance, a patient presents with lower back pain that is severe and the provider is suspicious it may be a disc pathology. However, until a proper scan or another test can provide conclusive evidence of a disc pathology the diagnosis will initiate as lower back pain (lumbago) M54.5. Once there is confirmation of the disc pathology then the disc codes may be utilized. Be sure to only code what you can confirm based on your history, physical examination, and testing. This would mean the initial diagnosis may indeed be pain but later be amended to a specific condition once confirmed.

 

Sign(s)/symptom(s) and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.

 

As confusing as it may seem at first glance ICD10 is simply is a detailed granulated method of description that can be very specific but not always as specific as we may assume and non-specific codes that are “unspecified or other” may be appropriate and the most correct code.

1500 Claim Form clarification and use of Block 24E “Diagnosis Pointer”

Many billing programs will automatically default to include the letters corresponding to the diagnosis in block 21. If you have 4 (or more) diagnosis in block 24e it will often simply default to ABCD. Having this protocol as a default should not lead to any problems for acupuncture claims. However in the instance that a provider has need to point a specific service to specific diagnosis this default would have to be edited. For instance acupuncture is being performed to the neck and back pain which corresponds to diagnosis A and B but there is also massage being done for muscle spasm of a region not related to the neck or back. The line of billing with massage could be pointed to C to correspond to the specific diagnosis where massage is being done.

This pointing is not as critical for acupuncture billing as there are generally no codes that must be reported to a separate region from the primary, acupuncture service. This need is common for chiropractors and physical therapist billing but not acupuncture. Therefore a default to ABCD (or any combination of letters simply not more than 4) would not lead to any denials.

The instruction manual for the 1500 describes use of 24E in this manner:

In 24E, enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple

services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be letters A through L or multiple letters as applicable. Each letter must be entered separately. Do not enter A-E or similar but 4 separate letters. Enter letters left justified in the field. Do not use commas between the letters. There may be a maximum of 4 letters listed in 24E any additional are simply not reported in this section.

ICD10 Updates and News

CMS has been carefully monitoring the transition and is pleased to report that claims are processing normally. Generally speaking, Medicare claims take several days to be processed and, once processed, Medicare must– by law – wait two weeks before issuing a payment. Based on the metrics comparing ICD9 and ICD10 there are lesser claims denied due to invalid coding with ICD10 when compared to ICD9. So far so god, though Noridian for California and Nevada were denying all claims for chiropractic initially they have corrected their error and have reprocessed all previously denied claims.

 

Metrics October 1-27 Historical Baseline*
Total Claims Submitted 4.6 million per day 4.6 million per day
Total Claims Rejected due to incomplete or invalid information 2.0% of total claims submitted 2.0% of total claims submitted
Total Claims Rejected due to invalid ICD-10 codes 0.09% of total claims submitted 0.17% of total claims submitted
Total Claims Rejected due to invalid ICD-9 codes 0.11% of total claims submitted 0.17% of total claims submitted
Total Claims Denied 10.1% of total claims processed 10% of total claims processed

 

 

Aetna has reported they are not experiencing any issues with processing ICD-10 claims. Other carriers have so far made no formal announcement but we have not had reports of carriers with any problems or issues with ICD10 processing.

 

Be aware that workers’ compensation claims and personal injury can be exempt from use and does vary from state to state as well as by carrier. The following is a breakdown of what states are using ICD10 and the others who are using ICD9 as well as personal injury carriers.

 

For workers’ compensation, twenty-one states have adopted ICD-10 billing for physicians, hospital inpatients and outpatients, according to WEDI.

They are: Alabama, California, Florida, Georgia, Hawaii, Idaho, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Mexico, New York, North Carolina, Ohio, Oregon, South Dakota, Texas and Washington.

Three states have adopted ICD-10 codes for hospital inpatient billing only: Indiana, Maine and South Carolina.

This leaves 26 states that have no plans for adopting ICD-10 for workers comp claims, unless there's a pending ICD-10 regulation: Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Iowa, Kansas, Kentucky, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Virginia, Wisconsin and Wyoming.

Personal injury verify with each carrier prior to billing but the following providers have indicated their use of ICD10

  • State Farm Insurance: Will transition to ICD-10 on 10/01/2015. All claims submitted with ICD-10 will be processed accordingly. Additionally, State Farm will continue to process as usual, all claims submitted with ICD-9 diagnoses for an indefinite period of time.
  • American Family Insurance: American Family Insurance is prepared to accept ICD-10 effective 10/01/2015. American Family Insurance will also continue to accept and process claims with ICD-9 diagnoses for an undetermined, but, limited time after 10/1/2015.
  • Progressive Insurance: Progressive Insurance will be transitioning to ICD-10 on the mandated date of 10/01/2015. Claims submit with ICD-9 will be rejected. Providers will receive remittance explaining the rejection and requiring providers to resubmit the claim using ICD-10 diagnosis.
  • GEICO: Will begin accepting ICD10 codes on 10/1/15. Bills with a date of service on or after 10/1/15 must contain a valid ICD10 code. For a date of service prior to 10/1/15 use only valid ICD9 codes. ICD9 and ICD10 codes cannot be combined on a bill.
  • Farmers: Accepting ICD10
  • Nationwide: Accepting ICD10.
  • Safe Co: Accepting ICD10
  • Travelers: Accepting ICD10
  • AAA: Accepting ICD10
  • Allstate & USAA: No confirmation

HIPAA Compliance Audits on the Horizon

Recently the Office of Inspector General (OIG) for the Dept of Health and Human Services (HHS) did a study and found that the Office of Civil Rights (OCR), which has responsibility for HIPAA compliance, is not doing enough to ensure covered entities (CEs), including healthcare providers and insurers, are effectively following HIPAA requirements. They found that most activities were reactive, not proactive. The OCR agreed with report's recommendations and that they need to do more oversight actvities.

Look for more HIPAA compliance audits and enforcement activities in the coming months as funding for these activities is provided to the OCR.

Have you gotten all your compliance requirements met? This includes: establishing your policies and procedures; implementing them within your practice; ensuring everyone has taken training; ensuring all your business associates have signed a BA Agreement and have security controls in place; and performing a risk assessment; just to name the major requirements.

Make plans in the near term to address all HIPAA compliance requirements.

NOTE: All the 50 State Attorneys General office are also ramping up to do their own HIPAA compliance audits and enforcement, in addition to the OCR's activities.
See the full report at http://oig.hhs.gov/oei/reports/oei-09-10-00510.pdf

1500 Claim Form Diagnosis Reporting with ICD-10- No Decimals

Reporting Diagnosis on the 1500 with ICD10 should NOT have decimals as they are implied. When reporting diagnosis in block 21 of the 1500 there is a 7 character limit and the use of a decimal will drop the final character of a 7 digit code. Therefore diagnosis on the 1500 should be reported without a decimal and simply the characters with no spacing.

Note the following examples of 3, 4, 5, 6, and 7 character codes.

R51, M545, M5431, M25511, MS134XXA

NUCC 1500 Claim Form Manual

http://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2012_02-v3.pdf

 

ITEM NUMBER 21

TITLE: Diagnosis or Nature of Illness or Injury

INSTRUCTIONS:

Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field.

Enter the codes left justified on each line to identify the patient’s diagnosis and/or condition. Do not include the decimal point in the diagnosis code, because it is implied. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A - L to the lines of service in 24E by the letter of the line. Use the greatest level of specificity. Do not provide narrative description in this field.

Workers’ Compensation and ICD10

Workers compensation claims systems in about half the states are ready for the switch on October 1, while half are not, according to Workgroup for Electronic Data Interchange, (WEDI).

WEDI has released data on worker's compensation readiness by state. Twenty-one states have adopted ICD-10 billing for physicians, hospital inpatients and outpatients, according to WEDI.
They are: Alabama, California, Florida, Georgia, Hawaii, Idaho, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Mexico, New York, North Carolina, Ohio, Oregon, South Dakota, Texas and Washington.

Three states have adopted ICD-10 codes for hospital inpatient billing only: Indiana, Maine and South Carolina.

This leaves 26 states that have no plans for adopting ICD-10 for workers comp claims, unless there's a pending ICD-10 regulation: Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Iowa, Kansas, Kentucky, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Virginia, Wisconsin and Wyoming.

Ask the Expert: ICD10 for Cash Practices and the Effect to Personal Injury and Workers’ Compensation

Q. I am a ‘cash only’ practice and do not contract with any payers. Do I still need to use ICD-10?
A. While technically you do not have to do so under the HIPAA federal regulations, it is still a good idea to include ICD-10 codes on the bill you provide to your patient. The reason for this is that some patients may submit claims to their insurance company on their own behalf and if the codes are not the current and correct ICD10 the patient will not receive any reimbursement.

Q. What benefits are there for Non-covered Entities (this includes workers’ compensation and personal injury claims) to transition to ICD-10?

A. According to AHIMA, there are several benefits for non-covered entities and notes that CMS plans to work with these organizations to encourage ICD-10 use.

Benefits: The increased detail in ICD-10 provides significant value to non-covered entities. For example, the expanded injury codes will be useful to automobile insurance and workers' compensation programs. Non-covered entities stand to achieve the same benefits of using more detailed, up-to-date code sets as covered entities, including better data for:

• Measuring the quality, safety, and efficacy of care
• Designing payment systems and processing claims for reimbursement
• Conducting research, epidemiological studies, and clinical trials
• Setting health policy
• Operational and strategic planning and designing healthcare delivery systems
• Monitoring resource utilization
• Improving clinical, financial, and administrative performance
• Preventing and detecting healthcare fraud and abuse
• Tracking public health and risks
In addition, ICD-9-CM will no longer be maintained once ICD-10 is implemented; meaning the usefulness of the ICD-9-CM code set will rapidly decline. ICD-9-CM products and resources also will become increasingly difficult to obtain. Those non-covered entities that continue to use ICD-9-CM after the ICD-10 compliance date will compromise their ability to compare data with covered entities.

Q. What will happen if our clinic does not switch to ICD-10?
A. Claims that are submitted by HIPAA covered entities (all claims except cash, PI and WC), without ICD-10 diagnosis after October 1, 2015 will not be processed.

Be Aware of Credit Card Fees

Many providers accept credit cards as a form of payment, but need to be aware of the associated fees when accepting virtual credit card payments from insurers for reimbursement purposes. Virtual credit cards are unique card numbers generated for a specific one-time transaction and linked to real accounts with card issuers. Clinics need to be aware that these transactions carry significant fees compared to traditional forms of payment--up to five percent of the transaction amount--and may include additional fees to offset fraud risk when card numbers are entered manually, which in effect reduces reimbursement to the clinic. It also effectively transfers the cost of the transaction from the payer to the clinic.

Acupuncture Timed Service Documentation Requirements

The 15 minute increment of time is defined as personal one-on-one contact with the patient. This means that the physician acupuncturist is in the room with the patient, is actively performing a medically necessary activity that is a component of acupuncture or electro acupuncture. The time that the needles are retained is specifically excluded for the purpose of determining time and consequently from reimbursement. 8 Minute Rule for Timed Codes – One Service

For services billed in 15-minute units, count the minutes of skilled treatment provided. Only direct, face-to-face time with the patient is considered for timed codes. 8 minute time rule for timed service

• 7 minutes or less of a single service is not billable.

• 8 minutes or more of a single service is billable as 1 unit or an additional unit if the prior units were each furnished for a full 15 minutes:

• 8 – 22 minutes = 1 unit

• 23 – 37 minutes = 2 units

• 38 – 52 minutes = 3 units

• 53 – 67 minutes = 4 units

The face-to-face time can be identified as pre-service work which includes greeting the patient and a brief interval history. Intra-service work for actions connected to the acupuncture procedure which may include pertinent evaluation and assessment of the patient (tongue, pulse, palpation, ROM etc.), hand washing, patient positioning, locating and cleaning the points, inserting and stimulating the needles, checking on the patient, removing the needles, and any discussion or counseling related to the acupuncture service. The face-to-face time does not include needle retention time where there is no need for direct patient monitoring or contact.