Wiki MA Performing Physical Exam via Telehealth

[caitlin1994]

I work at a third party billing company as a medical coder and biller. It has come to my attention that one of our clients has been "performing" physical exams in a way I've never heard of. My manager says this is completely okay to do, but I'm just wanting to make sure. So...

The provider in question uses telehealth to watch a medical assistant perform a physical exam on a patient. The doctor will watch (via live video and audio) the MA perform a full physical exam on a patient. Doctor is in one office location, patient and medical assistant are at another office location in a completely different town. From what I've been told, the doctor will watch/guide the medical assistant performing the exam (HEENT, lung/heart sounds, reflexes, dermatomes, etc.), and the assistant will note any abnormalities. Based on all of this, the doctor will then plan a course of treatment for the patient. They have been billing as telehealth for these visits.

Like I said before, my manager says this is completely okay, but I am not able to find any information on this. I feel like it's definitely not because MAs aren't licensed QHPs, and I didn't think they could do anything beyond vitals, injections, EKGs, etc. under the supervision of a provider who is at the same location at the time of the encounter, but I want to make sure I'm not missing something. Especially since the doctor isn't even in the same location as the patient. I am trying to find information to confirm or refute that what the doctor is doing is okay. I really don't think it is, but if someone is able to give me any guidance or provide sources I could take to my manager and our CEO, that would be very helpful. This has apparently been going on for awhile now (at least 2 years I believe), and I am very concerned.

Thank you!

 

[thomas7331]

I think it's valid concern and an important question you're asking here, but I don't think you are going to find much in the way of written guidance in the addressing this in the coding and billing areas. It's understood for telehealth services that the provider is going to have to rely on the assistance of staff members at the originating site. Prior to the pandemic, telehealth E&M services (which at that time required an exam component) were authorized mainly when specialists were not available on site at these facilities, and hospital staff would assist in the performance of the examinations - the written guidance at that time made it clear that this was expected. I've seen this frequently, although in the hospitals it was usually RNs and not MAs doing this work. But I've never seen any written guidance from CMS or any other payers that sets specific limits or guidelines regarding what the provider may or may not delegate to the staff who assist.

As I see it, the question you're asking gets into two areas: first, is it within the scope of the MA's license to do this, even when supervised in this manner; and second, to what extent is it clinically appropriate for the physician to rely on and make decisions based on findings performed by this individual under this kind of arrangement. The answer to the first question is going to vary depending on location since scope of practice is regulated at the state level - maybe a question to put to your state's board of nursing. The second question, I think, is a matter of provider judgment and standards of medical practice, which is something a coder is not at all qualified to try to answer. If I were in your place, I would refer this to the organization's medical director as I think that would be the individual most suited to try to address these concerns.