Wiki Physical exam in a Telehealth visit


True Blue
Columbus, OH
Best answers
Does anyone have information about documenting physical exam for established patient telehealth visits billable using 99201-99215? It would seem a limited exam could be documented based on physician observations during the call. I know it isn't technically required (2/3 elements and all that) since History and MDM will be documented.

And secondary question - do we have to include any statement in the visit note acknowledging it's a telehealth visit? Any examples if we do?

Yes, your telehealth exam will be limited at best. You might be able to get constitutional; you might be able to get psych. Anything other than that would certainly be difficult. I am advising my providers that most of these visits will be > 50% counseling, so document such and bill based on time.

My employer is strongly suggesting we obtain a very detailed consent in writing, but verbal is acceptable. I have not seen any advise from CMS or any commercial carrier that requires such a detailed consent. What I have seen is that simply consent must be obtained, and if not using a HIPAA compliant platform (ie Skype, FaceTime, etc), then advise patient that it is not HIPAA compliant and they must agree to it.
I'm certainly not legal counsel, but I believe something like "Verbal consent to billable telehealth encounter using non HIPPA complaint platform of [Skype, FaceTime] was given by (PATIENT) on (DATE) at (TIME)." should suffice.
Thanks. I'm where you are in regards to physical exam elements, just nice to hear it from someone else!

We have the actual consent part sorted out but I saw a document from the MGMA suggesting best practice is to include a statement (not the consent) in the visit note that the service was provided via telehealth, the location of both parties involved and the role of any other people participating in the telehealth visit. This made me wonder what others are doing in this regard, if anything? Have you seen any guidance from other groups about this?
At this point, I've read so much about it & sometimes I forget where I read something in order to more carefully re-read it. I do recall hearing/reading that it should be documented that visit took place as telehealth & the location of both parties. I no longer recall where. I had previously instructed my providers to include those items. I would rather document something that wasn't required (and took 10 seconds) than have compliance issues.
Oh, I feel the same way, especially about the compliance concerns. I think I'm driving my Director nuts but I want to make sure we've done as much due diligence as possible. And I hear you on the information overload! Thanks for your input. It is greatly appreciated!