Wiki Physical exam in a telehealth visit

[medicalauditor]

Hi fellow auditors,
Does anyone know of any exemptions for physical exam in a telehealth visit? What I mean is, you clearly can't examine most organ systems virtually, so this means that for all new patient visits, its going to be 99202 (I am talking about office visits prior to 2021) no matter how detailed the history or how complex the MDM, because New patient visits require all three elements (HEM) to be met or exceeded - so if the exam is focused or expanded problem focused, the E/M will be 99201/99202. Does anyone know of any CMS waivers where the provider can get credit for a comprehensive or extended exam even if it is not done, in view of the fact that it is a telehealth visit? If there is such an allowance, can someone please provide a link to the source?
Thank you

 

[csperoni]

CMS issued guidance that even in 2020, telehealth could be coded on MDM only or time.
From https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf currently on page 96 (my emphasis added):
"In the May 8, 2020 COVID-19 IFC, for the duration of the PHE, we also expanded the primary care exception to include the following services: Telephone E/M services (CPT codes 99441–99443), Transitional Care Management (CPT codes 99495-99496), and Communication Technology-Based Services (CPT codes 99421–99423 and 99452, and HCPCS codes G2010 and G2012). For office/outpatient E/M services furnished via telehealth, the E/M level selection can be based on Medical decision making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter. We also removed any requirements regarding documentation of history and/or physical exam in the medical record.
New: 6/19/20"

 

[medicalauditor]

CMS issued guidance that even in 2020, telehealth could be coded on MDM only or time.
From https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf currently on page 96 (my emphasis added):
"In the May 8, 2020 COVID-19 IFC, for the duration of the PHE, we also expanded the primary care exception to include the following services: Telephone E/M services (CPT codes 99441–99443), Transitional Care Management (CPT codes 99495-99496), and Communication Technology-Based Services (CPT codes 99421–99423 and 99452, and HCPCS codes G2010 and G2012). For office/outpatient E/M services furnished via telehealth, the E/M level selection can be based on Medical decision making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter. We also removed any requirements regarding documentation of history and/or physical exam in the medical record.
New: 6/19/20"

Thank you SO much. I was trying to find such a document but couldn't, for some reason. I appreciate your taking the time to respond.