Coding Q&A: Remote examinations

Q1: I know that Medicare allows us to bill Audio/video Telehealth visits based only on time or decision-making, even for new patients. But what about the commercial payers that don’t – is there a way to meet the exam criteria for them via Telehealth?

A1: We can’t speak for any given payer, you would need to ask them their individual requirements. But we have seen the emergence of ‘Remote Examinations’ emerging from the realm of Telemedicine and now Telehealth.

One we have seen that is quite close to the standard exam that we often see for primary care was developed by Dr. Julia Jenkins in association with faculty from the University of South Florida – Morton Plant Mease Family Medicine Residency in Clearwater FL for their telemedicine curriculum, and then recently shared with hundreds of family physicians throughout Florida as part of the Florida Academy of Family Physicians COVID-19 telemedicine webinar.

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In addition to the exam itself, there is guidance for conducting the exam as follows: 

• Ensure privacy

• Make sure there is adequate lighting in the room, avoid backlighting

• Have patient assist with exam, or someone else in the room

• Ask patient to measure health data such as:
• Temperature

• Heart rate

• Blood pressure

• Weight

• Blood sugar

• Pulse ox

What to Document for a Telemedicine physical exam

VITALS: Pt reports temp of _ degrees F orally. Home BP today _. (if measured)

Weight measured at home: _. Blood sugar measured at home: _. (if measured)

GENERAL: Stable appearing, in no distress. Alert and oriented. 

SKIN: no visible facial rash or concerning facial lesions noted. No skin redness or discoloration seen. Patient denies seeing new skin findings on brief self-exam of arms, legs, chest, and abdomen.

EYES: conjunctiva clear, sclera non-icteric, no eye drainage, grossly normal EOM.

EARS: hearing grossly intact, no pain elicited with ear tugging bilaterally

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MOUTH: no visible perioral lesions, no perioral cyanosis, no lip swelling.

NECK: Grossly normal ROM, no visible thyroid enlargement. Patient did not palpate any cervical LAD under physician-guided exam.

HEART: Patient self-reported heart rate of _ beats per minute (measured by patient with physician instruction, or by fitness tracker HR monitor).

LUNGS: Does not appear dyspneic. No audible wheezes or rales. No nasal flaring.

ABDOMEN: no tenderness with patient self-palpation diffusely around abdomen under physician guidance, no pain elicited with jumping or leg lifts

MUSCULOSKELETAL: No significant cervical kyphosis, grossly normal active ROM in upper extremities.

NEURO: Intact recent memory. No facial or eyelid drooping. No speech impairment, answering questions appropriately.

PSYCH: Judgment and insight good; normal mood and affect.

As above, we cannot speak to the endorsement of any payers in this regard, but from the perspective of the Federal Documentation Guidelines this approach would more than cover the required components of a comprehensive physical exam.  We have not seen any suggestions from Medicare in this regard.

Continue to page 2 for the second question...

Q2: There seems to have been some confusion about whether Medicare will cover AWV codes G0438 and G0439 via Telehealth during the Public Health Emergency (PHE).  

A2: We certainly understand any confusion given the oft-changing guidance from CMS on what is and what isn’t considered Telehealth, how various services are reported and also how they are paid.

The AWV codes remain on the list of covered Telehealth services for the audio/video visits. But as of the Thursday, May 14, 2020, CMS Office Hours call CMS also indicated that these services are also covered via audio-only connections. 

Bill Dacey, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at billdacey@msn.com.