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How to Conduct an Outpatient Telemedicine Rehabilitation or Prehabilitation

Visit

Article in PM&R · April 2020

DOI: 10.1002/pmrj.12380

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Practice Management
How to Conduct an Outpatient Telemedicine Rehabilitation or
Prehabilitation Visit
Monica Verduzco-Gutierrez, MD, Allison C. Bean, MD, PhD , Adam S. Tenforde, MD,
Rebecca N. Tapia, MD, Julie K. Silver, MD

Abstract

The novel coronavirus pandemic is resulting in an accelerated conversion of in-person physician visits to virtual visits. As barriers to
adoption of telemedicine are rapidly decreasing, it is important to recognize the need for practical and immediately deployable
information that can improve doctor-patient interactions, facilitate accurate documentation, and increase confidence in the transi-
tion to virtual visits. In this article we aim to outline the components of an outpatient telemedicine visit for physiatrists, with a par-
ticular focus on an adapted virtual physical examination. Uses of telemedicine may include future large scale concerns such as natural
disasters or climate change. We describe a general approach to the visit, review definitions of terms commonly used in telemedicine,
and offer tips for optimizing the encounter.

Introduction or without video), our focus is on synchronous visits utiliz-

ing audio with or without video.
In the midst of the novel coronavirus pandemic that Here we provide some tips on how to conduct physiatry
was first identified in China in late 2019, spreading world- telemedicine visits. It is our goal to support the acceler-
wide including to the United States, we have found our- ated experience by offering guidance on specific aspects,
selves quickly converting many in-person clinic visits to particularly the virtual physical examination that would
telemedicine. Telemedicine is defined as “the remote typically be conducted in an outpatient setting. We are
delivery of health care services and clinical information also providing requirements on documentation and cod-
using telecommunications technology.”1 The role of tele- ing for the encounters. It is notable that our report is
medicine has been reviewed previously for both inpatient not meant to be comprehensive or dense but covers infor-
and outpatient use in Physical Medicine and Rehabilita- mation that will be valuable both during and after the
tion (PM&R).2,3 Barriers relating to telemedicine plat- pandemic, and can be used to advance patient care, res-
forms, reimbursement, and even resident supervision ident training, and in future applications of
have changed quickly in response to the pandemic. How- telemedicine.
ever, physician familiarity with virtual care and literature
descriptions of best practices remain limited, and the Synchronous Telemedicine Visits
pace of change during the pandemic has not given phys-
iatrists the luxury of slowly building up experience with Synchronous visits are real-time and establish a
telemedicine. This toolset will also be useful for future physician-patient relationship. The advantages of virtual
large scale concerns such as natural disasters and climate visits during a pandemic are clear, including providing
change. Furthermore, although telemedicine may be access to care while limiting spread of illness. Beyond
conducted asynchronously (usually through electronic the immediate utility during a global pandemic, telemed-
medical record patient portals that are compliant with icine has the potential to reduce overhead costs,
privacy regulations) or synchronously in real-time (with decrease travel and time away from work for patients

© 2020 American Academy of Physical Medicine and Rehabilitation

https://dx.doi.org/10.1002/pmrj.12380
2 Telemedicine Rehabilitation Visit

(and physicians who can often work from home), and compliant with institutional regulations, state licensing
enhance capacity to provide care in geographic regions requirements, and meet guidelines for Health Insurance
with limited access to physiatrists. Synchronous visits fall Portability and Accountability Act (HIPAA) and the
under various categories based on the communication U.S. Food and Drug Administration (FDA). Secure commu-
technology (eg, telephone, computer via online plat- nication was a requirement prior to the legislation that
form) and who is involved. For example, “direct to con- allowed expansion of telehealth services. For security
sumer” visits involve physicians directly connecting with purposes, a landline should be used over mobile phone
patients who are remotely located in another location to reduce the risk for third party intercept as well as lim-
(eg, at home).4 Facilitated visits, on the other hand, iting use of public networks or Wi-Fi. During the public
involve the patient going to a medical facility where a health emergency, there is leniency with HIPAA, special-
health care provider (eg, nurse, therapist) facilitates ized equipment, and providers being allowed to use
the interaction. A telephone-only evaluation and man- everyday communication technologies, such as FaceTime
agement (E/M) service is provided by a physician to an or Skype.5 As with any patient visit, it is important to have
established patient not originating from a related E/M access to relevant medical records, including prior visit
service provided within the previous 7 days. This is differ- records and diagnostic testing and imaging prior to con-
ent than a telemedicine visit, which allows for the use of necting with the patient. It is also recommended that
telecommunications technology that have audio and the patient’s identification be checked prior to the start
video capabilities that are real-time, two-way, and inter- of a visit, especially in the case of a new patient or one
active. Currently these visits are considered the same as who does not have their identification scanned in the
in-person visits and can be billed and paid as such. Prior file/medical record. Figure 1 provides a workflow
to the pandemic, the Center for Medicare & Medicaid Ser- sequence that may be helpful to review.
vices (CMS) only allowed telemedicine under certain cir-
cumstances. Under a new waiver during this public Conducting a Telemedicine Visit
health emergency, patients in their homes and outside
of rural areas are eligible for telemedicine services. There are a variety of platforms currently in use for
Other policies that have been adjusted with the waiver telemedicine visits, with recent (and perhaps temporary)
include no need for established relationship and authoriz- expansion to familiar apps or features. The logistics and
ing use of telephones that have audio and video capabili- workflow for telemedicine varies widely depending on
ties (ie, more everyday communications technologies).5 the software platform utilized, the amount of support
There are also asynchronous E-visits, which are online staff available, the capabilities of the patient, and the
digital services that are patient-initiated and done via overall goals of the encounter. Support staff
the electronic medical record system/patient portal for (if available) can contribute by facilitating a review of
an established patient. systems by phone or email ahead of time, confirming
patient contact information including phone and email
Preparing for a Telemedicine Visit address, reviewing the process for the visit, answering
questions, and obtaining other relevant visit information
Developing a telemedicine program requires review of as indicated.
institutional and malpractice policies, collaboration with In general, each patient should receive instructions
stakeholders (eg, staff, administrators) and visit logistics prior to the visit including how to access the software
(eg, equipment, interface, documentation). During a cri- platform. Some programs can perform a “test call” with
sis situation such as the pandemic, the usual pace and support staff to ensure that the device runs the software
depth of this preparation may be altered. The technology correctly and has sufficient digital connection, ideally in
platform used to conduct telemedicine should be the location planned for a telemedicine visit. The patient

Figure 1. Virtual Visit Workflow. Legend: This is an example of the workflow before, during, and after a virtual visit. Of note is that the test call with
the patient is usually conducted by staff. During that time, the patient can be given additional information and medications can be reconciled (or the
patient can be told to have a list of medications ready for review with the physician). The test call is usually conducted only the first time a patient uses
the technology (ie, with new patients).
 M. Verduzco-Gutierrez et al. / PM R xx (2020) 1–7 3

typically accesses the visit through a secure URL link or in-person visit. The Veterans Administration practice is
online Web site, sometimes with a “virtual waiting to record the patient location at the time of visit, emer-
room,” or is contacted by the physician directly via exis- gency contact information, and verbal consent to the
ting smartphone apps. The visit begins when the physician visit. To facilitate compensation, during the pandemic,
connects with the patient. Start by confirming the it is advisable to state that the visit is being conducted
patient’s identity, obtaining verbal consent for telemedi- virtually due to the novel coronavirus pandemic. Of
cine, and providing a brief orientation to telemedicine at course, it is routine to document the chief complaint
the start of the encounter. It is best to follow a normal and reason for any visit as well as age and sex or gender.
sequence that is similar to an in-person visit, including History of present illness or interval history should be
identifying the chief complaint and purpose for the visit, recorded, followed by identifying other key aspects
along with relevant history. Instant messaging software or including relevant past medical, surgical, family history,
apps can be helpful for coordination between providers review of systems, functional status, family history, social
and office staff during and after the visit. history, and drug allergies. The patient can have their
For the physical examination, there are both limita- medications on hand for documentation of medicine rec-
tions and opportunities to use exam components that onciliation. The physical examination should reflect
you may not typically utilize and to think creatively about observations that can be augmented through video plat-
how to conduct various tests. To facilitate a virtual phys- form and patient instructions and may often be docu-
ical examination, Table 1 provides a system-based mented in a more narrative and descriptive format than
overview of a neurological and/or musculoskeletal the traditional office note. As with in-person visits, the
assessment. Table 2 lists examples of specialized tests assessment and plan should be identified. Standard lan-
that may be used. Notably, this information is not guage should be determined by the institution at the con-
designed to be comprehensive and physicians should clusion of the note to reflect that the visit was conducted
always take into account patient safety issues when using a telemedicine platform, including if it is HIPAA
selecting tests to perform (eg, such as limiting balance compliant. Table 4 offers a checklist of the documenta-
tests in patients at risk of falling during the virtual exam) tion requirements and examples of wording that can
and know that these tests may not be reliable virtually. be used.
Many telemedicine platforms provide the opportunity
to screen share, a functionality that allows for sharing
imaging, laboratory results, and educational materials Other Helpful Tips
with the patient. The patient can incorporate family
members and friends into the visit. Notably, others may The telemedicine visit should incorporate features
join the visit from different geographic locations (ie, they that constitute current practice for an in-person visit.
do not have to be in the same room as the patient). Fur- The appearance of the physician and environment should
thermore, the home environment and equipment can be maintain the same level of professionalism recommended
viewed using the video camera, suggesting that other for an in-person clinical encounter. The physician should
aspects of patient care can be enhanced with a telemed- be dressed professionally and be appropriately groomed.
icine visit. The clinician should also be aware of a poten- Background noise should be minimized, and anyone who
tial abusive situation where an abuser may be in the room is present at the time of the encounter should announce
but be off camera. being present to show respect to patient privacy. A video
At the conclusion of the visit, the physician should frame is often displayed that allows the physician to pre-
communicate the assessment and plan. Orders can be view what the patient is seeing. Similar to taking a photo-
placed to facilitate the treatment plan. Suggested prac- graph, the physician should be contained within the video
tice includes entering the appropriate diagnosis code(s), frame (eg, not having a portion of the head cut off).
and level of service should be determined using medical Maintaining eye contact and body cues are important
complexity and/or time spent during the full encounter. nonverbal forms of communication with the patient.
Because of physical examination limitations, the level of Although it is tempting to look at the screen, remember
service for telemedicine visits are often time-based, with that looking into the video camera lens will allow the
the majority of the visit focused on counseling and coordi- patient to experience direct eye contact.
nating care. As stated, we are not providing a comprehen- Results should be shared in a manner consistent with
sive update on coding and billing practices as these are in best clinical practice. For imaging review, sharing the
flux and likely to change; however, Table 3 lists some actual image is often possible and enhances the patient
guidance that we hope will be useful to readers. experience. When screen sharing, it is important to
ensure that nonessential or private information is not
Documenting the Telemedicine Visit inadvertently shared. Physicians can also use video to
demonstrate physical examination maneuvers that the
Suggested practice for documenting a telemedicine patient is instructed to perform. In addition, home exer-
visit is to follow a format similar to that of the typical cises can be displayed with proper mechanics using the
4 Telemedicine Rehabilitation Visit

Table 1
A system-based approach to performing and documenting a physical exam via telemedicine
System System Sub-Area Adaptation to Virtual Care Suggested Documentation for Normal Exam
Vital Signs Evaluate for tachypnea, cyanosis, orthostatic Normal rate of breathing, appears well-oxygenated
symptoms as applicable. May ask patient for without cyanosis, reports no dizziness or
height/weight. If patient has heart rate monitor orthostatic changes when asked to stand for 5 min
(wrist or chest) and/or automatic blood pressure after sitting
cuff, can have them provide values
General Practitioner’s observation, including alertness, Alert, cooperative, well-appearing, no acute
general appearance distress
Respiratory Practitioner’s observation, including labor of Nonlabored breathing, no cough or wheezing
breathing, presence of cough or wheezing
Skin Practitioner’s observation of patient’s skin for No lesions or ulcers visualized on exposed skin. No
masses, lesions, or ulcers. Inspect and comment discharge, drainage or redness at site(s) of prior
on any skin changes at anatomical site(s) injection
postinjection
Psych Practitioner’s observation of patient’s mood and Normal mood, congruent affect, answers questions
affect appropriately
Neuro Mental status Level of alertness, orientation to visit, able to Alert and oriented to person, time and reason for
identify objects and maintain attention to tasks visit. Able to identify objects including items of
clothing, electronic devices in use, and ability to
perform serial 7 s (or spell WORLD backwards if
fluent in English or more appropriate for
education)
Speech Rate of speech, word choice, and volume Fluent and normal rate of speech, no word finding
difficulties
CN I If patient accompanied, patient may be presented CN1 confirmed intact as patient able to accurately
with familiar smell (coffee, bread) to identify identify presented odor
with eyes closed
CN II Practitioner’s observation of pupils Pupils equal and round
CN III, IV, VI Ask patient to gaze in different directions Extraocular movements intact, no nystagmus, no
ptosis
CN V Ask patient to clench and release jaw Jaw movements intact and symmetric
CN VII Ask patient to smile, raise eyebrows Symmetric facial movement and smile
CN VIII Practitioner’s observation of patient’s hearing Hearing intact to normal voice
ability
CN IX/X Practitioner’s observation of vocal quality Normal vocal quality, no hoarseness
CN XI Ask patient to shrug shoulders, rotate neck Symmetric shoulder shrug and neck rotation
CN XII Ask patient to stick out tongue Tongue protrudes midline
Motor Practitioner’s observation of abnormal movement No tremor, dystonia, clonus observed. Rapid finger
at rest including tremor, dystonia, clonus; tapping intact. No pronator drift
instruct patient on rapid finger tapping, pronator
drift
Tone Practitioner’s observation on voluntary movement, Patient able to perform full active movements, no
co-contraction, posturing with position changes co-contraction, no posturing with position
changes
Coordination Practitioner instructs patient on performing rapid Rapid alternating movements intact and
alternating movements, finger-to-nose with symmetric; finger-to-nose and heel-to-shin intact
available targets (eg, edge of computer screen), bilaterally
heel-to-shin
Proprioception Practitioner instructs patient on performing Negative Romberg; normal tandem walking
Romberg and tandem walking tests
Sensation Practitioner asks patient or accompanying Sensation to light touch and sharp/dull subjectively
individual to gently touch appropriate intact
dermatomal regions, simultaneously if possible
and report any abnormal sensation. May also
provide diagram of dermatomes to further
instruct patient. Practitioner can also ask patient
to use tip of pencil and eraser to test sharp/dull
sensation.
Strength Practitioner’s observation of whether patient can Strength at least anti-gravity in all four limbs. Able
perform appropriate movements anti-gravity; to walk on heels and toes without difficulty
heel and toe walking can provide additional
information about dorsiflexion/plantarflexion
strength
Musculoskeletal Gait Practitioner’s observation of patient’s gait Symmetric, nonantalgic, heel-to-toe gait
(Continues)
 M. Verduzco-Gutierrez et al. / PM R xx (2020) 1–7 5

Table 1.
Continued
System System Sub-Area Adaptation to Virtual Care Suggested Documentation for Normal Exam
Inspection Practitioner’s observation of relevant body regions No asymmetry; no discoloration, erythema, or
as directed by patient and clinical suspicion swelling; no obvious deformity
Palpation Practitioner instructs patient to find area(s) of No tenderness to palpation; no crepitus reported,
tenderness, and guides patient to palpate equal warmth
relevant associated areas, sense temperature
differences in adjacent region or contralateral
side, and describes crepitus
Range of Motion Practitioner guides patient in performing Full Symmetric, active range of motion in bilateral
movements to observe active range of motion shoulders, elbows and knees
Special Testing Practitioner guides patient as appropriate for
patient’s chief complaint (see Table 2)
CN = Cranial nerve.

video platform and can be cued using audio and visual novel coronavirus. We must ensure they have enough sup-
feedback. port and services. Consideration should be taken to pre-
In the case of the novel coronavirus, the World Health scribe mail-order prescriptions for 90 days, order extra
Organization has released a document on disability consid- supplies for home care, find accessible home health agen-
erations during the outbreak and states that certain cies, and screen for exacerbation of mental health condi-
populations, such as those with disability, may be tions. Another consideration is discussing prehabilitation
impacted more significantly.6 Per those guidelines, phys- with the medically frail or at-risk patient. Prehabilitation
iatrists can educate persons with disabilities about their involves medical interventions aimed at preventing or
increased risk and basic protection measures, and to pre- reducing the severity of physical impairments in anticipa-
pare the household for the instant they do contract the tion of a physical stressor.7–9 Some home-based programs

Table 2
Examples of special tests that may be performed during telemedicine physical examination
Performed without assistance Performed with assistance from nonclinician
Cervical spine Spurling test (cervical radiculopathy)
Roos test (thoracic outlet syndrome)
Lumbar Spine Straight leg raise (lumbar radiculopathy)
Slump test (lumbar radiculopathy)
Hip/SI joint Single leg stance/squat (gluteus medius weakness) FABER (hip, SI joint, lumbar spine dysfunction)
Thomas test (iliopsoas tightness/contracture) FADIR (femoroacetabular impingement,
piriformis)
Ely test (rectus femoris tightness/contracture)
Stinchfield test (intra-articular hip pathology
Knee Thessaly test (meniscal injury) Noble compression test (iliotibial band
Duck walk (meniscal injury) syndrome)
Single leg squat (knee valgus, patellofemoral syndrome) Patellar grind test (patellofemoral syndrome)
Ankle/Foot Single leg heel raise (triceps surae, posterior tibialis dysfunction) Syndesmosis squeeze test (high ankle sprain)
Foot doming (intrinsic foot weakness) Thompson test (Achilles tendon injury
Metatarsal/Morton squeeze test (Morton’s neuroma)
Shoulder Drop arm test (supraspinatus tear) Speed test (biceps tendon injury)
Yocum test (subacromial impingement) Neer sign (subacromial impingement)
Lift-off test (subscapularis injury) O’Brien test (AC joint, glenoid labrum injury)
Apley scarf test (acromioclavicular joint pain) Sulcus sign test (glenohumeral instability)
Elbow Tinel test over ulnar groove (ulnar neuropathy at the elbow) Cozen test (lateral epicondylosis)
Maudsley test (lateral epicondylosis)
Wrist/Hand Finkelstein test (de Quervain’s tenosynovitis)
Tinel test (median/ulnar nerve entrapment at the wrist)
Phalen test (carpal tunnel syndrome)
Carpometacarpal Grind test (carpometacarpal osteoarthritis)
Bone (General) Palpation, direct and indirect percussion, hop test (bone stress
injury)
Tests are divided into those likely able to be performed by the patient without assistance and those which are most readily performed with another
person assisting. These are examples, and this table is not intended to be a complete list; furthermore, these tests may not be reliable virtually. Cli-
nicians should consider safety when asking patients and to perform the tests virtually.
SI = Sacroiliac joint; FABER = flexion, abduction, external rotation test; FADIR = flexion, adduction, internal rotation test.
6 Telemedicine Rehabilitation Visit

Table 3
Types of virtual services and associated billing codes during this public health emergency
Type of Service Description Code wRVUs
Telehealth Visit Telecommunication system with real-time audio 99201-99215 billed in the same 99204-2.43
and video manner as an in-person visit. 99205-3.17
Requires modifier 95 or GT 99213-0.67
99214-1.10
99215-1.77
Phone/ Virtual check-in Telephone discussion HCPCS code G2012 or
99441 5-10 min 99441-0.36
99442 11-20 min 99442-0.66
99443 21-30 min 99443-0.98
E-visit Discussion via patient portal and billed based on 99421 5-10 min 99421-0.25
cumulative amount of time spent over 7-day 99422 11-20 min 99422-0.50
period 99423 21+ min 99423-0.80
wRVU are examples. Data are subject to change and vary by region and payor. wRVU = work relative value units.

Table 4
Documentation criteria and examples for the telemedicine visit
Documentation criteria Example of how to document
Patient location at time of visit (city, state) Patient from Boston, MA presents for a virtual visit.
Emergency contact information
Verbal consent to the visit Patient agreed to use of this technology: Videoconferencing/telephone-only for
this visit.
Statement that the visit is being conducted virtually due to the This virtual visit is being used due to the novel coronavirus pandemic in place of
novel coronavirus pandemic an in-person visit.
Chief complaint/reason for visit
History of present illness/interval history
Relevant past medical, surgical, family, and social histories
Pertinent medications and drug allergies
Review of systems
Physical examination
Assessment and plan
Document time I spent a total of ___ minutes during this real-time, interactive telemedicine
encounter.
Conclude with patient understanding of plan and that the visit Patient understood the education and plan provided today and agreed to this
was done using a HIPAA compliant telemedicine platform HIPAA compliant telemedicine platform. Patient will communicate any change
in status that may necessitate a change in plan of care.
These are examples that may be used to support documentation. This is not meant to be a comprehensive list, and documentation requirements may
vary based on a variety of clinical and administrative factors.

can be delivered via telemedicine, and this is another ave- Acknowledgment(s)

nue to proactively monitor our vulnerable population.
The authors are grateful to Jacqueline Hausinger for
her help in the timely submission of this manuscript.
Conclusion
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Disclosure

M.V.-G. Department of Rehabilitation Medicine, UT Health San Antonio, San Anto- R.N.T. Department of Rehabilitation Medicine, UT Health San Antonio, San Anto-
nio, TX nio, TX
Disclosure: Dr. Verduzco-Gutierrez has no disclosures related to this work. She Disclosure: Dr. Tapia has no disclosures related to this work.
serves as Social Media editor of the American Journal of Physical Medicine and
Rehabilitation. She has also been a consultant or done prior research with Alle- J.K.S. Department of Physical Medicine and Rehabilitation, Harvard Medical
rgan, Merz, Ipsen, Medtronic, and ReNeuron. School, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Bos-
ton, MA. Address correspondence to: J.K.S.; e-mail: [email protected].
A.C.B. Department of Physical Medicine and Rehabilitation, University of Pitts- edu
burgh Medical Center, Pittsburgh, PA Disclosure: Dr. Silver has no disclosures related to this work.
Disclosure: Dr. Bean has no disclosures related to this work. She serves as an edito- As an academic physician, Dr. Silver has published books and receives royalties
rial board member for the Resident Fellow Section of the American Journal of from book publishers, she gives professional talks such as grand rounds and medi-
Physical Medicine and Rehabilitation. cal conference plenary lectures, and receives honoraria from conference orga-
nizers. She has participated in research funded by The Arnold P. Gold Foundation
A.S.T. Department of Physical Medicine and Rehabilitation, Harvard Medical (physician and patient care disparities); Binational Scientific Foundation (culinary
School, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Bos- telemedicine research); and the Warshaw Institute and Massachusetts General
ton, MA Hospital Department of Medical Oncology (pancreatic cancer). Dr. Silver is an
Disclosure: Dr. Tenforde has no disclosures related to this work. He serves as Senior uncompensated founding member of TIMES UP Healthcare.
editor for PM&R. He gives professional talks such as grand rounds and medical con-
ference plenary lectures and receives honoraria from conference organizers. He
has participated in research funded by The Arnold P. Gold Foundation (physician Submitted for publication March 26, 2020; accepted April 3, 2020.
and patient care disparities), Football Player Health Study at Harvard (health in
American-Style Football players), and the American Medical Society for Sports
Medicine (bone density research).

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