Telemedicine Physicians "Exam" documentation

I have 2 physicians asking what to do about the Exam portion of the visit via phone or Video. Most use EMR’s that do the coding automatically. If you did not “Physically” Exam how are we supposed to get the coding to 99213 equivalent? Any suggestions I can pass on to them?

Depending on what EMR is being used, they should be able to override what the system generates, etc…

Great question! As you create your templates for Telehealth, you’ll want to see what your EHR is capable of offering you. Reach out to your vendor to see what templates they may have already created that take into account the examination bullet points. You can use time for telehealth visits, so long as that time is spent for counseling or coordinating care (and don’t forget to document it!).

Here is a web link with some additional information from Dr. Sue Kressly. OP Users, you can also find the Telemedicine and COVID-19 templates she created for you to import here.


For established patients, leveling may be based on History and Medical Decision Making alone. Via video, there very well may be observations you can make that qualify for physical exam.

We cover this in the video… Lots of exam elements in a virtual visit… don’t sell yourself short.


Have heard great things about the telemed templates in OP…

1 Like

Yes the Telemed templates that Dr Kressley are brilliant. They express the limitations and make it clear it is observation

George Rogu MD


This is great. Thank you for posting. This will help my physicians.

1 Like

Really enjoying this video. Is it possible to have link to share with our providers that aren’t registered in this forum? We are on a steep learning curve in our first week!

1 Like

Yes we need a link to the video as well if its possible.

this is what I used got it from another pediatrician on FB.

General: no acute distress visible through the video platform (kids intermittently playing during exam)
Lungs: No signs of respiratory distress, able to speak in complete sentences with no distress
Skin: reveals no rash visible through video platform
Extremities: extremities normal, atraumatic, no cyanosis or edema
Neurological: awake and alert, grossly normal exam, MAE, answers questions appropriately

To complete this exam I make sure to have my MAs tell the parents to take a temperature and get there weight prior to exam. I count the RR and have the parents get the pulse during the exam. Document the time from start to finish and include it in your assessment and plan. Ways to get more documentation is discuss social history ( kids home from school due to pandemic, adjusting well to e learning. Or parents have lost job due to pandemic. They have a good support system but are currently reaching out to obtain further resources.) If significant can add to the diagnosis to bring it up to a 99214.