What is the expectation on how a provider would assess and document vitals or conduct a physical exam via telehealth for an Annual Wellness Visit (AWV) or Annual Physical Exam?

ANSWER: Physicians and healthcare providers should continue to apply accurate documentation to their medical note for telehealth visits on information they can collect during the telehealth visit. On March 30, 2020, CMS published an interim final rule (Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, PDF opens new window) to provide additional flexibility to physicians during the COVID-19 pandemic. CMS has removed any requirements regarding documentation of history and/or physical exam in the medical record for office/outpatient E/M encounters provided via telehealth.

Source: Centers for Medicare & Medicaid Services (CMS) Interim Final rule Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, March 30, 2020, https://www.cms.gov/files/document/covid-final-ifc.pdf, PDF opens new window