PM R 12 (2020) 714–720

www.pmrjournal.org

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-

In the midst of the novel coronavirus pandemic that
was first identified in China in late 2019, spreading world-
wide including to the United States, we have found our-
selves quickly converting many in-person clinic visits to
telemedicine. Telemedicine is defined as “the remote
delivery of health care services and clinical information
using telecommunications technology.”1 The role of tele-
medicine has been reviewed previously for both inpatient
and outpatient use in Physical Medicine and Rehabilita-
tion (PM&R).2,3 Barriers relating to telemedicine plat-
forms, reimbursement, and even resident supervision
have changed quickly in response to the pandemic. How-
ever, physician familiarity with virtual care and literature
descriptions of best practices remain limited, and the
pace of change during the pandemic has not given phys-
iatrists the luxury of slowly building up experience with
telemedicine. This toolset will also be useful for future
large scale concerns such as natural disasters and climate
change. Furthermore, although telemedicine may be
conducted asynchronously (usually through electronic
medical record patient portals that are compliant with
privacy regulations) or synchronously in real-time (with
ing audio with or without video.
Here we provide some tips on how to conduct physiatry
telemedicine visits. It is our goal to support the acceler-
ated experience by offering guidance on specific aspects,
particularly the virtual physical examination that would
typically be conducted in an outpatient setting. We are
also providing requirements on documentation and cod-
ing for the encounters. It is notable that our report is
not meant to be comprehensive or dense but covers infor-
mation that will be valuable both during and after the
pandemic, and can be used to advance patient care, res-
ident training, and in future applications of
telemedicine.
Synchronous Telemedicine Visits
Synchronous visits are real-time and establish a
physician-patient relationship. The advantages of virtual
visits during a pandemic are clear, including providing
access to care while limiting spread of illness. Beyond
the immediate utility during a global pandemic, telemed-
icine has the potential to reduce overhead costs,
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
 M. Verduzco-Gutierrez et al. / PM R 12 (2020) 714–720
(and physicians who can often work from home), and
enhance capacity to provide care in geographic regions
with limited access to physiatrists. Synchronous visits fall
under various categories based on the communication
technology (eg, telephone, computer via online plat-
form) and who is involved. For example, “direct to con-
sumer” visits involve physicians directly connecting with
patients who are remotely located in another location
(eg, at home).4 Facilitated visits, on the other hand,
involve the patient going to a medical facility where a
health care provider (eg, nurse, therapist) facilitates
the interaction. A telephone-only evaluation and man-
agement (E/M) service is provided by a physician to an
established patient not originating from a related E/M
service provided within the previous 7 days. This is differ-
ent than a telemedicine visit, which allows for the use of
telecommunications technology that have audio and
video capabilities that are real-time, two-way, and inter-
active. Currently these visits are considered the same as
in-person visits and can be billed and paid as such. Prior
to the pandemic, the Center for Medicare & Medicaid Ser-
vices (CMS) only allowed telemedicine under certain cir-
cumstances. Under a new waiver during this public
health emergency, patients in their homes and outside
of rural areas are eligible for telemedicine services.
Other policies that have been adjusted with the waiver
include no need for established relationship and authoriz-
ing use of telephones that have audio and video capabili-
ties (ie, more everyday communications technologies).5
There are also asynchronous E-visits, which are online
digital services that are patient-initiated and done via
the electronic medical record system/patient portal for
an established patient.
Preparing for a Telemedicine Visit
Developing a telemedicine program requires review of
institutional and malpractice policies, collaboration with
stakeholders (eg, staff, administrators) and visit logistics
(eg, equipment, interface, documentation). During a cri-
sis situation such as the pandemic, the usual pace and
depth of this preparation may be altered. The technology
platform used to conduct telemedicine should be
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).
715
compliant with institutional regulations, state licensing
requirements, and meet guidelines for Health Insurance
Portability and Accountability Act (HIPAA) and the
U.S. Food and Drug Administration (FDA). Secure commu-
nication was a requirement prior to the legislation that
allowed expansion of telehealth services. For security
purposes, a landline should be used over mobile phone
to reduce the risk for third party intercept as well as lim-
iting use of public networks or Wi-Fi. During the public
health emergency, there is leniency with HIPAA, special-
ized equipment, and providers being allowed to use
everyday communication technologies, such as FaceTime
or Skype.5 As with any patient visit, it is important to have
access to relevant medical records, including prior visit
records and diagnostic testing and imaging prior to con-
necting with the patient. It is also recommended that
the patient’s identification be checked prior to the start
of a visit, especially in the case of a new patient or one
who does not have their identification scanned in the
file/medical record. Figure 1 provides a workflow
sequence that may be helpful to review.
Conducting a Telemedicine Visit
There are a variety of platforms currently in use for
telemedicine visits, with recent (and perhaps temporary)
expansion to familiar apps or features. The logistics and
workflow for telemedicine varies widely depending on
the software platform utilized, the amount of support
staff available, the capabilities of the patient, and the
overall goals of the encounter. Support staff
(if available) can contribute by facilitating a review of
systems by phone or email ahead of time, confirming
patient contact information including phone and email
address, reviewing the process for the visit, answering
questions, and obtaining other relevant visit information
as indicated.
In general, each patient should receive instructions
prior to the visit including how to access the software
platform. Some programs can perform a “test call” with
support staff to ensure that the device runs the software
correctly and has sufficient digital connection, ideally in
the location planned for a telemedicine visit. The patient
716 Telemedicine Rehabilitation Visit
typically accesses the visit through a secure URL link or
online Web site, sometimes with a “virtual waiting
room,” or is contacted by the physician directly via exis-
ting smartphone apps. The visit begins when the physician
connects with the patient. Start by confirming the
patient’s identity, obtaining verbal consent for telemedi-
cine, and providing a brief orientation to telemedicine at
the start of the encounter. It is best to follow a normal
sequence that is similar to an in-person visit, including
identifying the chief complaint and purpose for the visit,
along with relevant history. Instant messaging software or
apps can be helpful for coordination between providers
and office staff during and after the visit.
For the physical examination, there are both limita-
tions and opportunities to use exam components that
you may not typically utilize and to think creatively about
how to conduct various tests. To facilitate a virtual phys-
ical examination, Table 1 provides a system-based
overview of a neurological and/or musculoskeletal
assessment. Table 2 lists examples of specialized tests
that may be used. Notably, this information is not
designed to be comprehensive and physicians should
always take into account patient safety issues when
selecting tests to perform (eg, such as limiting balance
tests in patients at risk of falling during the virtual exam)
and know that these tests may not be reliable virtually.
Many telemedicine platforms provide the opportunity
to screen share, a functionality that allows for sharing
imaging, laboratory results, and educational materials
with the patient. The patient can incorporate family
members and friends into the visit. Notably, others may
join the visit from different geographic locations (ie, they
do not have to be in the same room as the patient). Fur-
thermore, the home environment and equipment can be
viewed using the video camera, suggesting that other
aspects of patient care can be enhanced with a telemed-
icine visit. The clinician should also be aware of a poten-
tial abusive situation where an abuser may be in the room
but be off camera.
At the conclusion of the visit, the physician should
communicate the assessment and plan. Orders can be
placed to facilitate the treatment plan. Suggested prac-
tice includes entering the appropriate diagnosis code(s),
and level of service should be determined using medical
complexity and/or time spent during the full encounter.
Because of physical examination limitations, the level of
service for telemedicine visits are often time-based, with
the majority of the visit focused on counseling and coordi-
nating care. As stated, we are not providing a comprehen-
sive update on coding and billing practices as these are in
flux and likely to change; however, Table 3 lists some
guidance that we hope will be useful to readers.
Documenting the Telemedicine Visit
Suggested practice for documenting a telemedicine
visit is to follow a format similar to that of the typical
in-person visit. The Veterans Administration practice is
to record the patient location at the time of visit, emer-
gency contact information, and verbal consent to the
visit. To facilitate compensation, during the pandemic,
it is advisable to state that the visit is being conducted
virtually due to the novel coronavirus pandemic. Of
course, it is routine to document the chief complaint
and reason for any visit as well as age and sex or gender.
History of present illness or interval history should be
recorded, followed by identifying other key aspects
including relevant past medical, surgical, family history,
review of systems, functional status, family history, social
history, and drug allergies. The patient can have their
medications on hand for documentation of medicine rec-
onciliation. The physical examination should reflect
observations that can be augmented through video plat-
form and patient instructions and may often be docu-
mented in a more narrative and descriptive format than
the traditional office note. As with in-person visits, the
assessment and plan should be identified. Standard lan-
guage should be determined by the institution at the con-
clusion of the note to reflect that the visit was conducted
using a telemedicine platform, including if it is HIPAA
compliant. Table 4 offers a checklist of the documenta-
tion requirements and examples of wording that can
be used.
Other Helpful Tips
The telemedicine visit should incorporate features
that constitute current practice for an in-person visit.
The appearance of the physician and environment should
maintain the same level of professionalism recommended
for an in-person clinical encounter. The physician should
be dressed professionally and be appropriately groomed.
Background noise should be minimized, and anyone who
is present at the time of the encounter should announce
being present to show respect to patient privacy. A video
frame is often displayed that allows the physician to pre-
view what the patient is seeing. Similar to taking a photo-
graph, the physician should be contained within the video
frame (eg, not having a portion of the head cut off).
Maintaining eye contact and body cues are important
nonverbal forms of communication with the patient.
Although it is tempting to look at the screen, remember
that looking into the video camera lens will allow the
patient to experience direct eye contact.
Results should be shared in a manner consistent with
best clinical practice. For imaging review, sharing the
actual image is often possible and enhances the patient
experience. When screen sharing, it is important to
ensure that nonessential or private information is not
inadvertently shared. Physicians can also use video to
demonstrate physical examination maneuvers that the
patient is instructed to perform. In addition, home exer-
cises can be displayed with proper mechanics using the
 M. Verduzco-Gutierrez et al. / PM R 12 (2020) 714–720
Table 1
A system-based approach to performing and documenting a physical exam via telemedicine
System System Sub-Area Adaptation to Virtual Care
Vital Signs Evaluate for tachypnea, cyanosis, orthostatic
symptoms as applicable. May ask patient for
height/weight. If patient has heart rate monitor
(wrist or chest) and/or automatic blood pressure
cuff, can have them provide values
General Practitioner’s observation, including alertness,
general appearance
Respiratory Practitioner’s observation, including labor of
breathing, presence of cough or wheezing
Skin Practitioner’s observation of patient’s skin for
masses, lesions, or ulcers. Inspect and comment
on any skin changes at anatomical site(s)
postinjection
Psych Practitioner’s observation of patient’s mood and
affect
Neuro Mental status Level of alertness, orientation to visit, able to
identify objects and maintain attention to tasks
Speech Rate of speech, word choice, and volume
CN I If patient accompanied, patient may be presented
with familiar smell (coffee, bread) to identify
with eyes closed
CN II Practitioner’s observation of pupils
CN III, IV, VI Ask patient to gaze in different directions
CN V Ask patient to clench and release jaw
CN VII Ask patient to smile, raise eyebrows
CN VIII Practitioner’s observation of patient’s hearing
ability
CN IX/X Practitioner’s observation of vocal quality
CN XI Ask patient to shrug shoulders, rotate neck
CN XII Ask patient to stick out tongue
Motor Practitioner’s observation of abnormal movement
at rest including tremor, dystonia, clonus;
instruct patient on rapid finger tapping, pronator
drift
Tone Practitioner’s observation on voluntary movement,
co-contraction, posturing with position changes
Coordination Practitioner instructs patient on performing rapid
alternating movements, finger-to-nose with
available targets (eg, edge of computer screen),
heel-to-shin
Proprioception Practitioner instructs patient on performing
Romberg and tandem walking tests
Sensation Practitioner asks patient or accompanying
individual to gently touch appropriate
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
perform appropriate movements anti-gravity;
heel and toe walking can provide additional
information about dorsiflexion/plantarflexion
strength
Musculoskeletal Gait Practitioner’s observation of patient’s gait
717
Suggested Documentation for Normal Exam
Normal rate of breathing, appears well-oxygenated
without cyanosis, reports no dizziness or
orthostatic changes when asked to stand for 5 min
after sitting
Alert, cooperative, well-appearing, no acute
distress
Nonlabored breathing, no cough or wheezing
No lesions or ulcers visualized on exposed skin. No
discharge, drainage or redness at site(s) of prior
injection
Normal mood, congruent affect, answers questions
appropriately
Alert and oriented to person, time and reason for
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)
Fluent and normal rate of speech, no word finding
difficulties
CN1 confirmed intact as patient able to accurately
identify presented odor
Pupils equal and round
Extraocular movements intact, no nystagmus, no
ptosis
Jaw movements intact and symmetric
Symmetric facial movement and smile
Hearing intact to normal voice
Normal vocal quality, no hoarseness
Symmetric shoulder shrug and neck rotation
Tongue protrudes midline
No tremor, dystonia, clonus observed. Rapid finger
tapping intact. No pronator drift
Patient able to perform full active movements, no
co-contraction, no posturing with position
changes
Rapid alternating movements intact and
symmetric; finger-to-nose and heel-to-shin intact
bilaterally
Negative Romberg; normal tandem walking
Sensation to light touch and sharp/dull subjectively
intact
Strength at least anti-gravity in all four limbs. Able
to walk on heels and toes without difficulty
Symmetric, nonantalgic, heel-to-toe gait
(Continues)
718 Telemedicine Rehabilitation Visit

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
feedback.
In the case of the novel coronavirus, the World Health
Organization has released a document on disability consid-
erations during the outbreak and states that certain
populations, such as those with disability, may be
impacted more significantly.6 Per those guidelines, phys-
iatrists can educate persons with disabilities about their
increased risk and basic protection measures, and to pre-
pare the household for the instant they do contract the
novel coronavirus. We must ensure they have enough sup-
port and services. Consideration should be taken to pre-
scribe mail-order prescriptions for 90 days, order extra
supplies for home care, find accessible home health agen-
cies, and screen for exacerbation of mental health condi-
tions. Another consideration is discussing prehabilitation
with the medically frail or at-risk patient. Prehabilitation
involves medical interventions aimed at preventing or
reducing the severity of physical impairments in anticipa-
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.
 M. Verduzco-Gutierrez et al. / PM R 12 (2020) 714–720 719

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.
Conclusion
As physiatrists pivot toward increased use of telemed-
icine, we have an opportunity to improve access to care
and reduce costs for generations to come. Rehabilitation
clinicians have been pioneers in bringing care to patients’
homes with home evaluations and home exercise pro-
grams. Telemedicine will now expand access to rural
areas. We have outlined here a general format and ver-
biage to consider while adopting telemedicine for an out-
patient physiatry practice. PM&R has always advocated
for patients facing mobility and other barriers and we
are well-positioned to continue addressing these barriers
through virtual care during this pandemic and beyond.
The authors are grateful to Jacqueline Hausinger for
her help in the timely submission of this manuscript.
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Disclosure
M.V.-G. Department of Rehabilitation Medicine, UT Health San Antonio, San Anto-
nio, TX
Disclosure: Dr. Verduzco-Gutierrez has no disclosures related to this work. She
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-
rgan, Merz, Ipsen, Medtronic, and ReNeuron.
A.C.B. Department of Physical Medicine and Rehabilitation, University of Pitts-
burgh Medical Center, Pittsburgh, PA
Disclosure: Dr. Bean has no disclosures related to this work. She serves as an edito-
rial board member for the Resident Fellow Section of the American Journal of
Physical Medicine and Rehabilitation.
A.S.T. Department of Physical Medicine and Rehabilitation, Harvard Medical
School, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Bos-
ton, MA
Disclosure: Dr. Tenforde has no disclosures related to this work. He serves as Senior
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
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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1097/PHM.0b013e31829b4afe.
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peri-pandemic surgical morbidity and mortality. Am J Phys Med
Rehabil. 2020. https://doi.org/10.1097/PHM.0000000000001452.
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2020;369:m1386. https://doi.org/10.1136/bmj.m1386.
R.N.T. Department of Rehabilitation Medicine, UT Health San Antonio, San Anto-
nio, TX
Disclosure: Dr. Tapia has no disclosures related to this work.
J.K.S. Department of Physical Medicine and Rehabilitation, Harvard Medical
School, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Bos-
ton, MA. Address correspondence to: J.K.S.; e-mail: julie_silver@hms.harvard.
edu
Disclosure: Dr. Silver has no disclosures related to this work.
As an academic physician, Dr. Silver has published books and receives royalties
from book publishers, she gives professional talks such as grand rounds and medi-
cal conference plenary lectures, and receives honoraria from conference orga-
nizers. She has participated in research funded by The Arnold P. Gold Foundation
(physician and patient care disparities); Binational Scientific Foundation (culinary
telemedicine research); and the Warshaw Institute and Massachusetts General
Hospital Department of Medical Oncology (pancreatic cancer). Dr. Silver is an
uncompensated founding member of TIMES UP Healthcare.
Submitted for publication March 26, 2020; accepted April 3, 2020.