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The Telehealth Quick Start Guide has been created by Berkeley Optometry’s Dr. Mika Moy.

General Tips

  • Medicare/MediCal are reimbursing more codes now, with commercial insurances expected to follow suit.
  • You must still meet coding requirements despite the fact that your exam is through Telehealth.
  • You can inform patients/advertise that you are providing Telehealth Services.
  • For most billing codes, patient must initiate visit.
  • It is strongly recommended that you practice the technology with a colleague prior to your first Telehealth exam.

Initiating Exam

  • Greet patient, confirm patient’s identity: ask for name and date of birth.
  • Get verbal confirmation to proceed, “I need your verbal consent to continue this telehealth visit.”

Case History

Telehealth exams are largely case history driven.


It is preferred for patient to use a smart phone for the visit so they can move to the bathroom (wash hands, good lighting, mirror) for the exam. Ask them to use the camera on the back of the phone (not selfie-camera) if possible for better quality image. They can use the mirror to help them line up the image. Expect to have to coach the patient through this part of the exam.

Exam elements possible with Telehealth exam

  • Acuity: Use home acuity chart or app (requires set-up and accuracy by patient).”
  • General observations: “How does your vision seem? Distance? Near?”
  • Extraocular muscle motility.
  • Adnexa.
  • Lids/Lashes.
  • Bulbar Conjunctiva.
  • Palpebral Conjunctiva
  • Pupil/Iris. Example: Pupils equal and round.
  • Cornea. Example: grossly normal.


Decide if you can diagnose and manage with a Telehealth exam and maintain a standard of care considering shelter in place orders. Telehealth exams cannot produce as much data as in-person exams, but there are many diagnoses where they are more than sufficient.

Key phrases to include in chart

  • “Patient initiated request for care and verbal consent given for Telehealth Visit.”
  • “Gross Observation via Telehealth due to COVID pandemic.”
  • “VA equal and unchanged as per patient observation.” Or other appropriate description.


Use modifier -95 (modifier -GT has been eliminated), and Place of Service -02 for Telehealth policies are changing rapidly — we recommend checking websites regularly for updates.