Telehealth FAQs – Risk adjustment

The Centers for Medicare & Medicaid Services (CMS) has announced that Medicare will pay for certain services conducted by telephone and has added such audio-only services to the list of Medicare telehealth services. Does this mean these audio-only services are acceptable for risk adjustment purposes?

CMS published an interim final rule on April 30, 2020 waiving the video requirement for certain telephone evaluation and management (E/M) services, as Medicare beneficiaries may not have access to or prefer not to utilize real-time interactive audio-video technology required for Medicare telehealth services. These qualifying E/M services have been added to the list of Medicare telehealth services and are acceptable if performed using a real-time interactive audio system. However, this interim final rule applies to Original Medicare coverage criteria and does not address the criteria for Medicare Advantage risk adjustment data eligibility. Based on CMS’ April 10, 2020 health plan management system (HPMS) memo and an update made on Jan. 15, 2021, Humana maintains that in order for these services to qualify for risk adjustment they must be performed using interactive audio telecommunication simultaneously with video telecommunication to permit real-time interactive communication.

How should physician and health care professionals bill services that CMS has covered when provided as audio only?

Although services may be covered when provided as audio-only, Humana requests that providers bill audio only services using telephonic Current Procedural Terminology (CPT^®) codes 99441-99443 in order to identify services as being audio only and therefore, not eligible for MA risk adjustment. Billing the telephonic CPT code will clearly indicate that the service was provided as audio only. For interactive audio telecommunication simultaneously with video telecommunication, use CPT telehealth modifier “95” with any place of service (POS) and the appropriate CPT and Healthcare Common Procedure Coding System (HCPCS) codes as exemplified in the grid below under “Common CPT and HCPCS Codes”.

If providers have previously submitted audio only visits with CPT codes other than telephonic CPT codes, Humana requests providers to correct the service that was billed by submitting corrected claims for those visits using telephonic CPT codes in order identify them as audio only services. Note: Correcting the service that was billed requires a corrected claim, which is a different process than submitting a diagnosis code deletion request.

Are there additional documentation requirements associated with telehealth services?

As a best practice, Humana recommends documenting in the medical record whether a visit was conducted via interactive audio telecommunication simultaneously with video telecommunication or through other virtual mechanisms, such as audio only.

If a telehealth consultation discusses and addresses a Medicare risk adjustment (MRA) condition, will CMS recognize the diagnosis for risk adjustment purposes?

In order to submit the diagnoses from a visit for risk adjustment purposes, the visit must be an allowable inpatient, outpatient or professional service, AND  the visit must be a face-to-face encounter. CMS recently released guidance clarifying the face-to-face encounter requirement in the context of telehealth and other virtual services. CMS clarified that telehealth services provided interactive audio telecommunication simultaneously with video telecommunication satisfies the face-to-face requirement for purposes of risk adjustment eligibility. This clarifying guidance applies to all telehealth services provided in 2019, 2020 and 2021.

Are audio-only services acceptable for commercial risk adjustment (CRA)?

On Aug. 3, 2020 CMS published a revision to the April 27th, 2020 memo announcing the addition of telephonic CPT codes (98966-98968, 99441-99443) valid for 2020 benefit year data submissions for the Department of Health and Human Services- (HHS-) operated risk adjustment program. This is a key difference between Commercial and Medicare risk adjustment; which is outlined on the “COVID-19 telehealth and other virtual services eligible for risk adjustment” grid below. On May 6th, 2021, CMS published a revision to the April 27, 2020 memo announcing that HHS is extending the policy to the 2021 benefit year data submissions for HHS-operated risk adjustment program. HHS designated diagnosis codes from telephone-only service CPT codes listed above as valid for risk adjustment diagnosis filtering purposes in risk adjustment data submissions for the 2020 and 2021 benefit years, subject to applicable state law requirements.

Will this affect risk adjustment processing system (RAPS) and encounter data system (EDS) submissions to CMS?

The CMS guidance related to diagnoses from telehealth services applies to both submissions to the RAPS and the EDS. While MA organizations and other organizations that submit diagnoses for risk adjusted payment identify which diagnoses meet risk adjustment criteria for their submissions to RAPS, MA organizations (and other organizations as required) report all the services they provide to beneficiaries to the EDS, and CMS identifies those diagnoses that meet risk adjustment filtering criteria. In order to report services to the EDS that have been provided via telehealth and that satisfy the face-to-face encounter requirement, use CPT telehealth modifier 95 with any place of service.

Please note it is important to use specific codes when services provided are telephonic only, e-visits or virtual check-ins, so that MA organizations and CMS can identify that telehealth services provided were audio only or otherwise not acceptable for risk adjustment purposes. Please refer to the “COVID-19 telehealth and other virtual services eligible for risk adjustment” grid above.