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?

ANSWER: 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 (MA) risk adjustment data eligibility. Based on CMS’ April 10, 2020, health plan management system (HPMS) memo and updates made on Jan. 15, 2021, and May 4, 2022, 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 healthcare professionals bill services that CMS has covered when provided as real-time interactive audio and video?

ANSWER: For synchronous telemedicine services rendered via real-time interactive audio telecommunication systems, use Current Procedural Terminology (CPT^®) telehealth modifier “95” with appropriate place of service (POS). As referenced in the May 4, 2022 CMS memo, effective January 1, 2022, there are two code options to indicate the place of service (POS) when a service provided via telehealth is submitted: 1) POS 02 for telehealth services provided other than in patients home, or 2) new POS 10 for telehealth services provided in patients home (which is a location other than a hospital or other facility where the patient receives care in a private residence). Telehealth services provided by synchronous, real-time interactive audio and video, with modifier ‘95’, appropriate POS and common CPT and Healthcare Common Procedure Coding System (HCPCS) codes are exemplified in the table below, titled “COVID-19 telehealth and other virtual services eligible for risk adjustment”.

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

ANSWER: 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.

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?

ANSWER: 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?

ANSWER: 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. In its May 4, 2022, HMPS memo, CMS reiterated its guidance that telehealth services provided interactive audio telecommunication simultaneously with video telecommunication satisfies the face-to-face requirement for purposes of risk adjustment eligibility.

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

ANSWER: On Aug. 3, 2020, CMS published a revision to the April 27, 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 6, 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.