Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
May 13th, 2020

On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states:

“Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.”

On April 30th, CMS expanded telehealth waivers (among other provisions) to include audio-only telehealth encounters for those beneficiaries who either do not want to or cannot communicate via an audio-video telecommunications system for any reason. This begs the question: In light of the new waivers, does this mean that the audio-only encounters are eligible for risk adjustment purposes? 

The answer is yes, they are definitely risk adjustable but only as far as they also meet the criteria for the individual code selected. It is important to realize that although we know how services are risk-adjusted, we still need to verify that the actual service itself has been documented and coded correctly to actually qualify as one of the services that can be used in the risk adjustment process.

Reporting Telehealth Services to be Recognizable by Medicare 

We contacted the Medicare COVID-19 Hotline and asked the following questions: 

1. How does Medicare want the audio-only telehealth services reported? Medicare responded that these should be reported with codes 99441-99443 (telephone E/M services performed by a physician or other QHP for an established patient), which fulfills the requirement of an audio-only service. While codes 99441-99443 are not technically telehealth services due to the PHE COVID-19 PHE (Public Health Emergency) crisis, as of April 30, 2020 they were officially added (temporarily) to the telehealth list.  However, they should still be reported according to their individual reporting rules.
2. Do we add modifier 95 or POS 02 to identify these as telehealth services? Medicare responded that, since they are technically not telehealth services, modifier 95 or POS 02 are not required for reporting purposes. However, Medicare also stated that if 99441-99443 were reported with modifier 95 or POS 02, they might still be reimbursed. If not, simply remove them and submit a corrected claim. 
3. Can audio-only services be risk-adjusted? According to Medicare these services can be risk-adjusted, even though they are audio-only services, as long as the documentation supports the reported diagnoses. 

To select a specific encounter for risk adjustment, the documentation must support the code(s) reported, both services and diagnoses; and for telehealth, it requires the service be on the telehealth list, performed according to the requirements for audiovisual (real-time), or that it meets the telecommunications requirements, as seen in the example listed in question #2 above. 

Coding Tip: 

Medicare states that services which are normally performed via telehealth (and not because of COVID-19) should continue to be reported with POS 02 but do not require the use of modifier 95. Services that are being performed via telehealth because of the COVID-19 PHE should be identified with modifier 95 and the place of service where the encounter took place instead of POS 02. 

Medicare’s most important recommendation was to ensure providers continue to take the time necessary to document correctly and with the kind of detail required to support diagnoses, procedures or other services ordered or performed, and include any unusual circumstances, such as how the patient may be affected by COVID-19, including exposure, symptoms, test results, etc. Also, if services are performed via telehealth, document: 

• Distant site (provider location) and originating site (patient location)
• All participants
• How the service was performed (e.g., telephone, virtual, e-visit, real-time [audiovisual])

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.