How CMS Determines Which Telehealth Services are Risk Adjustable

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Aug 9th, 2022

The question has been asked repeatedly as to whether or not data collected from telehealth, virtual care, and telephone encounters can be reported for risk adjustment (RA) purposes. The Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) originally answered this question in April 2020 when they published the Risk Adjustment Telehealth and Telephone Services During COVID-19 FAQs April 27, 2020, which outlined the regulations surrounding this issue, and the CPT and HCPCS codes that describe these services that qualify for RA reporting. 

As the public health emergency (PHE) was still in place in 2021, CMS HHS pointed out that these regulations were still in effect, and would continue to be so until the PHE is declared over by the Administration. The same document was updated in April 2022 and continues to support reporting diagnoses obtained from telehealth, virtual care, and telephone encounters performed by approved providers adhering to the rules and regulations associated with performing these types of services. 

It is important to note that we will receive a 60-day notification before the end of the PHE is declared. Of note, if the end of the PHE takes place during the current year, the policies for the PHE will remain in effect until the end of the year in which the PHE was declared over. Therefore, as it stands today, these policies should remain in effect until December 31, 2022, unless the PHE is extended into 2023. 

When considering the codes for services that are eligible for RA reporting, it is important to remember what HHS stated: 

“If a code submitted to an issuer’s EDGE server is descriptive of a face-to-face service furnished by a qualified healthcare professional and is an acceptable source of new diagnoses, it will be included in the risk adjustment filtering. Telehealth visits are considered equivalent to face-to-face interactions, and they are subject to the same requirements regarding provider type and diagnostic value.”

In the 2023 Medicare Physician Fee Schedule (PFS) Proposed Rule, CMS proposes an extension of the temporarily-available telemedicine services approved for the PHE, through the entire 2023 year because they feel this will allow them additional time to collect data to make a determination as to which telehealth services should become permanent and which should go away when the PHE ends. In the Consolidated Appropriations Act of 2022, CMS promised there would be a period of 151 days following the termination date of the COVID-19 PHE where the following telehealth services will continue to be reimbursed, begging the question of timing. The question is, is it the end of the year in which the PHE is declared over that the regulations surrounding the PHE also end, or will telehealth services have an additional extension of 151 days? For now, the 2023 proposed rule says that during the 151 days following the declaration of the end of the PHE, the following will be continued with regard to Telehealth services:

• Telehealth services may be furnished in any geographic area and in any originating site setting (e.g., home).
• Telehealth services may be furnished via audio-only telecommunications systems.
• Physical and occupational therapists, speech-language pathologists, and audiologists may furnish telehealth services.
• The in-person visit requirements for telehealth mental health services will be removed.

However as of day 152, CMS has proposed that the following Telehealth service changes may be put into place: 

• Providers will report the appropriate place of service (POS) code on the claim instead of reporting modifier 95.
• Providers will add modifier 93 to any telehealth service to indicate the specific service was performed by audio-only technology.

If there is anything that we can declare to be consistent, it is change. For now, this is the proposed rule for 2023 and the comment period is open until September 6, 2022. The final rule will let us plan better for 2023 and whether or not risk adjustment reporting for telehealth, virtual care, and telephone (audio only) services will still be considered acceptable sources of risk adjustment data. 

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.