Is COVID-19 Causing Risk Adjustment “Gotcha’s”?

August 27th, 2020 - Wyn Staheli, Director of Research
Categories:   Covid-19  
0 Votes - Sign in to vote or comment.

The COVID-19 public health emergency (PHE) has created some possible problems when it comes to risk adjustment. Be sure your organization has implemented policies and procedures to try and overcome these new hurdles.

Insufficient Management of Patients with Chronic Conditions

Some have expressed concerns that patients with chronic conditions have not been coming in for regular visits. Because of this, these patients might not have an appropriate RAF score due to the lack of clinical visits. More importantly, they may not be receiving the care that they need to adequately manage their conditions which leads to poor patient outcomes and increased costs. Consider working with providers to help them identify their patients with chronic conditions to make sure they get the visits that they need to both care for them and document the management of their conditions. If the patient is worried about in-person visits, then encourage telehealth options (see below).

Difficulty Obtaining Medical Records

In an effort to control COVID-19 exposure, many organizations have cut office hours (or have been closed for long periods of time) and changed work staffing (e.g., alternating shifts). An unexpected consequence of this is that some risk adjustment reviewers have reported that it has become more difficult to obtain patient records than it was previously. This may result in reporting delays. Contact reviewers and if this has been a problem, work with them to create a plan to make this process a little easier.

Does Telehealth Count? 

This is the big question. Does telehealth count or not? To answer that question, look at the following Q/A from the CMS COVID-19 FAQ document (emphasis added):

Question: Will diagnoses from telehealth visits be used in the CMS-HCC risk scores used in program calculations for ACOs? Are ACOs included in the ‘other organizations’ that may submit diagnoses codes that are referenced in the 4/10/2020 HPMS memo that addressed the applicability of diagnoses from telehealth visits for [sic] purpose of risk adjustment?

Answer: CMS calculates risk scores for all Medicare beneficiaries, and uses the final CMSHCC risk scores calculated for FFS beneficiaries in ACO program calculations; the Medicare Shared Savings Program and existing CMMI ACO models do not calculate separate CMSHCC risk scores for these ACO initiatives. Final CMS-HCC risk scores will include telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service. 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.

While Medicare Advantage organizations submit diagnoses for their enrollees, CMS calculates the risk scores of FFS beneficiaries, including those assigned to ACOs, with those diagnoses that are submitted on claims by FFS providers, and that meet risk adjustment criteria. CMS uses the information on these FFS claims to determine whether diagnoses are risk adjustment eligible, including those from telehealth visits. In other words, when diagnoses from applicable telehealth visits meet the risk adjustment criteria, they will be used in calculating risk scores for FFS beneficiaries. The 4/10/20 HPMS memo was referring to plans that submit diagnoses on behalf of their enrollees, and that submit data to the Risk Adjustment Processing System (RAPS) or Encounter Data System (EDS) for purposes of calculating risk scores. Because beneficiaries participating in ACOs are FFS beneficiaries, and CMS uses diagnoses from FFS claims to calculate their risk scores, ACOs are not considered ‘other organizations’ and do not submit data to RAPS or EDS for purposes of calculating risk scores.

CMS also published a document entitled “Risk Adjustment Telehealth and Telephone Services During COVID-19 FAQs” on  April 27, 2020 which was later updated on August 3, 2020. This document clarifies which codes may be submitted for risk adjustment data submissions. It states “Any service provided through telehealth that is reimbursable under applicable state law and otherwise meets applicable risk adjustment data submission standards…” is considered valid for data submission for the 2020 benefit year.

Even though Medicare is allowing a telephone call to be reimbursed as an E/M visit during the PHE, it is clear that when it comes to risk adjustment, the rules are not the same. There will need to be a face-to-face encounter, which can be done via telehealth as long as all applicable rules are met (as outlined above). This encounter does not need to have a recording of the encounter, but it is essential that the documentation clearly states that this encounter was conducted via telehealth using video and audio telecommunications and was not just a phone call. 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...
How to Properly Assign ICD-10-CM Codes for Pain
July 14th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Pain is a common diagnosis among all specialties so it should not be surprising to find there are 162 ICD-10-CM codes for reporting it and over 80 mentions in the ICD-10-CM Official Guidelines for Coding and Reporting which describe when certain types of pain should be reported and how the codes should be sequenced.
Will CMS Allow Medicare Advantage Organizations to Risk Adjust from Audio-Only Encounters? 
July 13th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
While audio-only telehealth services became a covered benefit during the PHE, CMS put limitations on using the data from those encounters for risk adjustment scoring. Medicare Advantage (MA) plans cannot use the information from these encounters to be scored for risk adjustment; however, it can be used for risk adjustment scoring of ACA plans.
Compliance in the Dental Office or Small Practice
June 29th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...
Important Changes to Shared/Split Services
June 16th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
Reporting of split (or shared) services has always been wrought with the potential for incorrect reporting when the fundamental principles of the service are not understood. A recent CMS publication about these services further complicates the matter.
Understanding Non-face-to-face Prolonged Services (99358-99359) in 2021
June 3rd, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
Due to the extensive changes in office or other outpatient services (99202-99215), there are many questions which still need to be answered, one of which is related to the prolonged services without face-to-face contact. This article explores the question regarding the appropriate use of codes 99358/99359 and how to report it.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association