How CMS Determines Which Telehealth Services are Risk Adjustable

August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Categories:   Billing  
0 Votes - Sign in to vote or comment.

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. 


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)

Medicare Updates -- SNF, Neurostimulators, Ambulance Fee Schedule and more (2022-10-20)
October 27th, 2022 - CMS - MLNConnects
Skilled Nursing Facility Provider Preview Reports: Review by November 14 - Help Your Patients Make Informed Health Care Decisions - Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes...
2023 Evaluation & Management Updates Free Webinar
October 24th, 2022 - Aimee Wilcox
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
Are Leading Queries Prohibited by Law or Lore?
October 13th, 2022 - Erica E. Remer
AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag. Halacha is law; it is the prescriptions...
2023 ICD-10-CM Guideline Changes
October 13th, 2022 - Chris Woolstenhulme
View the ICD-10-CM Guideline Changes for 2023 Chapter 19 (Injury, poisoning, and certain other consequences of external causes [S00-T88])The guidelines clarify that coders do not need to see a change in the patient’s condition to assign an underdosing code. According to the updated guidelines, “Documentation that the patient is taking less ...
Z Codes: Understanding Palliative Care and Related Z Codes
October 11th, 2022 - Gloryanne Bryant
Palliative care is often considered to be hospice and comfort care. Palliative care is sometimes used interchangeably with “comfort care” and then again sometimes with “hospice care.”  But these terms do have slightly different meanings and sometimes the meaning varies depending on who is stating it. The National...
2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Yes, You Have What It Takes To Lead Your Practice And Your Profession
September 20th, 2022 - Kem Tolliver
If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.

Home About Contact Terms Privacy

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

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association