Telehealth Risk Adjustment During COVID-19 Pandemic

Can a diagnosis made during a telehealth visit be counted for risk adjustment? That has been the big question surrounding the Risk Adjustment community as our government and top healthcare officials continue to battle COVID-19.

The answer is yes!

From the Department of Health & Human Services on April 10, 2020:

“CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnosis for risk adjusted payment are able to submit diagnosis for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter. This use of diagnosis from telehealth services applies both to submissions to the Risk Adjustment Processing System (RAPS), and those submitted to the Encounter Data System (EDS). In order to report services to the EDS that have been provided via telehealth, use place of service code “02” for telehealth or use the CPT telehealth modifier “95” with any place of service.”

The full letter can be found on the CMS website.