COVID-19 Impacts Risk Adjustment and Telehealth

Kathy Ormsby, CPC, CPCO
Vice President of  Compliance and Analytics

“Medicare beneficiaries are at the greatest risk of serious illness due to COVID-19 and CMS will continue doing everything in our power to protect them” said CMS Administrator, Seema Verma. “Today we announced guidance to Medicare Advantage and Part D plans to remove barriers that could prevent or delay beneficiaries from receiving care”.

The health and well-being of millions of Americans in the face of COVID-19 depends on the way we provide and administer care for our patients. As new information and more reliable data emerges, new policies and procedures are developed to support better care and improve outcomes.

The Center for Medicare and Medicaid Services (CMS) continues to implement policy changes in response to this pandemic. One of the most impactful changes relating to risk adjustment comes from a memo from the Department of Health & Human Services and the CMS, date April 10, 2020, titled, “Applicability of diagnoses from telehealth services for risk adjustment”, provides that diagnosis codes submitted from telehealth encounters can meet the risk adjustment face-to-face requirement. This is a drastic change from the stringent rules outlined in the Medicare Managed Care Manual which indicates in Chapter 7, paragraph 40 that all diagnosis codes must be the result of a face-to-face visit.

Due to the highly contagious COVID-19 and its impacts on public safety, CMS has relaxed the face-to-face requirement and will now accept the codes submitted during a telehealth visit for Medicare Advantage plans. The new rule prevents patients from being inadvertently exposed to the virus, prevents needless spread, and provides for the care and management of many chronic conditions. This is just one way CMS is changing policy to improve quality of life and care and at the same time becoming more cost efficient.

This is important information for plans, providers, and coders to understand. Knowing and utilizing the appropriate telehealth Current Procedural Terminology codes, modifiers, and diagnosis codes can provide the necessary revenue needed to care for patients during this unprecedented time in our history. It is important to note that CMS suggests when risk adjustment diagnoses are submitted during the telehealth encounter, coders use modifier 95 and place of service code 02.

We are blazing new trails and as new trails are discovered and new government policy is written, qrcAnalytics will continue to monitor and blog about these modifications. Follow us to stay informed.

The Medicare Managed Care Manual is a helpful resource; the link is as here:

The CMS memo discussed above, “Applicability of diagnoses from telehealth services for risk adjustment” can be found here: