February 24, 2021

Volume XI, Number 55

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CMS Issues Guidance on Risk Adjustment and Telehealth Services

CMS has issued long-awaited guidance on the use of diagnoses from telehealth services for risk adjusted payment purposes. The guidance applies to Medicare Advantage, Cost, PACE, and Demonstration organizations.

Under the guidance, Medicare Advantage organizations and other organizations that submit diagnoses for risk adjusted payment purposes are able to submit diagnoses that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, including being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter.  The guidance clarifies that telehealth services that are provided using an interactive audio and video telecommunications system that permits real-time interactive communication, e.g., a smart phone, will satisfy the face-to-face requirement.  A standard landline or non-smart phone would not satisfy the face-to-face requirement.

The use of diagnoses 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 telehealth services to the EDS, organizations are instructed to use place of service code “02” for telehealth or use the CPT telehealth modifier “95” with any place of service.

While the COVID-19 pandemic is the impetus for the guidance, nothing in the guidance suggests that it is limited to the duration of the current emergency.

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Copyright © 2020, Sheppard Mullin Richter & Hampton LLP.National Law Review, Volume X, Number 101
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About this Author

Christine Clements, Sheppard Mullin Law Firm, Washington DC, Corporate and Health Care Law Attorney
Partner

Christine M. Clements is a partner in the Healthcare Team in the firm's Washington, D.C. office with 25 years of experience on managed care law issues. Ms. Clements focuses her practice on federal healthcare government contract programs, with particular focus on the Medicare Advantage Program, the Medicare Prescription Drug Benefit, the Federal Employees Health Benefits Program, Medicaid managed care, and the Medicare-Medicaid Plans. Ms. Clements advises clients on the issues most important to them, including contract applications and service area expansions, responses...

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