Risk Adjustment

CMS Releases Telehealth Ruling Regarding Applicability of Services for Risk Adjustment

Announcement States Telehealth Visits Provide Risk Adjustable Diagnoses


In response to the incredible burden placed on American healthcare institutions by the novel coronavirus outbreak, the Centers for Medicare & Medicaid Services (CMS) have announced their decision to allow diagnoses captured during telehealth visits to be risk adjustable.

“Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses 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…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.”

-CMS Announcement, 4/10/2020

We welcome and fully support this announcement as an appropriate response to the global COVID-19 outbreak. Telehealth, as a means of continuing care for the most vulnerable during these unstable times, has been a closely-watched subject by members of the healthcare industry, and we are happy to see CMS putting their full support behind the initiative.

To better assist health plans and provider groups wishing to deploy telehealth, Episource is well positioned to provide assistance through our new telehealth solution, available for immediate use.

Our comprehensive telehealth solution is available as part of our end-to-end in-home health assessment offering that includes scheduling and outreach, as well as visits via our network of nurse practitioners (NPs).

“While MA organizations and other organizations that submit diagnoses for risk adjusted payment identify which diagnoses meet risk adjustment criteria for their submissions to RAPS, MA organizations (and other organizations as required) report all the services they provide to enrollees to the encounter data system and CMS identifies those diagnoses that meet risk adjustment filtering criteria. 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.”

-CMS Announcement, 4/10/2020

Although this announcement is a temporary response to systemic stresses, we feel these measures are an appropriate response to the current crisis and we hope these regulations will expand beyond the current need. We look forward to the near future when telehealth will become an integral addition to our nation’s healthcare capabilities and can be used to deliver superlative care.


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