Healthcare News
Are you Prepared for CMS Issues Guidance on Risk Adjustment related to Telehealth Services.
Due to the COVID-19 situaiton, CMS has issued updated guidelines in the use of diagnoses from tele-health services for risk adjusted payment purposes. The guidance applies to Medicare Advantage, Cost, PACE, and Demonstration organizations. CMS has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility.
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.
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.
It is important for Medicare Advantage organisation and other Demonstration Organisations like to ensure right validations are performed to ensure the Tele health services are reported accurately to ensure the right CPT/HCPCS codes and modifiers are used to report the conditions. There are already guidelines/medical policies on how to report telelhealth services between MA organisations and providers which is termed as E-Visits. There are some guidelines which were provided for Medicare and can be leveraged for MA plans that can ensure valid Diagnostic codes are reported for Risk Adjustment purpose.
Following that must happen inorder to be prepared for your system to report diagnosis codes for risk Adjustment purposes for both EDPS and RAPS. EDPS and RAPS risk eligible logic must be updated to include:
Process
Track office visits and other speciality visits that must be done via Telehealth sevice during the COVID-19 period and implement ML model to flag claims that are reported without right CPT/Modifiers/Place of service for manual reviews.
Create a dashboard/Report which can categorise Telehealth services and analyse them weekly to review and ensure diagnosis codes
Risk Adjustment Logic
Ensure place of service logic is updated to include “02”. Healthplans and Providers need to update guidelines to report and have validation of Modifier 95 and Place of service “02” along with right Dates of services.
Identify and Include CPT/HCPCS codes that are Telehealth procedures as Risk adjustment eligible and track them.
Add modifier based logic to business rules to include Modifier “95” for RAPS eligible services.
