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New official guidance on diagnoses from telehealth services for risk adjustment

CMS has already expanded their coverage on Telehealth services due to COVID-19 emergency.

The memo, entitled “Applicability of diagnoses from telehealth services for risk adjustment,” explains when MA organizations and other organizations may submit diagnoses from telehealth visits for risk adjusted payment. The memo was sent to organizations on Friday but has not yet been posted on the CMS site. However, you can find a copy of it uploaded on the Sheppard Mullin health care law blog.

1. Risk adjustment eligibility: Visits must meet all criteria for risk adjustment eligibility. That criteria includes being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter, according to the memo.

2. RAPS and EDS submissions: CMS said the use of telehealth services diagnoses applies to submissions to the Risk Adjustment Processing System (RAPS) and those submitted to the Encounter Data System (EDS).

For RAPS, MA organizations must identify which diagnoses meet risk adjustment criteria.
For EDS, organizations must report all the services they provided to enrollees and CMS identifies those diagnoses that meet risk adjustment filtering criteria. Use place of service code “02” for telehealth services or use the CPT telehealth modifier “95” with any place of service.

3. Risk-adjustment face-to-face requirements: Diagnoses that result from a telehealth visit can meet the risk adjustment face-to-face requirement when the services are provided via an interactive audio and video telecommunications system that permits real-time interactive communication. Christine M. Clements, a partner with Sheppard Mullin in Washington, D.C., explains that a smart phone will satisfy the requirement, but a standard landline will not be acceptable.

4. For more information: CMS asked organizations to send questions to