Risk Adjustment and Telehealth Policy under COVID-19

Risk Adjustment Policy Guidance from Chris Gluhak Health FidelityWith the novel coronavirus pandemic, the CDC and CMS have issued a flurry of telehealth policy updates around coding and risk adjustment. In many cases, each document leaves room for interpretation, and all organizations should work with their own counsel to evaluate how to augment their impacted policies. However, as a risk adjustment technology company, we want to offer our own conclusions, further informed by our payer and provider partners.

COVID-19 Related ICD-10 Codes

On 3/18/20 the CDC announced the introduction by WHO CSAC of a new ICD-10 code for the new COVID-19 diagnosis. The new ICD-10 code, U07.1 (“2019-nCoV acute respiratory disease“) is effective for all dates of service 4/1/20 and later.

The label of this new code is likely to change once the name of the virus is formally updated by the WHO. It is also notable that this off-cycle effective date of a new ICD-10 code has never before occurred.  As of this post’s publication, there has been no communication by a regulatory body that would suggest that this new ICD-10 code would be adopted into a risk adjustment model. The code will be subject to update per the existing annual ICD-10 refresh that starts on October 1.

Telehealth Encounter Eligibility Policy

CMS and the CDC have published five significant updates on their policies, on 3/17/20, on 4/6/20, on 4/10/20, 4/21/20, and on 4/30/20 around telehealth eligibility (virtual services) for provider reimbursement under Medicare. This guidance, under the 1135 waiver authority, constitutes an expansion of telehealth services. For all dates of service, beginning 3/1/20, through the end of the COVID-19 public health emergency, Medicare is paying providers for an additional range of visits under the telehealth umbrella. The first update only referred to Medicare and Part B, but the subsequent updates clarified to generally include Part C, then finally suggesting all encounters normally used for risk score calculation would continue to be useful if a combined audio/video communication system were used. The 4/21/20 update reinforced the prior viability of risk adjustment via telehealth for previously risk adjustable encounters and added language to include special needs plans (SNPs).

The most recent guidance from 4/30/20 introduces an audio-only option for a limited set of Medicare services in addition to those directly tied to COVID-19. It also includes additional provider categories not previously authorized to render telehealth services under Medicare, namely physical therapists, occupational therapists, and speech language pathologists.

While not explicitly naming applicability to risk adjustment, the 4/30/20 guidance strongly suggests that Part C payer participants may also benefit from the expansion to these provider types. RAPS submissions can now apparently include risk adjusted diagnoses documented via telehealth visits by the named provider types, who previously had been subject to the face-to-face requirement for risk adjustment-eligible submissions into RAPS. It is not immediately clear whether these affected provider types may also contribute telehealth-derived diagnoses into EDPS, where stricter rules around eligible provider types normally apply.

These visits were previously only recognized within the proper office, hospital, or other approved settings. Now, patients in any region, and in particular from urban areas, may have virtual encounters with their physician without the need to personally present in the care facility. It is still left open to some interpretation exactly which set of telehealth encounters may be eligible, but only insofar as CMS is effectively reserving its right to exclude some telehealth claims from risk score calculation down the line. Overall, the extent to which telehealth encounters may be used for Part C risk adjustment – while likely unrestricted, relative to the traditionally accepted encounter settings for risk adjustment outside of telehealth – remains a matter of individual decision by health plans because of the implicit reservation by CMS.

Our recommendation is to progress forward as if they are recognized, as a good faith capturing and coding of the data under this expanded care delivery model is the best way to ensure a properly adjusted risk profile for patients and populations going forward.


Telehealth Covered Services Policy

For some context, the prior, pre-COVID-19 rules around telehealth are available here. These policy updates are now slightly modified due to the 1135 waiver expansion outlined above, with those modifications itemized below. Under each of the following variants of telehealth, there are several conditions that must be fulfilled for the non-face-to-face encounter type to qualify for reimbursement under Medicare. Note, it is the union of all conditions named in each of these three telehealth variants that constitutes the rule update under the 1135 waiver expansion.

The full list of 190 Medicare-covered telehealth codes is available here. The following table is a guideline for fulfilling coverage criteria.


Type of Service Conditions of Service Criteria Detectable HCPCS/CPT Codes
Medicare Telehealth Visits
  • Some of the covered provider types in many states appear to include dieticians and social workers, etc. That said, this is a matter of state law, and not exhaustively covered.
  • Communication system that employs simultaneous video and audio is required for eligibility. The only exception is for patients expressly being examined for COVID-19 infection, in which case audio-only methods qualify for Medicare reimbursement. Note that for MSSP ACOs, audio-only telehealth encounters do qualify under Medicare regardless of COVID-19 relevance.
  • E/M levels (CPT codes): 99201 – 99215
  • HCPCS codes: G0425 – G0427 and G0406 – G0408

Virtual Check-in
  • Patients must be established for the visit to qualify.
  • Patient must initiate contact with the provider.
  • Patient must have verbally consented to accept virtual check-in services.
  • Patient’s communication is unrelated to medical visits within last 7 days.
  • Patient’s communication does not lead to a medical visit within the following 24 hours (or to the soonest appointment available after 24 hours).
  • G2010 and G2012

  • Patients must be established for the visit to qualify.
  • Patient must initiate contact with the provider.
  • Communications must occur within 7 days from the date of the patient’s initiation.
  • Patient must have verbally consented to accept virtual check-in services.
  • E/M levels (CPT codes): 99421 – 99423
  • HCPCS codes: G2061 – G2063

If you have any questions on evolving policy in value-based care or would like to engage with a member of our professional services team for evaluating how you can ensure continued operation during this ongoing and complex situation, contact us today.