The Center for Consumer Information & Insurance Oversight (CCIIO) at the Centers for Medicare & Medicaid Services this week issued guidance for the ACA marketplace about risk adjustment and telehealth and telephone services during COVID-19.
The CCIIO originally published the frequently asked questions (FAQs) on April 27 and updated them on August 3 to further clarify which telehealth claims are valid for risk adjustment .
Telehealth under the HHS-operated risk adjustment program
CCIIO said that any telehealth service is reimbursable under applicable state law and if they meet all other criteria for risk adjustment eligibility. Under those conditions, these services may be submitted to a health insurer’s External Data Gathering Environment (EDGE) server for the purposes of the Department of Health and Human Services-(HHS) operated risk adjustment program.
Submitted codes that describe a face-to-face service by a qualified health care professional and are an acceptable source of new diagnoses will be included in the risk adjustment filtering. Although telehealth visits are considered the same as face-to-face interactions, they must meet the same requirements for provider type and diagnostic value.
Codes for services that are eligible for inclusion in risk adjustment and explicitly mention telehealth include those related to the emergency department or initial inpatient telehealth consultation:
- HCPCS codes G0425, G0426, and G042
Other codes eligible include those for follow-up telehealth consultations furnished in hospitals or skilled nursing facilities:
- HCPCS codes G0406, G0407, G0408, G0459, G0508, and G0509
CCIIO also said that additional services provided in the telehealth setting can be submitted with a modifier code (95/ GQ/ GT) and/or with a place of service code 02.
Changing the modifier or place of service for an otherwise acceptable face-to-face service to telehealth or telephone-only will have no impact on the inclusion of specific services for purposes of the risk adjustment program because these settings are the equivalent to the face-to-face setting for purposes of the HHS-operated risk adjustment program.
In addition, due to COVID-19, HHS has established nine e-visit codes for calendar year 2020 that will be valid for 2020 benefit year and may be submitted for risk adjustment (subject to applicable state law requirements). These new codes took effect Jan. 1:
- CPT codes 98970-98972
- CPT codes 99421-99423
- HCPCS codes G2061-G2063
The codes describe short online assessments where qualified healthcare professionals review patient input and determine whether an office visit is warranted. These e-visit codes allow for online evaluation and management (E&M) or professional assessment conducted via a patient portal, including subsequent communication with the patient through online, telephone, email, or other digitally supported communication.
The e-visit CPT set is for use by physicians and nonphysician qualified health professionals who may independently bill for E&M visits. The e-visit HCPCS code set is for use by non-physician qualified health professionals who may not be able to bill independently for E&M visits (e.g., clinical psychologists).
CCIIO said these e-visit codes will be valid for diagnosis filtering purposes in risk adjustment data submissions for the 2020 benefit year.
“Risk adjustment eligible diagnosis codes provided via allowable telehealth and virtual services will be validated in HHS risk adjustment data validation in the same manner as risk adjustment diagnosis codes provided via in-person services are validated,” CCIIO said in the guidance.
Furthermore, it said HHS may include these codes in future benefit years if appropriate, such as if the COVID-19 public health emergency continues into the 2021 benefit year.
Telephone-only service codes
In addition, the guidance said that HHS recognizes the increased need to provide telephone and virtual services during the emergency. As a result, it has given additional consideration as to how it will treat telephone-only (also referred to as audio-only) services in the HHS-operated risk adjustment program.
CCIIO said diagnosis codes from telephone-only service CPT codes 98966-98968, 99441-99443 are valid for risk adjustment diagnosis filtering purposes in risk adjustment data submissions for the 2020 benefit year if they meet state law requirements.
Like telehealth visits, telephone-only services must meet the same requirements for provider type and diagnostic value and reimbursable under applicable state law.
“We recognize that many conditions cannot be diagnosed telephonically but will defer to applicable coding and diagnosis guidelines setting groups (e.g., American Medical Association) on what a permissible diagnosis telephonically may be,” CCIIO said in the FAQ.
Risk adjustment eligible diagnosis codes provided via allowable telehealth and telephone-only services will be validated in HHS’ risk adjustment data validation in the same manner it validates risk adjustment diagnosis codes via in-person services. The agency said it may consider including these codes in future benefit years if appropriate.