Capturing HCCs for Telehealth Services


by Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA

In response to my recent article “Using Telehealth to Mitigate the Impact of COVID-19 on your HCCs,” we received the following question.

…We need information related to capture of HCC’s with telehealth visits, during and after the pandemic. In the past there seemed to be a limitation of capture through telehealth but with the expansion of acceptable codes for these visits, we need to share any support for coding capture with our providers.  Can you provide any information to support the capture of HCC with telehealth? ….

This is a great question and an indication that the writer is working to ensure her organization stays both compliant with the rules as they change and able to code and bill for services accurately. Good job!

The relaxation of the telehealth rules during this pandemic (and anticipated to be extended to some extent after the pandemic ends) encourages us to code our telehealth cases with the same detail as any other encounter. This means that we need to remind our providers to conduct and document a thorough history and assessment of both prior and current conditions so we can code them!

Additionally, the use of telehealth may result in a decrease in newly identified HCCs because our providers may not be able to assess the degree of some physical conditions. This will be more commonly true when telephone-only telehealth visits have occurred.

One of my colleagues, Jan Trumbo, RHIT, shared a helpful link:

CMS Notice: All Medicare Advantage, Cost, PACE, and Demonstration Organizations
SUBJECT: Applicability of diagnoses from telehealth services for risk adjustment
April 10, 2020

(Highlights mine)

The 2019 Coronavirus Disease (COVID-19) pandemic has resulted in an urgency to expand the use of virtual care to reduce the risk of spreading the virus; CMS is stating that 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. This use of diagnoses from telehealth services applies both to submissions to the Risk Adjustment Processing System (RAPS), and those submitted to the Encounter Data System (EDS).

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. (Note: Medicaid may permit audio only visits.) 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.

Questions can be addressed to [email protected], please specify, “Applicability of Telehealth Services for Risk Adjustment” in the subject line.

Telehealth services may also be provided by non-MA plan providers during this crisis according to this March 10 notice from CMS.

Medicare Advantage Organizations may also provide enrollees access to Medicare Part B services via telehealth in any geographic area and from a variety of places, including beneficiaries’ homes. In response to the unique circumstances resulting from the outbreak of COVID-19, should an Medicare Advantage Organization wish to expand coverage of telehealth services beyond those approved by CMS in the plan’s benefit package for similarly situated enrollees impacted by the outbreak, CMS will exercise its enforcement discretion regarding the administration of Medicare Advantage Organizations’ benefit packages as approved by CMS until it is determined that the exercise of this discretion is no longer necessary in conjunction with the COVID-19 outbreak. CMS consulted with the HHS OIG and HHS OIG advised that should a Medicare Advantage Organization choose to expand coverage of telehealth benefits, as approved by CMS herein, such additional coverage would satisfy the safe harbor to the Federal anti-kickback statute set forth at 42 CFR 1001.952(l).

CMS will notify Medicare Advantage Organizations and Part D Sponsors through the Health Plan Management System when CMS is ending the enforcement discretion described herein.

Care must be taken to confirm your state requirements relative to telehealth during the pandemic. Additional resources that may be helpful are:

HCC: Auditing in the Risk Adjustment Environment
Internal HCC auditors: get the essential information you need to ensure your organization receives proper reimbursement — and that codes and claims are supported by clinical documentation.

Learn what to look for and how to communicate your findings. Tips and techniques offered by nationally recognized HCC authority Rose T. Dunn! Learn more here.

About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

2 thoughts on “Capturing HCCs for Telehealth Services

  1. Mary Hanson, CPC, CRC - July 1, 2020 at 3:30 pm

    Thank you very much for all of the work you do to ensure we’re following CMS/MA guidelines correctly, Rose! One clarification I’d like to share is that use of Place of Service (POS) “02” may lead to disparity in allowances from CMS; as, their current policy indicates Telehealth (POS 02) reimbursement to be at the ‘Facility’ (vs. non-facility) allowance. Most of our major MA plans now follow CMS’s guidance about reporting the POS where the patient ‘would have been seen if the encounter took place face-to-face.’ Therefore, I do not recommend we report POS “02” for Telehealth services. It is appropriate, as you noted above, to report Telehealth services with the 95 modifier, as this modifier does not reduce reimbursement. Thanks for listening!

    • Rose T. Dunn - July 2, 2020 at 10:10 pm

      Good point and we all should recognize that the telehealth reporting requirements have been very dynamic during this pandemic, not just for CMS but for our commercial payers. Trying to keep track of each of them is like playing Sherlock Holmes!