Is COVID-19 Causing Risk Adjustment “Gotcha’s”?

by  Wyn Staheli, Director of Content - innoviHealth
Aug 27th, 2020

The COVID-19 public health emergency (PHE) has created some possible problems when it comes to risk adjustment. Be sure your organization has implemented policies and procedures to try and overcome these new hurdles.

Insufficient Management of Patients with Chronic Conditions

Some have expressed concerns that patients with chronic conditions have not been coming in for regular visits. Because of this, these patients might not have an appropriate RAF score due to the lack of clinical visits. More importantly, they may not be receiving the care that they need to adequately manage their conditions which leads to poor patient outcomes and increased costs. Consider working with providers to help them identify their patients with chronic conditions to make sure they get the visits that they need to both care for them and document the management of their conditions. If the patient is worried about in-person visits, then encourage telehealth options (see below).

Difficulty Obtaining Medical Records

In an effort to control COVID-19 exposure, many organizations have cut office hours (or have been closed for long periods of time) and changed work staffing (e.g., alternating shifts). An unexpected consequence of this is that some risk adjustment reviewers have reported that it has become more difficult to obtain patient records than it was previously. This may result in reporting delays. Contact reviewers and if this has been a problem, work with them to create a plan to make this process a little easier.

Does Telehealth Count? 

This is the big question. Does telehealth count or not? To answer that question, look at the following Q/A from the CMS COVID-19 FAQ document (emphasis added):

Question: Will diagnoses from telehealth visits be used in the CMS-HCC risk scores used in program calculations for ACOs? Are ACOs included in the ‘other organizations’ that may submit diagnoses codes that are referenced in the 4/10/2020 HPMS memo that addressed the applicability of diagnoses from telehealth visits for [sic] purpose of risk adjustment?

Answer: CMS calculates risk scores for all Medicare beneficiaries, and uses the final CMSHCC risk scores calculated for FFS beneficiaries in ACO program calculations; the Medicare Shared Savings Program and existing CMMI ACO models do not calculate separate CMSHCC risk scores for these ACO initiatives. Final CMS-HCC risk scores will include telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service. 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.

While Medicare Advantage organizations submit diagnoses for their enrollees, CMS calculates the risk scores of FFS beneficiaries, including those assigned to ACOs, with those diagnoses that are submitted on claims by FFS providers, and that meet risk adjustment criteria. CMS uses the information on these FFS claims to determine whether diagnoses are risk adjustment eligible, including those from telehealth visits. In other words, when diagnoses from applicable telehealth visits meet the risk adjustment criteria, they will be used in calculating risk scores for FFS beneficiaries. The 4/10/20 HPMS memo was referring to plans that submit diagnoses on behalf of their enrollees, and that submit data to the Risk Adjustment Processing System (RAPS) or Encounter Data System (EDS) for purposes of calculating risk scores. Because beneficiaries participating in ACOs are FFS beneficiaries, and CMS uses diagnoses from FFS claims to calculate their risk scores, ACOs are not considered ‘other organizations’ and do not submit data to RAPS or EDS for purposes of calculating risk scores.

CMS also published a document entitled “Risk Adjustment Telehealth and Telephone Services During COVID-19 FAQs” on  April 27, 2020 which was later updated on August 3, 2020. This document clarifies which codes may be submitted for risk adjustment data submissions. It states “Any service provided through telehealth that is reimbursable under applicable state law and otherwise meets applicable risk adjustment data submission standards…” is considered valid for data submission for the 2020 benefit year.

Even though Medicare is allowing a telephone call to be reimbursed as an E/M visit during the PHE, it is clear that when it comes to risk adjustment, the rules are not the same. There will need to be a face-to-face encounter, which can be done via telehealth as long as all applicable rules are met (as outlined above). This encounter does not need to have a recording of the encounter, but it is essential that the documentation clearly states that this encounter was conducted via telehealth using video and audio telecommunications and was not just a phone call.