Applicability of diagnoses from telehealth services for risk adjustment
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This policy explains CMS guidance allowing Medicare Advantage and other organizations to submit diagnoses from telehealth visits for risk-adjusted payment when those visits meet existing risk-adjustment eligibility criteria, and how to report such services to RAPS and the Encounter Data System (EDS). It affects MA organizations and entities that submit diagnoses for risk-adjusted payment.
No material clinical or coverage changes in this revision.
Risk Adjustment Criteria for Telehealth Diagnoses
Risk adjustment applicability criteria for telehealth diagnoses
Diagnoses from telehealth visits qualify for risk adjustment when ALL of the following are met:
ALL of the following
ALL of the following
- The diagnosis is from an allowable inpatient, outpatient, or professional service.
ALL of the following
- The encounter is a face-to-face encounter, which can be satisfied when services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.
Meets the risk-adjustment face-to-face requirement per CMS guidance.
Submission path-specific requirements
ALL of the following
- The MA organization (or other submitting organization) must identify which diagnoses meet risk-adjustment criteria for their RAPS submission.
ALL of the following
- When reporting telehealth services to the Encounter Data System (EDS), report services using Place of Service code '02' for telehealth or append CPT telehealth modifier '95' with any place of service.
This policy applies to submissions to both the Risk Adjustment Processing System (RAPS) and the Encounter Data System (EDS); organizations should follow the submission-specific instructions above.
Telehealth Reporting Codes
| 02 | Place of Service code for telehealth |
| 95 | CPT telehealth modifier indicating synchronous telemedicine service |
How to Report Telehealth Services for Risk Adjustment
Report telehealth services to EDS with POS '02' or modifier '95'; identify risk-adjustment diagnoses for RAPS
When submitting telehealth services to the Encounter Data System (EDS), report the service using Place of Service code '02' for telehealth or append the CPT telehealth modifier '95' to the service so CMS can identify diagnoses that meet risk-adjustment filtering criteria. For RAPS submissions, MA organizations must continue to identify which diagnoses meet risk-adjustment criteria themselves.
- EDS: use Place of Service '02' for telehealth OR append CPT telehealth modifier '95' with any place of service.
- RAPS: MA organizations must identify which diagnoses meet risk-adjustment criteria for their submissions.
Key Definitions
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