Telehealth HCC Coding Guidelines – What’s In, What’s Not? (Post 4 of 5)

With the current COVID-19 crisis, CMS has used the 1135 waiver to expand the applicability of telehealth visits to help patients get timely medical care. The waiver has helped millions of patients engage their Primary Care Physicians (PCPs) and other providers in place of in-person visits due to lock-downs and social distancing guidelines. Telemedicine visits enable patients to seek medical care via smartphone, tablet, and desktop or laptop computers.  Cell phones without a video interface only permit an audio telehealth visit. 

The updated CMS telehealth guidelines for Medicare Advantage (MA) plans allow telehealth visit claims to be counted towards the Risk Adjustment calculations for the contract year.  The telehealth visit satisfies the face-to-face visit requirements when the services are provided via an interactive audio and video telecommunications system that permits real-time interaction between the physician and the patient. This means that visits should be conducted as audio-visual visits, and the claims should indicate the proper use of modifier (-95) with the appropriate Place of Service (POS) code (-02). Encounters via phone with audio-only do not qualify as “face-to-face” visits.

There are limitations whereby MA plans will have to be very careful with the submission of such telemedicine visit claims that carry HCC codes. Since a physical exam cannot be conducted over a telehealth visit, an HCC condition requiring an actual face to face exam or lab test to make a diagnosis cannot be claimed solely based on a telehealth visit. MA plans should bring this into scrutiny before submitting claims with HCC data to CMS for Risk score calculations.

Condition Examples Not Qualified for HCC Claims Via Telehealth Only Visit

heartbeat heart rate monitor icon

A medical condition that cannot be confirmed without a physical exam and proper documentation will be prone to audit. For example, screening or diagnosis of Diabetic neuropathy in a patient with uncomplicated Diabetes Type 2 patient requires a monofilament testing of the peripheral sensations. Patient complaints of numbness and tingling cannot be assessed without a thorough physical exam. Carrying over an HCC code from year-to-year also requires a provider to be able to attest to the current status of the medical condition, which may not be easily substantiated during an audio-visual telehealth visit.

In another example, a new diagnosis of chronic obstructive pulmonary disease (COPD) should NOT be confirmed if the physician is unable to listen to lung sounds comparable to an in-person visit. Other new diagnoses such as morbid obesity and diabetic retinopathy also cannot be confirmed via audio-video telehealth visits due to the lack of physical exam requirements.

Condition Examples That Do Qualify for HCC Claims

In order to accurately assess and document such conditions, the telehealth visit needs to be accompanied by a lab test or physical exam. For instance, a new diagnosis of hyperglycemia in a diabetic patient could be diagnosed via a telemedicine as long as the visit is combined with confirming lab test results. Physicians can order or interpret ordered lab tests and follow-up with patients via the telehealth visit. That being said, an existing diagnosis of neuropathy in an established patient can be validated with a good History of Present Illness (HPI) in which the associated symptoms are discussed. 

Mental health conditions are a set of medical conditions that can be well documented via audio-video telehealth sessions. Mental health providers can perform patient interviews, make appropriate diagnoses, and modify the treatment for patients with conditions such as major depressive disorder (MDD), bipolar disorders, and Schizophrenia. Technology offers significant advantages in mental health as patient encounters can be conducted in a safe environment and with limited in-person requirements. Patients with substance-induced disorder can also be managed appropriately via telemedicine visits complemented by additional lab testing.  Advanced neurological practices can also confirm year-over-year (YoY) diagnoses for established patients with Epilepsy and Seizures disorders. New diagnoses among new or established patients can be made with additional on-site EEG monitoring or supplemental lab testing.

Condition Examples that Fall Into a Gray Area for HCC Claims

In the coming year, CMS will likely produce more guidance for documenting HCCs that can be permitted via telehealth visits. Important recurring diagnoses such as morbid obesity can be handled via a telehealth visit and the use of weight scale telemetry and already documented height in the patient’s record. But from a policy guideline standpoint, there are no hard, fast answers. These are gray policy areas involving CMS guideline interpretations along with the provider and health plans level of confidence in obtaining proper documentation. 

Talix Subject Matter Experts on HCC coding guidelines have examined diagnosis codes belonging to a specific HCC category that can be recaptured over a telemedicine visit and which diagnoses are contingent upon in-person face-to-face visits with the physician and may require further diagnostic testing to confirm the diagnosis.

Below is a sample of the HCC coding guidelines analysis performed by the Talix SME team:

Table Key

Click here to learn more about HCC codes and Talix’s telemedicine recommendations.

*Disclaimer – This chart is the interpretation by Talix employees. Please consult CMS for official recommendations and guidance on telehealth coding guidelines.

In a nutshell, the recapture of some HCC categories via telemedicine visit remains challenging as the onus lies with the providers to validate in the medical record such diagnosis codes that have risk-adjusted HCC value. Equally important, the health plan has the responsibility to validate the HCC diagnosis code that is eligible to be recaptured via a telemedicine visit before submitting the encounter data to CMS for RAF score calculation.

Subscribe to the SHIFT blog to be notified when the next telehealth series article is posted. The next topic in the series is Telehealth Security. See the prior Telehealth blog post titled, Avoid Telehealth Documentation Pitfalls.”