Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: April 27, 2020

Program Area: Risk Adjustment (RA)

Question: In light of the COVID-19 pandemic, can CMS clarify which telehealth services are valid for data submissions for the HHS-operated risk adjustment program?

Answer: Any service provided through telehealth that is reimbursable under applicable state law (1) and otherwise meets applicable risk adjustment data submission standards (2) may be submitted to issuers' External Gathering Data Environments (EDGE) servers for purposes of the HHS-operated risk adjustment program.(3) If a code submitted to an issuer's EDGE server is descriptive of a face-to-face service furnished by a qualified healthcare professional and is an acceptable source of new diagnoses, it will be included in the risk adjustment filtering.(4) Telehealth visits are considered equivalent to face-to-face interactions, but are still subject to the same requirements regarding provider type and diagnostic value. Some codes for services that are eligible for inclusion in risk adjustment explicitly mention telehealth, such as the telehealth consultation, emergency departments, or initial inpatient HCPCS codes (G0425, G0426 and G0427). Other examples of such codes include those for follow-up telehealth consultations furnished in hospitals or skilled nursing facilities (G0406, G0407, G0408, G0459, G0508, and G0509). Furthermore, many additional services can be furnished in the telehealth setting and this can be reflected in the data submissions with the addition of 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 has no impact on the inclusion of specific services for purposes of the risk adjustment program because, as mentioned above, the telehealth setting is considered equivalent to the face-to-face setting. In response to the COVID-19 pandemic and the increased need to expand the use of telehealth and virtual care, HHS will be designating 6 e-visit codes, new for calendar year 2020, as valid for 2020 benefit year HHS-operated risk adjustment data submissions subject to applicable state law requirements. This newly released group of CPT codes (99421-99423) and HCPCS codes (G2061-G2063), which were effective January 1, 2020, are generally for 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. The CPT set is for use by physicians and other qualified health professionals who may independently bill for E&M visits. The HCPCS code set is for use by other qualified health professionals who may not be able to bill independently for E&M visits (e.g., clinical psychologists). Due to the expansion and encouragement of telehealth and virtual services during the COVID-19 pandemic, these e-visit codes will be valid for diagnosis filtering purposes in risk adjustment data submissions for the 2020 benefit year.(5) Questions about this FAQ can be addressed to RARIPaymentOperations@cms.hhs.gov, please specify, "HHS-RA COVID-19 Question" in the subject line. Additional References: (1) Applicable state law refers to the laws of the state, in which the issuer is licensed, for services that are rendered by a health care professional licensed in the state in which he or she practices and if required, in the state in which the enrollee resides. (2) EDGE Server Business Rules are posted to REGTAP at: https://www.regtap.info/reg_librarye.php?i=2673. (3) Beginning with the 2017 benefit year, HHS has operated the risk adjustment program under section 1343 of the Patient Protection and Affordable Care Act on behalf of all states and the District of Columbia. (4) For more information on risk adjustment filtering, see discussion in prior years' 'Do It Yourself (DIY)' Software Documentation; the 2019 Benefit Year Risk Adjustment Updated HHS-Developed Risk Adjustment Model Algorithm DIY is available at: https://www.cms.gov/CCIIO/Resources/Regulations-and- Guidance/Downloads/CY2019-DIY-instructions.04.15.2020.pdf. (5) These e-visit codes will be incorporated in the 2020 DIY software final version. We release quarterly versions of DIY software, ahead of the final version, and these codes might not appear in the first couple quarterly 2020 DIY software updates.

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