News: CMS guide for telehealth diagnosis submission, doctors struggle to get paid

In response to the COVID-19 pandemic, CMS has urged the expansion of telehealth visits to reduce the risk of spreading the disease. The memo, while not yet on the CMS website, was sent to Medicare Advantage organizations explaining when and how to submit diagnoses from telehealth visits, Rise Health reported.

Visits must meet all criteria for risk adjustment eligibility, which includes being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter.

CMS said the use of telehealth service diagnoses applies to submissions to the Risk Adjustment Processing System, where Medicare Advantage organizations must identify which diagnoses meet risk adjustment criteria.

Diagnoses resulting from virtual visits can meet the risk adjustment face-to-face requirement when services are provided through real-time interactive audio and video communication, with both components being a requirement.

While telehealth reimbursement has increased quickly during the pandemic, providers say they are not being paid to the promised extent or near what they were making with in-person visits. This is at least partially because of inconsistent policies and lack of standardization among different insurance plans.

Both public and private payers have been slow to embrace telehealth appointments, but the skyrocketing number of these visits because of COVID-19 has forced insurance companies to adopt it more quickly than they were prepared for.

While providers and other insiders say that some bills are being returned as only partially paid, CMS has said that Medicare would reimburse providers in the future for telehealth visits at the same rate as in-person visits, and urged private payers to follow similar policies.

While telehealth record reviews haven’t traditionally been within CDI’s scope of work, as the number of visits increases, CDI professionals may find themselves asked to step in. In the past, a federal audit found that telehealth records rarely passed documentation audits, so those reviewing these records will need to lend a careful eye to ensure the claims aren’t denied on the backend.

Editor’s note: To read about the CMS announcement, click here. To read about providers’ payment struggles, check out this article from MedPage Today. Find out why most Medicare telehealth claims fail a documentation audit.