Publication Date: 

In response to provider questions, Blue Cross NC is clarifying that telehealth claims are risk-adjustable for Medicare and Affordable Care Act patients if they meet all other criteria for risk adjustment eligibility. The Centers for Medicare and Medicaid Services (CMS) has issued guidance that audio-visual telehealth claims are risk-adjustable under the COVID-19 emergency waiver.

While the waiver is in effect, Medicare is paying for telehealth visits that take place in a patient's place of residence as of March 6, 2020. CMS guidance indicates these audio-visual visits in a patient's place of residence are risk-adjustable for Medicare Advantage. Refer to the CMS memo for details.

Further Medicare guidance from CMS specifies that office or outpatient evaluation and management claims can be based either on time or medical decision-making (MDM). CMS has removed requirements for documentation of history and physical exam in the medical record, but providers should continue to document visits as necessary to ensure quality and continuity of care. This includes documentation and coding of all conditions that coexist at the time of the encounter and require or affect patient treatment or management. Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the conditions.

For both ACA and MA, telehealth visits must be face-to-face for the claim to be risk adjustable. Telecommunications systems that permit real-time video and audio communication satisfy this requirement, but audio-only visits do not.

This guidance is applicable to Blue Cross NC members on ACA and MA plans that Blue Cross NC offers or administers, including Experience Health.