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Risk Adjustment from Early Telehealth Visits

Risk Adjustment from Early Telehealth Visits

Written by Ted Kyi

June 16, 2020

Because of social distancing concerns about the spread of COVID-19, and CMS’s acceptance of telehealth visits as risk adjusting encounters, most plans have started doing prospective telehealth visits.  With a couple months of experience completing prospective visits virtually, it’s natural to ask how the risk adjustment impact from telehealth visits compares to in-home visits.  I’ve been monitoring this situation, and wanted to share some early data.

First, let me say a word about some challenges to comparing diagnosing from different time periods.  The main challenge is that there is strong seasonality in the complexity of patients seen, and there can be significant variation from plan to plan or from year to year.  Below is a chart showing a high level snapshot of the seasonality in risk scores for a few sample plans:

Chart showing large month by month variability in patient complexity for four MA plans, which combined averaged over 15,000 visits per month in 2019

The overall increasing or decreasing trends and the sharp spikes both make it difficult to get a reasonable apples-to-apples comparison between any two time periods.  A simple solution to this problem is to compare charts for the same patient from this year and from last year.

A second challenge to measuring revenue management impact is that most plans use some form of net impact calculation, measuring the RAF impact from diagnoses that are unique to the prospective assessment, and not counting any conditions that come across claims from any other provider in that same calendar year, before or after the assessment.  Given that we are looking to analyze telehealth assessments from April and May, we will have only a tiny fraction of the claims run out needed to accurately measure net impact.  To address this challenge, we will use the All Lift (AL) risk score, which includes every diagnosis from the prospective assessment.  I have found that the ratio between the net impact and the AL risk score tends to stay relatively constant over time.  This means that if the AL score goes up then the net impact usually also goes up, and if the AL score goes down then the net impact usually also goes down.  By checking to see if there is any change in the AL risk score from last year to this year on same patient reassessments, we get a pretty good leading indicator whether there will be any change to the net revenue management impact.

With those preliminaries out of the way, let’s take a look at the results.  My analytics team has performed multiple reassessment analyses, and here are the results of the latest one.

Upon reviewing the data, it was immediately clear that risk scores are up overall in 2020.  I know that my organization implemented clinical guideline changes in January and early February, so we devised a way to control for that.  We started by looking to see how much telehealth diagnosis rates and risk scores from April and May reassessments changed from the prior year assessment.  Then we did the same thing for late February and early March in-home reassessments.  To control for the impact of the clinical guideline changes, we planned to subtract the increases we saw from the in-home reassessments from the increases we saw from the telehealth reassessments.  Subtracting should adjust for any underling increases in 2020 that weren’t due to telehealth.  When we pulled the data for Feb/Mar in-home and Apr/May telehealth reassessments, what we saw was they had identical percentage increases in both average AL risk scores and number of HCCs diagnosed per assessment.  Telehealth was right on parity with in-home, with both increasing over 2019 by the same amount.

In terms of individual HCCs, the top ten HCCs diagnosed were the also the same for both in-home and telehealth, although in a slightly different order:

Home Telehealth
1 HCC18 – Diabetes with Chronic Complications HCC18 – Diabetes with Chronic Complications
2 HCC108 – Vascular Disease HCC59 – Major Depressive, Bipolar, and Paranoid Disorders
3 HCC22 – Morbid Obesity HCC22 – Morbid Obesity
4 HCC111 – Chronic Obstructive Pulmonary Disease HCC19 – Diabetes without Complication
5 HCC96 – Specified Heart Arrhythmias HCC111 – Chronic Obstructive Pulmonary Disease
6 HCC59 – Major Depressive, Bipolar, and Paranoid Disorders HCC96 – Specified Heart Arrhythmias
7 HCC85 – Congestive Heart Failure HCC108 – Vascular Disease
8 HCC19 – Diabetes without Complication HCC85 – Congestive Heart Failure
9 HCC88 – Angina Pectoris HCC88 – Angina Pectoris
10 HCC40 – Rheumatoid Arthritis and Inflammatory Connective Tissue Disease HCC40 – Rheumatoid Arthritis and Inflammatory Connective Tissue Disease

Most commonly diagnosed HCCs in 2020 comprehensive health assessments

In the telehealth timeframe, HCC 59 (major depression) and HCC 19 (uncomplicated diabetes) have moved up, and HCC 108 (vascular disease) has moved down.  Note that while existing vascular disease conditions were largely being re-diagnosed in telehealth visits, no PAD diagnostic tests were being performed, eliminating that source of PAD diagnoses.

Looking at this study as well as an analysis of national payers, Medicare Advantage diagnosis rates for telehealth for major depression and uncomplicated diabetes seem to be about 1% higher than earlier 2020 in-home assessments.  On the other hand, vascular disease, morbid obesity, and congestive heart failure have decreased about 2%.

One question I’ve gotten multiple times is if there are HCCs we no longer capture in telehealth visits.  Our clinical and coding teams reviewed each of the body systems and reported that they expected decreased diagnosis rates for morbid obesity, malnutrition and chronic skin ulcers, but there were no HCCs which we diagnose in the home that would drop to zero.  This has been verified in the telehealth reassessment data.  Every single HCC category with diagnoses in 2019 also had diagnoses in 2020 telehealth assessments.

It should be noted that while the risk adjustment impact for telehealth assessments is close to that of in-home assessments, there are key limitations to the virtual encounter:

  • Most in-person diagnostic tests, such as PAD testing or spirometry, are not being performed
  • While some tests can be mailed to members, such as a FIT kit, the key metric of test completion rate remains unproven
  • Blood pressure, BMI, and other portions of the physical exam are infrequently documented
  • Environmental scans and other elements of the assessment are limited

While we are dealing with the COVID-19 pandemic, the early data shows that prospective telehealth visits are a viable alternative to prospective in home visits for overall proper documentation of each member’s disease burden.  For members who are comfortable with the virtual encounter, the risk adjustment impact is probably around 95% that of in-home assessments, and both the member and provider can safely stay in their homes.

Interesting recent articles about telehealth:

There are many articles about telehealth these days.  Here are just a couple articles I thought were worth mentioning.

Right in my backyard, in San Diego, Steven Green from Sharp Rees-Stealy commented on the need to allow audio-only telehealth visits to risk adjust.  There are several good quotes, but this is my favorite:

“The main value of having a video visit is more for the human connection and seeing their face. I agree that a video visit can help you get more of a connection to the patient while you’re talking with them,” he emphasized. “But I don’t think it contributes very much to what’s going on in their clinical care.”

You can read the full article and all of his arguments here: Audio-only Telehealth Coverage Essential During COVID-19 Outbreak.

I’m also paying attention to the Washington Post story about a Census Bureau survey about anxiety and depression, where they reported that a third of Americans are showing signs of clinical anxiety or depression.  It was nearly one half in Mississippi.  I’m interested to follow these kinds of reports, and to see if we can analyze the data from our assessments to see increases in depression diagnoses.  I invite readers to share their own experiences, or to suggest other ideas for research.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Clarification of Coding for Medicare Advantage

Clarification of Coding for Medicare Advantage

Written by Ted Kyi

May 26, 2020

There have been a lot of questions about appropriate coding for telehealth visits.  (Full disclosure, as new information was coming out, I have offered different coding recommendations, so I may have contributed to the confusion.)  Let’s recap some of the discussion about coding telehealth visits for Medicare:

First, the March 17 FAQ about the section 1135 waiver mentioned the use of POS code “02” for all telehealth encounters.

Q: How does a qualified provider bill for telehealth services?

A: Medicare telehealth services are generally billed as if the service had been furnished in-person. For Medicare telehealth services, the claim should reflect the designated Place of Service (POS) code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site.

Then, the April 10 memo on applicability of diagnoses from telehealth services for risk adjustment offered CPT modifier “95” as a second option:

“In order to report services to the EDS that have been provided via telehealth, use place of service code “02” for telehealth or use the CPT telehealth modifier “95” with any place of service.”

This seems to offer flexibility between using the POS code or using the CPT modifier to designate a telehealth encounter.

The latest Medicare guidance that I’ve read differentiates telehealth allowed before the pandemic from services under the waiver:

“To implement this change on an interim basis, we are instructing physicians and practitioners who bill for Medicare telehealth services to report the POS code that would have been reported had the service been furnished in person. This will allow our systems to make appropriate payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic, would have been furnished in person, at the same rate they would have been paid if the services were furnished in person. Given the potential importance of using telehealth services as means of minimizing exposure risks for patients, practitioners, and the community at large, we believe this interim change will maintain overall relativity under the PFS for similar services and eliminate potential financial deterrents to the clinically appropriate use of telehealth. Because we currently use the POS code on the claim to identify Medicare telehealth services, we are finalizing on an interim basis the use of the CPT telehealth modifier, modifier 95, which should be applied to claim lines that describe services furnished via telehealth. We note that we are maintaining the facility payment rate for services billed using the general telehealth POS code 02, should practitioners choose, for whatever reason, to maintain their current billing practices for Medicare telehealth during the PHE for the COVID-19 pandemic.”

(Note that CMS is referring to the Public Health Emergency as “PHE” and abbreviating the Medicare Physician Fee Schedule as “PFS.”) Based on this information, I recommend that only the telehealth services that were allowed prior to the pandemic and the section 1135 waiver should use POS “02.”  Those services always used POS “02,” and they should continue to be coded exactly the same way they used to be coded.

For Medicare services which would have taken place in person, but are now using telehealth under the section 1135 waiver, I recommend the claims use the same CPT and POS codes they would have used if they had taken place in person, with the only change being the addition of the CPT modifier “95.” I haven’t seen anything saying that POS “02” won’t be accepted on EDS submissions, so plans not coding this way do not have to change. It seems that for anyone reviewing or newly implementing coding, the CPT modifier is the safer route.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Telehealth Risk Adjustment by Line of Business

Telehealth Risk Adjustment by Line of Business

Written by Ted Kyi

May 5, 2020

I know I have focused on Medicare Advantage in my posts here, which is a reflection of both the size of the risk adjustment market for MA, as well as the lack of clarity about risk adjustment which had surrounded MA.  Here is a recap of how telehealth visits can be used for risk adjustment by line of business:

Medicare Advantage – telehealth is allowed, requires video with audio for diagnoses to count toward risk adjustment

ACA commercial – telehealth allowed, state regulation of the practice of medicine determines allowed modalities (audio-only or video)

Medicaid – regulation delegated to the states, so also state-by-state which modalities allowed.  Note that Medicaid regulations about telehealth aren’t always the same as the regulations that govern ACA in the same state. For example, in Georgia, “standard telephone” calls do not constitute telemedicine services, but the Georgia Medicaid waiver explicitly allows telephone communication.

CMS has extended section 1135 waivers for many states, allowing them to relax rules during the public health emergency.  These waivers cover expanded use of telehealth, reduced cost sharing, as well as extending out of state license reciprocity.  Three great resources for tracking the individual state regulations on licensure and telehealth regulations are:

National Council of State Boards of Nursing (NCSBN)

Federation of State Medical Boards (FSMB)

Center for Connected Health Policy (CCHP)

You should also refer to the CMS website for the list of approved state waivers.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Telehealth Visits Will Risk Adjust for Medicare Advantage

Telehealth Visits Will Risk Adjust for Medicare Advantage

Written by Ted Kyi

April 10, 2020

The official guidance which those of us in the risk adjustment community have been waiting for has finally arrived.  Exactly one month after the HPMS memo authorizing MA plans to expand use of telehealth, the agency has announced that diagnoses from telehealth visits will be included in risk adjustment calculations.

The requirements are that the encounter meet the usual face-to-face rules, and that the telehealth use audio and video.

CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter….  Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


MA Final Notice Silent on Risk Adjustment for Telehealth

MA Final Notice Silent on Risk Adjustment for Telehealth Visits

Written by Ted Kyi

April 6, 2020

As I suspected, the final notice for MA and Part D came out today, and it does not address whether telehealth visits will risk adjust. In the announcement, CMS is limited to finalizing regulations which were proposed in the Advanced Notices and went through public comment. For this reason, telehealth needs to be addressed separately. Guidance about telehealth may come soon, but it will be under the umbrella of the Section 1135 waiver authority of the public health emergency. Stay tuned!


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Telehealth as an Alternate Modality for Medicare

Telehealth as an Alternate Modality for Medicare

Written by Ted Kyi

March 17, 2020

Today, CMS published a fact sheet and FAQ which answered a lot of questions about the use of telehealth for Medicare beneficiaries.  I still have questions as to the degree to which these announcements pertain only to FFS Original Medicare, or also apply to Medicare Advantage.

To understand today’s documents, we have to go back to March 6, 2020 when H.R.6074 — the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 — was signed into law.  This act amended the section 1135 waiver authority granted to the HHS Secretary.  Secretary Azar declared a public health emergency on January 31, 2020, and as soon as the act became law, used the expanded section 1135 waiver to broaden access to telehealth services so that Medicare beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility.

The waiver applies to three virtual services:  Telehealth visits, Virtual check-ins, and E-visits.  In brief, these services are defined as:

  • Telehealth visits pertain to general office visit services
  • Virtual check-ins are brief communications with established patients
  • E-visits are communications with established patients via an online patient portal

Wearing my risk adjustment hat, prospective health assessments, like the Matrix Comprehensive Health Assessment, are neither brief nor patient initiated through an online patient portal, so they align with telehealth visits.

Under the telehealth visits provision, visits with a provider (which include NPs) that generally take place in-person may take place using audio and video telecommunications between a distant site and the patient at home.  The usual restrictions regarding a prior established relationship or the originating site are explicitly waived.

Additionally, providers are allowed to use everyday communications technologies, such as FaceTime or Skype, without fear of penalties for HIPAA violations.

“Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.”

This will make a significant impact on the ease with which providers will be able to ramp up telehealth, since they will be able to use commercially available products, and not have to stand up HIPAA certified applications.

Expanded telehealth services will be allowed from March 6, 2020 through the end of the public health emergency.

Both the CMS fact sheet and FAQ are available on the CMS website.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Medicare Advantage Allowed to Expand Telehealth

Medicare Advantage allowed to Expand Telehealth

Written by Ted Kyi

March 10, 2020

This blog is intended to discuss data-driven decision making in healthcare, in particular with risk adjustment and managed care. Given that these days the top story every day is about the novel coronavirus, there are many interesting questions about how telehealth may play a role as people look to reduce the amount of contact they have with others.

With growing numbers of cases and numbers of deaths due to the coronavirus around the globe, questions are beginning to arise about the safety of in-person healthcare visits. These concerns are exacerbated here in the United States by a number of factors, including:

  • Lack of testing
  • Lack of contact tracing of positive patients
  • Possibility of mildly symptomatic or asymptomatic patients who are contagious

For these reasons, many people have discussed avoiding elective procedures and not seeking in-person care unless it is an emergency. This is especially true for seniors, and even more so for those with multiple chronic conditions.

Telemedicine offers an alternative modality for delivering care – a modality which does not carry the risk of infection. Today, CMS released a memo authorizing Medicare Advantage plans to expand access to telehealth. Here is the key passage:

“Medicare Advantage Organizations may also provide enrollees access to Medicare Part B services via telehealth in any geographic area and from a variety of places, including beneficiaries’ homes. In response to the unique circumstances resulting from the outbreak of COVID-19, should an Medicare Advantage Organization wish to expand coverage of telehealth services beyond those approved by CMS in the plan’s benefit package for similarly situated enrollees impacted by the outbreak, CMS will exercise its enforcement discretion regarding the administration of Medicare Advantage Organizations’ benefit packages as approved by CMS until it is determined that the exercise of this discretion is no longer necessary in conjunction with the COVID-19 outbreak. CMS consulted with the HHS OIG and HHS OIG advised that should a Medicare Advantage Organization choose to expand coverage of telehealth benefits, as approved by CMS herein, such additional coverage would satisfy the safe harbor to the Federal anti-kickback statute set forth at 42 CFR 1001.952(l).”

The memo also gave permission to change cost sharing for members for COVID-19 services, including telehealth.

“Medicare Advantage Organizations may waive or reduce enrollee cost-sharing for beneficiaries enrolled in their Medicare Advantage plans impacted by the outbreak. For example, Medicare Advantage Organizations may waive or reduce enrollee cost-sharing for COVID-19 laboratory tests, telehealth benefits or other services to address the outbreak provided that Medicare Advantage Organizations waive or reduce cost-sharing for all similarly situated plan enrollees on a uniform basis.”

You can read the full HPMS memo on the CMS website.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.