Six Emergent Best Practices in Telehealth Risk Adjustment Coding

Six Emergent Best Practices in Telehealth Risk Adjustment Coding Author Evan HetuIn March, CMS and the CDC began offering regulatory updates around telehealth encounters both generally, and specifically for risk adjustment. As a result, encounters that are risk adjustable in a traditional, designated care setting are now adjustable via telehealth (if the necessary actions or data points are accessible), to allow for a continuity of care for covered populations during the COVID-19 pandemic.

Fortunately, coders have been able to navigate the regulatory updates in stride and offer education upstream to provider organizations as new best practices emerge. Now, with telehealth accelerating in adoption, sufficient volumes have paved the way for actionable insights to ensure effective submission and mitigate audit risk. Here are the top guidelines to follow while managing risk for telehealth encounters:

1. Risk adjustable telehealth encounters require synchronous audio and video.

The rules from CMS are very clear. Telemedicine is defined as synchronous audio and video. One or the other, in isolation, does not fulfill the requirement and therefore any encounter lacking will not be risk adjustable. Technological barriers, whether through users struggling with applications or connectivity issues, can quickly pivot a telehealth encounter to a phone call, or audio only. While delivering care is the top priority, the video requirement is, at least for now, inviolable.


2. Telehealth, and that synchronous audio and video, must be documented.

The old expression, “If a tree falls in the forest, and there is no one around to hear it, does it make a sound?” is never more apt in healthcare than with risk adjustment and appropriate documentation. Coders have already reported instances where the documentation is undifferentiated from an in-person visit, despite the high likelihood that the encounter was via telehealth (for example, not coding it as telehealth, but mentioning in the notes that it was done via Zoom or another platform). Those ambiguities can dramatically impact coder productivity and/or submission quality, especially if a physician query is necessary. Health Fidelity partners, at least, will be less concerned about this: we are in the process of updating the lexicon in our NLP engine, Lumanent Insights to find these narrative indications of telehealth to rapidly flag, appropriately code, and adjust for risk.

Many EMRs have sought to support physicians by automatically noting, via canned messages, when an encounter is telehealth, but it must still be mentioned in the clinical narrative to fully capture the care provided for patients.


3. Document time spent on care.

Evaluation and management (E&M) coding levels are contingent on criteria being met. Specifically, “History and exam, if performed or updated, should also be documented, along with the patient response or comprehension of information. An acceptable C/CC time entry may be noted as, “Total visit time = 35 minutes; > 50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

Office visits are typically based on the components mentioned above being met; history, exam, complexity of clinical decision making. Each of these determines the level of the code. The flip side of that is, if you are unable to meet those certain levels you can capture the time. How much time you spent coordinating, talking with that patient, what was discussed, etc. can fall under the above example of appropriate coding levels achieved through acceptable C/CC time entries. A lot of the typical approaches to documenting case complexity are not viable through telehealth but documenting total time at the appropriate thresholds is.


4. Document visual (or auditory!) identification of conditions.

Physical exams via telehealth are complicated. Cardiovascular patients are more likely to have a heart rate monitor or blood pressure cuff at home, and can show the readouts directly over the video (or are using tech-enabled monitoring equipment, piping the data directly to their doctor, limiting layperson error), but for most patients, these tools are not available. Visual identification of conditions is less complex for skin conditions, or anything with more apparent symptoms, like crackling sounds when breathing, are relatively accessible, albeit limited, via telehealth, but documenting that the symptomatology is seen and heard is critical.


5. Ensure the right patients are being seen.

Even with the proper technology and documentation to support the care provided via telemedicine, identifying the patients that can benefit the most from this rapidly evolving care path, setting the appointment, and then connecting is the biggest hurdle. It’s still proving complicated, with encounter volumes, and therefore necessary care management, at decreased levels. To mitigate the barriers, Health Fidelity provided free report specifications to help identify eligible patients, parsing both need and likelihood to engage.


6. Be mindful of HIPAA and the platform you use.

As general caution, HIPAA compliance involves more than end to end encryption. Sometimes this is done at the vendor level, others it is down to the organization using the utility, i.e. two organizations could be both using the same video conference, but in one case an administrator has signed a BAA, meaning only that instance of a given platform is compliant.

Telemedicine is accelerating, in both adoption and refinement. And as a risk adjustment technology partner, we are heavily involved in making the coding outputs from those encounters as complete and accurate as possible for our partners. As best practices continue to emerge, you can trust that we’ll continue to publish our own guidance to support patients, providers, and payers alike.

If you have any more questions, or want support in your own risk adjustment workflow going forward, contact us here.