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Physician groups are unhappy with the Centers for Medicare & Medicaid Services' (CMS) decision not to allow them to use audio-only visits -- such as phone calls -- for determining risk adjustment for patients in Medicare Advantage (MA) programs.

In the MA program, participating physicians must document annually the underlying conditions each patient has in order to determine the level of reimbursement for that patient. However, Medicare requires that this visit be done face-to-face or via telehealth "when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication."

However, the video component can be a problem for some patients, according to Norman Chenven, MD, founder of the Austin (Texas) Regional Clinic, a 340-physician practice. "We're doing the best we can, as are physicians all over the country, to coach people on how to use their [smartphone], or have their children come in and help them, but that's not always possible," Chenven said during a phone interview at which a public relations person was present. "The other issue is that there are people in rural areas, where there is not always good broadband, and it is technically impossible" to make a video stream work.

Documentation of underlying conditions using CMS's Hierarchical Condition Codes (HCCs) "has functioned extremely well over the past decade ... That's how Medicare, on a patient-by-patient basis, determines the following year's premiums," explained Chenven, who is also vice chairman of the Council of Accountable Physician Practices (CAPP), a group for physicians in accountable care organizations and other types of organized practices. "If someone has diabetes with renal complications and also has a below-the-knee amputation, that's a much higher index of risk going forward as an expensive patient needing a lot of care, compared to someone who has garden-variety diabetes with complications."

But if the underlying condition codes aren't documented in a particular year, the patient's status "reverts back to zero," he said. "Someone who has an amputation, Medicare has it in their system, but if it's not addressed in an office visit and put into coding for reimbursement and recorded, then the next year, Medicare for that patient will not indicate that the patient had an amputation."

Although CAPP is grateful that CMS has as a way for physicians to document underlying conditions, the group would like to see audio-only visits included as well. "More than 90% of seniors have cellphones, but less than 40% have smartphones with video capabilities," the organization said in a press statement. "That means more than 60% of Medicare beneficiaries would be unable to communicate with their physician on video, and would have to rely on telephone visits."

While CMS may be hesitant to allow it, much of the necessary risk adjustment information can be collected with just a phone call, said Darryl Drevna, senior director for regulatory affairs at , an association for medical practice managers. "The risk adjustment and capture of HCC information [is] probably the bigger issue at this point," Drevna said in a phone interview. His organization at the end of April asking for the agency to address the issue.

"How do you accurately diagnose someone without actually seeing that person? How do you do this through audio only? I think if they work with the provider community, they would develop an understanding that there is a way to do this, especially with an established patient," said Drevna. "If you've got a relationship with the patient, you've got their history already, and there's really nothing that video is going to add."

This issue with audio-only visits is symptomatic of the problems with Medicare's patchwork of rules around telehealth, said Mollie Gelburd, JD, associate director of government affairs at the Medical Group Management Association (MGMA), a trade group for physician practice managers. Initially CMS "created a list of services that it didn't consider telehealth for purposes of Medicare payment ... so for an audio visit, they were calling it 'outside' of telehealth."

However, the agency recently added audio-only codes to the list of Medicare-reimbursed telehealth visits -- but only for certain reasons, she continued. "It creates a patchwork of program rules -- for some purposes for reimbursement, it is considered telehealth, but for other purposes, like risk adjustment, you can't have audio-only codes. So that's confusing, and for those in the field it's difficult to keep track." Instead, MGMA has been advocating that Medicare reimburse all telehealth modalities, including audio-only visits, which would make things more consistent, Gelburd added.

Asked about the issue, a CMS spokesperson said the agency's hands are tied: "The statutory deadline for final risk adjustment policies was April 6, 2020. Without a change by Congress, CMS cannot change the methodologies that were published by this deadline. CMS does not plan to make any significant changes to methodologies for risk scoring and similar factors at this point in the statutory cycle."

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