Which statement correctly describes the telehealth requirement for HCC diagnosis capture in HHS commercial risk adjustment versus CMS Medicare Advantage?

Which statement correctly describes the telehealth requirement for HCC diagnosis capture in HHS commercial risk adjustment versus CMS Medicare Advantage?

• A. Both HHS and CMS require audio and video telehealth visits for HCC diagnoses.
• B. HHS allows audio-only telehealth for HCC diagnoses, while CMS requires an audio and video telehealth visit for HCC diagnoses.
• C. HHS requires audio and video telehealth for HCC diagnoses, while CMS allows audio-only telehealth for HCC diagnoses.
• D. Neither HHS nor CMS accepts telehealth for HCC diagnoses.

Answer: (B)

Telehealth encounters used to capture HCC diagnoses must meet program-specific rules. For HHS commercial risk adjustment, audio-only telehealth visits can support an HCC diagnosis as long as the documentation clearly substantiates the condition and the encounter meets coding standards. In CMS Medicare Advantage, however, the standard is stricter: the telehealth visit for an HCC capture typically must be audio and video, providing a more robust clinical encounter that supports the diagnosis and plan. This difference matters because HCC risk adjustment relies on documented conditions from a legitimate encounter. Video capabilities give clinicians the opportunity to observe clinical signs and conduct a fuller assessment during the visit, which CMS treats as stronger evidence for coding. Audio-only visits, while acceptable in some HHS commercial risk-adjustment contexts, may not meet CMS’s threshold for an encounter used to adjust risk scores. So, the statement that HHS allows audio-only telehealth for HCC diagnoses while CMS requires an audio and video telehealth visit best describes the distinction.

Telehealth encounters used to capture HCC diagnoses must meet program-specific rules. For HHS commercial risk adjustment, audio-only telehealth visits can support an HCC diagnosis as long as the documentation clearly substantiates the condition and the encounter meets coding standards. In CMS Medicare Advantage, however, the standard is stricter: the telehealth visit for an HCC capture typically must be audio and video, providing a more robust clinical encounter that supports the diagnosis and plan.

This difference matters because HCC risk adjustment relies on documented conditions from a legitimate encounter. Video capabilities give clinicians the opportunity to observe clinical signs and conduct a fuller assessment during the visit, which CMS treats as stronger evidence for coding. Audio-only visits, while acceptable in some HHS commercial risk-adjustment contexts, may not meet CMS’s threshold for an encounter used to adjust risk scores.

So, the statement that HHS allows audio-only telehealth for HCC diagnoses while CMS requires an audio and video telehealth visit best describes the distinction.