The federal government’s recent 43-day shutdown impacted many facets of everyday life in the United States, including Americans’ health, wellbeing, and access to care. One increasingly vital (yet uniquely vulnerable) component of our healthcare delivery system was adversely affected during the shutdown, yet it received little attention: telehealth. Since the beginning of the COVID pandemic in early 2020, patients have come to rely on telehealth to access a myriad of services that do not require in-person office visits.
Telehealth has become critical to the care of particularly vulnerable populations, such as those with transportation needs, compromised immunity, or low income – or the many Americans who cannot leave work two hours early to make an in-person appointment but can squeeze in a 20-minute telehealth visit during a break in their workday. Telemedicine also enables providers to work more efficiently. Clinicians can connect with many more patients per day without the slowdowns of check-in, rooming, paperwork (now electronic), and so on.
We’ve reached the point where it seems most patients, providers, and payers barely remember a time when telehealth was not an available and easy option for delivering services and coordinating care. I recently educated a group of medical coding professionals who were completely unaware of telehealth’s relatively short history and the complex hoops previously required to make this service work. When studying the evolution of healthcare in the United States, one must recognize that Medicare now largely determines what services are acceptable for reimbursement. As Medicare goes, so go payers and their policies. In a moment, I’ll discuss how abrupt shifts in federal policy can directly impact Medicare recipients and their medical providers.
Telehealth Pre-COVID
Before the COVID pandemic changed the playing field in March 2020, Medicare required patients who needed virtual visits to travel to a pre-approved location (for example, a specific office, hospital, or clinic) to access the telehealth service. Patients’ homes were almost never an option. Ironic, isn’t it? Further complicating access, patients only qualified for this kind of service if they resided in certain Medicare-defined rural areas. Only physicians, NPs, PAs, clinical psychologists, LCSWs, and registered dieticians/nutritionists could be on the other end of that line; PT, OT, SLP and audiology providers were excluded, as were many (physician) specialists and those practicing in certain facilities.
Even after qualifying, traveling to a facility, and arranging to see one of only a few Medicare-approved providers, these beneficiaries then only received services from a limited list of CPT/HCPCS codes – CMS’s “annual telehealth list” – which consisted mostly of office visits and psychotherapy. Each of these services had to be audio-video capable. Audio-only encounters (aka “telephone calls”) were separately coded and rarely reimbursed by payers, even for mental health care, which depends heavily on talk-based therapy.
Telehealth Expanded—in a Big Way
The COVID pandemic ravaged the nation in numerous ways, but one positive outcome was the creation of the Coronavirus Preparedness and Response Supplemental Appropriations Act in 2020, which explicitly authorized Medicare to reimburse for telehealth services under the COVID emergency.
Suddenly, telehealth services could be received by a patient located practically anywhere, including their own home. This legislation paved the way for a wide array of services to be reimbursed for video-based delivery. By the end of April 2020, CMS added audio-only Evaluation & Management (E/M) encounters to its list of available services.
The underlying reasons for these changes and the resulting solutions are fairly obvious. Under the COVID public health emergency, traveling to a doctor’s office or other facility was to risk becoming infected with the COVID-19 virus or another contagious disease; or, if you were the carrier of COVID, you risked infecting others. Providers and facilities became absolutely overwhelmed in dealing with the pandemic. As usual, the most vulnerable members of society were the most at-risk, including seniors, low-income persons, individuals with chronic illnesses, and those who could not be vaccinated due to age or other exclusion criteria. These are the people who battled weakened immune systems, food insecurity, and risky public transit to attempt something most of us take for granted – a routine office visit. Suddenly, almost overnight, anyone with a smart phone could receive much of their needed care while safely at home.
The COVID-19 public health emergency formally ended in May 2023, and a previously approved 151-day extension kept telehealth available until October. By that time, a new paradigm was established in healthcare delivery. Since then, the federal government repeatedly extended telehealth coverage through various appropriations acts and continuing resolutions – that is, until a couple of months ago.
By default, when Congressional funding measures lapsed on October 1, 2025, Medicare rules and regulations instantly, and without widespread notification, rolled back to their pre-COVID status. For Medicare beneficiaries with telehealth encounters on October 1 or later, this meant that visits were no longer approved for reimbursement.
So, what does this have to do with Risk Adjustment?
For any Medicare Advantage (Part C) or Medicare Part D plan, only encounters with Medicare-approved providers and circumstances create a medical record which can be utilized for the reporting of Risk Adjusting (HCC) diagnoses. Almost immediately, plan administrators, compliance officers, coding professionals, and IT experts were left scrambling trying to figure out how they could filter non-covered encounters from their CMS submissions – that is, if they realized there was a problem, which many did not. Consider:
- All telehealth encounters should arrive at the health plan on a claim with the following: 1) an appropriate modifier attached, such as 93 (depending on the circumstances), 95, GT, or FQ; 2) the payer; and 3) the time period. In practice, however, many providers fail to include modifiers on procedure codes, especially when those modifiers are new, relatively obscure, or confusing.
- Likewise, all telehealth encounters should be submitted to the plan with a Place of Service code of 10 (Telehealth Provided in Patient’s Home) or 02 (Telehealth Provided Other than in Patient’s Home). I’ve seen many providers confusingly submit telehealth encounters using their location for the POS instead of the patient’s location. This relatively common mistake is an easy one to make.
- What about those new telehealth E/M codes? For 2025 dates of service, CPT created codes 98000-98007 to describe Synchronous Audio-Video E/M Services, and codes 98008-98016 for Synchronous Audio-Only E/M Services; however, according to CMS, Medicare refuses to recognize these codes and has declared them ineligible 2026 dates of service. Instead, Medicare (Part B) continues to call for office E/M codes to be utilized with one of the four modifiers noted above. As for Medicare Risk Adjustment, CMS has repeatedly told the industry that encounter data is only acceptable if it represents an “allowable inpatient, outpatient or professional service,” meaning that the 98000 codes will not be considered for Medicare RA.
- There’s one more confusing caveat to consider: Medicare beneficiaries with multiple coverages, particularly dual-eligible Medicare-Medicaid patients. For example, here in Colorado, the state Medicaid program requires the new 98000 series codes, while CMS refuses them. Health plans handling dual-eligible members are suddenly left trying to sort out how to submit certain procedures to one government agency and other procedures to another agency.
- This represents a potentially chaotic situation for providers and their patients. Which codes should they be using? Some sources recommended that providers urge Medicare Part B beneficiaries to sign ABNs if coverage is doubtful, while encouraging those in Part C & D plans to call their insurers and find out if their upcoming telehealth visits are covered.
To make a long story short, we recently experienced 43 days of intense, time-compressed effort to try to identify and submit the correct encounters with the correct codes under a system that suddenly, after five-and-a-half years, abruptly changed the rules.
But wait! We’re back, kind of.
Just as quickly as the healthcare industry sorted out the coding confusion, the shutdown ended – which changed the rules once again. On November 12, Congress passed a resolution to fund the US government through January 30, 2026. According to CMS’s most recent Telehealth FAQ, the telemedicine services depended upon by many Americans were retroactively restored to dates of service beginning October 1, 2025.
Unfortunately, this cycle repeats itself beginning January 31, 2026, just a few short weeks from when I’m writing this. CMS has already forewarned, “Starting January 31, 2026 … beneficiaries will generally need to be in a medical facility and in a rural area to receive Medicare telehealth services.” Payers and providers will find themselves right back where they were a few weeks ago: attempting to sort out what codes to send and where. One can assume that RAF scores will be negatively impacted when diagnoses from telehealth encounters are no longer accepted – assuming that you can tell those encounters apart before a RADV or other audit asks to review the documentation.
What Should Risk Adjusted Health Plans Do Immediately?
- Create or update payment policies on telehealth encounters. Ensure that your health plan has clear direction on reimbursement for telehealth services (audio-only AND audio & video), and don’t forget to observe special regulations regarding behavioral/mental health. Will your plan continue to reimburse providers for these services even if/when Congress and Medicare do not? How will you inform your members, for whom this might be a significant change? Plans should consider the impact on member satisfaction; for Medicare Advantage plans, this will almost certainly be reflected in CAHPS surveys and could affect Star ratings.
- Understand your plan’s specific complexities and situational factors. If you are a Medicare SNP, PACE program, Medicaid Managed Care plan, etc., it is imperative that the health plan research, understand, and plan to deal with the complexities of these situations. Some states’ Medicaid programs (e.g., Colorado) require that telehealth be reimbursed and may utilize certain coding that differs from the usual CMS requirements. Pursue clarification from state Medicaid programs or other sources, if needed. These factors must be fully understood and incorporated into your policies and plans.
- Communicate policies to members and providers – and prepare to field their questions. Now is a perfect time to communicate your plan’s telehealth policy to both providers and members. Plans must be prepared to field a litany of questions from both, particularly if you are presenting a change to existing policy. If/when Medicare telehealth flexibility again expires, health plans will need to be prepared to answer questions. The best practice here involves establishing clear internal policies on what to expect and how best to answer – and to whom escalations should be made.
- Educate providers (and their coders) on the specifics of telehealth claims for your plan. Providers must clearly document and coders must correctly code these services, paying close attention to plan-specific requirements. In order to correctly identify and handle these claims, the health plan likely needs to know when telehealth services occur, where the patient is located, and what mechanisms are utilized (audio/video), at a minimum. Billing for these services can include existing office visit codes, new telehealth codes, modifiers, special Place-of-Service (POS) indicators, and potentially additional mechanisms.
- Create internal edits and claims review processes to identify telehealth encounters. As noted, telehealth services should include certain modifiers, Place-of-Service (POS) codes, and may involve certain CPT and HCPCS procedural codes for both Evaluation & Management (E/M) and other services, medical care, and behavioral/mental health services. Claims edits to flag these items are a good place to start, and a program of educating your providers will help to ensure greater accuracy on these claims. Unfortunately, many providers may not be well versed in these coding intricacies; also, they might try to satisfy guidelines from multiple payers with one set of rules that doesn’t fit. Use analytics to guide coder reviews of common circumstances, diagnostic conditions, and coding trends that may indicate telehealth encounters not properly identified in the claim. While this can be an internal process, health plans are increasingly partnering with specialized vendors to conduct medical record reviews.
- Implement a procedure to “hold” telehealth encounters from CMS submissions and RAF calculations – and to release them when the time comes. One lesson learned from the recent shutdown is that if the legislature again allows Medicare telehealth provisions to lapse and telehealth encounters become non grata for RA encounter data submissions, it will be far better for health plans to have procedures in place to hold identified telehealth encounter data internally – and if/when such provisions are extended, to release those encounters for submission and to reincorporate those diagnoses into RAF calculations and other analytics. In light of the confusion and scrambling in response to the shutdown, having a plan and mechanism in place ahead of time is a no-brainer.
- Express yourself to Congress. Finally, health plans should work closely with industry organizations to educate Congress on the negative effects that telehealth uncertainty has on payers, providers, and members. Plans need to use their collective voice to encourage the federal government to make telehealth “flexibility” permanent. There should be no more guessing whether or not telehealth will disappear. Given the interconnected, online nature of the world today, and the vast advantages and financial gains associated with telehealth, it only makes sense that we keep it around indefinitely. Let’s put this question to rest and affirm that telehealth is, and will continue to be, a vital and acceptable method of care for everyone.
