New CMS “Guidance” – Clear As Mud

The Centers for Medicare and Medicaid Services recently issued new guidance for healthcare providers on documenting and reporting electronic clinical quality measures (“eCQMs”) for telehealth encounters.  The new guidance was intended to provide clarity but may in fact lead to more confusion about what claims will be reimbursed if provided by telehealth methods as opposed to in person visits, and places the burden on the provider to choose the proper encounter format.

As noted by CMS, “there may be instances where the quality action cannot be completed during the telehealth encounter by eligible professionals and eligible clinicians. Specifically, telehealth-eligible CPT and HCPCS codes may be included in value sets where the required quality action in the numerator cannot be completed via telehealth.”

For example, if a patient presents with glaucoma but the provider is unable to evaluate the optic nerve via telehealth, the visit fails the telehealth eligibility measures even though a diabetes related eye exam is listed as telehealth eligible.  Because CMS imposed the responsibility on the provider for determining whether all aspects of the quality action within the measure specification can be completed by telehealth, providers must be careful to assess the type of care required and code appropriately.

Further clarification on this new guidance is expected to be forthcoming.

The set of 42 eCQMs eligible for telehealth encounters, and those not eligible, for the 2020 performance period can be accessed at the following link:

The set of 39 eCQMs eligible for telehealth encounters, and those not eligible, for the 2021 performance period and can be accessed at the following link:

For assistance in remaining compliant and up-to-date with the rapidly changing state and federal rules on telehealth or implementing a telehealth program with your business, reach out to your Dickinson Wright healthcare law attorney.

About the author:

Kimberly Ruppel is a co-chair of Dickinson Wright PLLC’s Telehealth Task Force.  She has over 20 years’ experience as a commercial litigator who represents healthcare providers, insurers and benefit plans in matters related to healthcare litigation, licensing and regulatory disputes, governmental fraud and abuse investigations, HIPAA compliance, ERISA and insurance claims, coverage and fiduciary disputes, and class actions in state and Federal courts.