Telehealth Diagnoses For Risk Adjustment: Check The Source Before You Keep The HCC

Quick Answer

Yes — if the encounter is an eligible source type, used real-time audio and video, and is documented well enough to support the code. Audio-only encounters (modifier 93 or FQ) have a separate rule for CY 2027. Start with the source, not the diagnosis.

Can Telehealth Diagnoses Count For Risk Adjustment?

Yes, when the visit meets CMS risk adjustment eligibility criteria.

In its January 15, 2021 telehealth risk adjustment memo, CMS confirmed that MA organizations can submit diagnoses from telehealth visits for risk adjustment when those visits meet all standard eligibility criteria. Three things have to be true:

Wrong question. Asking whether it was telehealth doesn't tell you anything. Ask whether the encounter was an eligible source type, whether the setup meets face-to-face, and whether the note holds up. Same review, different frame.

A video encounter that meets those three criteria goes through the same documentation review as any other eligible source. An audio-only encounter has a different pathway for 2027 — more on that below.

What Changed For Audio-Only Diagnoses In CY 2027?

CMS finalized a narrower rule for audio-only visits in the 2027 Medicare Advantage Rate Announcement, published April 6, 2026.

The policy tracks CMS's existing face-to-face requirement. CMS says diagnoses must result from a face-to-face encounter to count for risk adjustment, and telehealth using an interactive audio and video telecommunications system fulfills that requirement. If the record shows only audio-only service lines, CMS treats that as no face-to-face encounter for risk purposes. That's the rule for 2027.

For CY 2027, CMS finalized excluding diagnoses from audio-only encounters using modifier 93 or FQ from risk score calculation when no other line on the encounter data record, chart review record, or FFS claim is risk adjustment eligible.

That last clause is the one to read carefully. The exclusion applies when the audio-only source is the only risk adjustment eligible line. If another eligible service line exists on the same record, the team should trace the diagnosis to that eligible source instead of stopping at the modifier.

CMS isn't saying audio visits are bad medicine. They're saying audio-only doesn't count as face-to-face for risk adjustment purposes. That's the whole thing.

What Should Coders Check On A Telehealth Chart?

Confirm the source type is eligible

CMS publishes a Medicare risk adjustment eligible CPT and HCPCS code list. Use the version that applies to the payment year under review, not an old spreadsheet or a generic telehealth reference. The list is updated annually — there was a January 1, 2026 update, for instance.

If the service line itself doesn't qualify, a clean diagnosis statement won't fix the source problem. Source eligibility is upstream of everything else.

Check the telehealth modality

CMS draws a practical line between real-time audio and video telehealth and audio-only service lines. If the record shows audio and video, continue the normal documentation review. If the record is audio-only, check the modifier before you do anything else.

Check for modifier 93 or FQ

Modifier 93 is the CPT modifier for synchronous telemedicine service via telephone or other real-time interactive audio-only telecommunications system. Modifier FQ indicates the service was furnished using audio-only communication technology. CMS uses it in Medicare telehealth billing across multiple settings, including FQHC and RHC contexts and others where audio-only service identification is required — it's not limited to FQHC/RHC. CMS finalized using both markers to exclude audio-only diagnoses for CY 2027 when no other eligible line exists.

Check whether another eligible line exists

If the record carries modifier 93 or FQ, the next step is to look for other risk adjustment eligible service lines on the same encounter data record, chart review record, or FFS claim. If another eligible line exists, the team should trace the diagnosis to that source and confirm it's documented well enough to support the HCC.

If the audio-only line is the only source, the diagnosis doesn't count toward the CY 2027 risk score under the finalized rule.

Does This Change ICD-10-CM Coding?

No. This is a source eligibility and risk score calculation issue, not a new ICD-10-CM coding rule.

The provider still needs to document the diagnosis. The code still needs to match the specificity in the record. The condition still needs current support. A video telehealth visit doesn't make a vague diagnosis more specific. An audio-only encounter doesn't make a real clinical condition disappear from the chart.

The payment question is whether the diagnosis came from a risk adjustment eligible source. The coding question is whether the record actually supports the ICD-10-CM code.

Two common errors come from mixing these up:

What Should Coding Managers Recheck Before 2027?

Recheck telehealth rules in your job aids

If your internal documentation says "telehealth counts" without distinguishing audio and video from audio-only, update it. If it says "telehealth never counts," also update it. Both are wrong.

Build a modifier-driven work queue

Create a review queue for claims or encounter records with modifier 93 or FQ. The goal isn't to automatically drop every diagnosis. The goal is to isolate records where the only source line is audio-only so the team can assess each one before the submission cycle closes.

Verify your vendor and payer exports

Some exports flatten encounter details in a way that hides the source line and the modifier. Make sure reviewers can see the service code, modifier, place of service, and whether another risk adjustment eligible service line exists. If the export doesn't surface those fields, fix the export before the submission window opens.

Keep provider education focused on documentation

The telehealth source rule doesn't change the documentation bar. Providers still need to document the diagnosis with specificity, current support, and enough detail to support the ICD-10-CM code path. The source check is a separate layer on top of that, not a substitute for it.

Where HCC Buddy Fits

Once the source passes review, HCC Buddy helps with the diagnosis side. You can look up the ICD-10-CM code, check the HCC mapping against the current V28 model, and see whether the documented specificity supports the code path.

It doesn't replace encounter source validation, modifier review, or plan-side submission logic. Telehealth HCC review needs both. First, confirm the source qualifies. Then, confirm the diagnosis and mapping are right. The ICD-10 encoder is useful for the second part.

Sources

CMS telehealth risk adjustment memo, updated January 15, 2021

CMS 2027 Medicare Advantage and Part D Rate Announcement fact sheet

CMS 2027 Rate Announcement PDF

CMS Medicare Risk Adjustment Eligible CPT/HCPCS Codes

CMS Medicare Advantage RADV program page

Read the 2027 MA Rate Announcement guide for HCC coders.

Read the RADV audit schedule checklist.

Check encounter data submission deadlines.