2.1 Telemedicine
2.1.1 Scope of Coverage. The use of interactive telecommunications
systems may be used to provide diagnostic and treatment services
when such services are medically or psychologically necessary and
appropriate. These services and corresponding Current Procedure
Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS)
codes are listed below:
2.1.1.1 For care
provided before July 26, 2017:
• Consultations (CPT
procedure codes 99241-99255)
• Office or other
outpatient visits (CPT procedure codes 99201 – 99215)
• End Stage Renal
Disease (ESRD) related services (CPT procedure codes 90951-90952, 90954-90955,
90957-90958, 90960-90961)
• Individual
psychotherapy (CPT procedure codes 90832-90838)
• Psychiatric
diagnostic evaluation (CPT procedure codes 90791-90792)
• Pharmacologic
management (CPT procedure code 90863)
2.1.1.2 For care provided on or after July 26, 2017:
The use of interactive telecommunications systems may be used to
provide diagnostic and treatment services for otherwise covered
TRICARE benefits when such services are medically or psychologically
necessary and appropriate medical care.
2.1.2 Any applicable
referral and/or preauthorization requirements that apply for services
under the TRICARE Program also apply when such services are delivered
via telemedicine.
2.1.3 Ancillary services (e.g.,
laboratory tests, Durable Medical Equipment (DME)) may be ordered/prescribed
in conjunction with a telemedicine visit to the same extent as during
an in-person visit. All ancillary services that are ordered or prescribed
must conform to TRICARE regulation(s) and state law(s) at both the
originating site and the distant site.
All ancillary orders or prescriptions must be medically appropriate
and prescribed by a licensed clinician who is directly involved
in the patient’s current telemedicine episode of care.
2.1.4 All prescriptions for pharmaceuticals must
conform to TRICARE regulation(s) and states law(s) at both the originating
site and the distant site. Prescription(s)
for pharmaceutical(s) must be medically appropriate and prescribed
by a licensed clinician who is directly involved in the patient’s current
telemedicine episode of care.
2.2 General Telemedicine Requirements
The following requirements, criteria, and limitations are applicable
to the provisions of medically or psychologically necessary care
delivered via telemedicine.
2.2.1 Technical Requirements
2.2.1.1 Videoconferencing
Platforms
Video conferencing platforms
used for telemedicine services must have the appropriate verification,
confidentiality, and security parameters necessary to be properly
utilized for this purpose and must meet the requirements of the
Health Insurance Portability and Accountability Act (HIPAA) Privacy
and Security Rules. Video-chat applications (e.g., Skype, Facetime)
may not meet such requirements and should not be used unless appropriate
measures are taken to ensure the application meets these requirements
and that appropriate business associates agreements (if necessary)
are in place to utilize such applications for telemedicine.
2.2.1.2 Connectivity
Telemedicine services provided through personal
computers or mobile devices that use internet-based videoconferencing
software programs must provide such services at a bandwidth and with
sufficient resolutions to ensure the quality of the image and/or
audio received is sufficient for the type of telemedicine services
being delivered. Telemedicine services shall not be provided if
this functional requirement is not met.
2.2.1.3 Privacy
and Security
The following guidelines
shall be followed to ensure the privacy and security of telemedicine
services:
• Providers
of telemedicine services shall ensure audio and video transmissions
used are secured using point-to-point encryption that meets recognized
standards.
• Providers of telemedicine
services shall not utilize videoconference software that allows
multiple concurrent sessions to be opened by a single user. While
only one session may be open at a time, a provider may include more
than two sites/patients as participants in that session with the
consent of all participants (e.g., group psychotherapy).
• Protected
Health Information (PHI) and other confidential data shall only
be backed up to or stored on secure data storage locations that
have been approved for this purpose. Cloud services unable to achieve
compliance shall not be used for PHI or confidential data.
2.2.2 Asynchronous
“Store and Forward” Services
Asynchronous,
or “store and forward” telemedicine services, under conventional
health care delivery, includes medical services that do not require
face-to-face or “hands-on” contact between patient and physician.
For example, TRICARE permits coverage of teleradiology, which is
the most widely used and reimbursed form of telemedicine, as well
as physician interpretation of electrocardiogram and electroencephalogram
readings that are transmitted electronically. Other examples for
use of telemedicine by using “store and forward” technology include
telepathology and teledermatology.
2.2.3 Contractor
Responsibilities
2.2.3.1 The contractor
shall instruct providers rendering telemedicine services to follow telemedicine-specific
regulatory, licensing, credentialing and privileging, malpractice
and insurance laws and rules for their profession in both the jurisdiction
(site) in which they are practicing as well as the jurisdiction
(site) where the patient is receiving care, and shall ensure compliance
as required by appropriate regulatory and accrediting agencies.
For services provided outside of the United States (US), this would
include all applicable TRICARE Overseas Program (TOP) and host nation
requirements.
2.2.3.2 The contractor
shall instruct providers rendering telemedicine services to follow professional
discipline and national practice guidelines when practicing via
telemedicine, and any modifications to applicable clinical practice
guidelines for the telemedicine setting shall ensure that clinical
requirements specific to the discipline are maintained. In addition,
arrangements for handling emergency situations should be determined
at the outset of treatment to ensure consistency with established
local procedures. In particular, for mental health services, this
should include processes for hospitalization or civil commitment
within the jurisdiction where the patient is located if necessary.
2.2.3.3 For synchronous telemedicine services, the
contractors shall instruct providers rendering telemedicine services
to implement means for verification of provider and patient identity.
For telemedicine services where the originating site is an authorized
institutional provider, the verification of both professional and
patient identity may occur at the host facility. For telemedicine
services where the originating site does not have an immediately
available health professional (e.g., the patient’s home), the telemedicine
provider shall provide the patient (or legal representative) with
the provider’s qualifications, licensure information, and, when
applicable, registration number (e.g., National Provider Identification
(NPI)). The patient shall provide two-factor authentication.
2.2.3.4 For synchronous telemedicine services, the
contractor shall instruct providers that provider and patient location
must be documented in the medical record as required for the appropriate payment
of services. Documentation will include elements such as city/town,
state, and zip code (or country for overseas services).
2.2.3.5 The contractor shall instruct providers to
ensure that transmission and storage of data associated with asynchronous
telemedicine services is conducted over a secure network and is compliant
with HIPAA requirements.
2.2.3.6 The contractor
shall instruct providers to establish an alternate plan for communicating with
the patient (e.g., telephone) in the event of a technological breakdown/failure.
This should be developed at the outset of treatment. In order for
the telemedicine services to resume, all technological requirements
of this policy must be restored, as telemedicine cannot be performed
by telephone services alone.
2.2.3.7 The contractor
shall instruct providers that HIPAA privacy and security requirements
for the use and disclosure of PHI apply to all telemedicine services.
2.2.4 Conditions
of Payment
2.2.4.1 For TRICARE
payment to be authorized for synchronous telemedicine services between
a provider and patient, interactive telecommunication systems, permitting
real-time audio and video communication between the TRICARE-authorized
provider (i.e., distant site) and the beneficiary (i.e., originating
site) must be used.
2.2.4.2 As a condition
of payment for synchronous telemedicine services, both the patient
and healthcare provider must be present on the connection and participating.
2.2.4.3 TRICARE allows payment for asynchronous telemedicine
services in which, under conventional health care delivery, do not
require face-to-face or “hands-on” contact between patient and provider.
For TRICARE payment to be authorized for asynchronous telemedicine
services, interpretive services must be rendered by the consulting
provider to the referring provider.
2.3 Reimbursement
for Telemedicine
2.3.1 Distant Site
2.3.1.1 The payment amount for synchronous telemedicine services provided
via an interactive telecommunication system by a TRICARE authorized
provider at the distant site shall be the lower of the CHAMPUS Maximum
Allowable Charge (CMAC), the billed charge, or the negotiated rate,
for the service provided. Payment for an office visit, consultation,
individual psychotherapy or pharmacologic management via an interactive telecommunications
system should be the lower of the CMAC, billed or negotiated rate as
when these services are furnished without the use of an interactive telecommunications
system.
2.3.1.2 For TRICARE
payment to be authorized, the provider must be a TRICARE authorized provider
and the service must be within a provider’s scope of practice under
all applicable state(s) law(s) in which services are provided and
or received. For services provided outside of the US, the services
must be within a provider’s scope of practice under all applicable
TOP and host nation requirements. Reimbursement will be established
on the allowable rate for the country in which the authorized provider
is providing the service(s) from.
2.3.1.3 The beneficiary is responsible for any applicable
copay or cost-sharing. The copayment amount shall be the same as
if the service was without the use of an interactive telecommunications system.
2.3.2 Originating
Site Facility
2.3.2.1 For covered synchronous telemedicine
services delivered via an interactive telecommunications system,
the payment for the originating site facility fee (Q3014) will be
the lesser of the originating site facility fee, the negotiated
rate or the billed charge. The facility fee for the originating
site is updated annually by the Medicare Economic Index (MEI). Annual
updates of the originating site facility fee (Q3014) will be included
in the annual updates of the CMAC file and TRICARE contractors shall implement
these updates in accordance with the annual CMAC updates.
2.3.2.2 Payment of the originating site facility fee
is limited to facilities where an otherwise authorized TRICARE provider
normally offers medical or psychological services, such as the office
of a TRICARE-authorized individual professional provider (e.g.,
physician’s office), or a TRICARE-authorized institutional provider.
Facility fee payment will not be made when a patient’s home is the
originating site.
2.3.2.3 When billing
for synchronous telemedicine services, providers will use CPT or
HCPCS codes with a GT modifier for distant site and
Q3014 for originating site to distinguish telemedicine services. In addition,
Place of Service POS 02 is to be reported in conjunction
with GT modifier. By coding and billing the GT modifier
with a covered telemedicine procedure code, the distant site provider
certifies that the beneficiary was present at an eligible originating
site when the telemedicine service was furnished.
2.3.2.4 For billing asynchronous telemedicine services,
providers will use CPT or HCPCS codes with a GQ modifier.
In addition, POS 02 is to be reported in conjunction
with the CQ modifier.