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 GQ modifier. Place
of Service Code 02 is not required for telehealth claims if a more
appropriate Place of Service Code is necessary for correct billing.