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 codes 99241-99255)
• Office or other outpatient
visits (CPT codes 99201-99215)
• End Stage Renal Disease (ESRD)
related services (CPT codes 90951-90952, 90954-90955, 90957-90958,
90960-90961)
• Individual psychotherapy (CPT
codes 90832-90838)
• Psychiatric diagnostic evaluation
(CPT codes 90791-90792)
• Pharmacologic management (CPT
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 The
contractor shall instruct providers rendering telemedicine services
to implement means for verification of provider and patient identity
for synchronous telemedicine services. 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 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 for synchronous telemedicine 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 health care 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).
2.3.2.1.1 Annual updates of the originating
site facility fee (Q3014) will be included in the annual updates
of the CMAC file.
2.3.2.1.2 The contractor 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) code 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
code 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.