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.