2.1 Telemedicine
/Telehealth2.1.1 Scope of Coverag
e2.1.1.1 For care provided
before July 26, 2017, 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)
codes are listed below
:
• 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 telehealth.
2.1.3 Ancillary services (e.g., laboratory
tests, Durable Medical Equipment (DME)) may be ordered/prescribed
in conjunction with a telehealth 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 or
psychologically necessary and appropriate and prescribed
by a licensed clinician who is directly involved in the patient’s
current telehealth 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 or psychologically necessary and appropriate
and prescribed by a licensed clinician who is directly involved
in the patient’s current telehealth episode
of care.
2.2 General
Telehealth Requirements
The following requirements,
criteria, and limitations are applicable to the provisions of medically
or psychologically necessary and appropriate care
delivered via telehealth.
2.2.1 Technical Requirements
2.2.1.1 Clinical VTC Platforms
Clinical VTC platforms
used for telehealth 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 (collectively
“the HIPAA Rules”). For telehealth
services provided outside the 50 United States (US), District of
Columbia, and US Territories including the Commonwealth of Puerto
Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth
of the Northern Mariana Islands, the TRICARE Overseas Program (TOP)
contractor shall comply with the privacy and security laws, regulations,
and guidance of the host nation. Video-chat applications
(i.e., Skype,
Facetime) 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 telehealth.
2.2.1.2 Connectivity
Telehealth 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 telehealth services
being delivered. Telehealth 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 telehealth services:
• Providers of telehealth services
shall ensure audio and video transmissions used are secured using
point-to-point encryption that meets recognized standards.
• Providers of telehealth 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 (i.e., 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.
• For telehealth
services provided outside of the 50 US, District of Columbia, and
US Territories including the Commonwealth of Puerto Rico, the Virgin
Islands, Guam, American Samoa, and the Commonwealth of the Northern
Mariana Islands, the privacy and security laws, regulations and
guidance of the host nation apply.
• Enforcement of
the HIPAA Rules is the responsibility of the Office of Civil Rights
(OCR).
2.2.2 Asynchronous “Store and Forward”
Services
Asynchronous,
or “store and forward” telehealth 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 telehealth,
as well as physician interpretation of electrocardiogram and electroencephalogram
readings that are transmitted electronically. Other examples for
use of telehealth 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 telehealth services
to follow telehealth-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 US, District
of Columbia, and US Territories, this includes all
applicable TOP and
host nation requirements including privacy and security
laws, regulations and guidance.
2.2.3.2 The
contractor shall instruct providers rendering telemedicine services
to follow professional discipline and national practice guidelines
when practicing via telehealth, and
any modifications to applicable clinical practice guidelines for
the telehealth 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 telehealth services, the
contractors shall instruct providers rendering telehealth services
to implement means for verification of provider and patient identity.
For telehealth 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 telehealth services where the originating
site does not have an immediately available health professional
(i.e., the
patient’s home), the telehealth provider
shall provide the patient (or legal representative) with the provider’s qualifications,
licensure information, and, when applicable, registration number
(i.e., National
Provider Identification (NPI)). The patient shall provide two-factor
authentication.
2.2.3.4 For synchronous telehealth 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 telehealth services
is conducted over a secure network and is compliant with HIPAA requirements. The
TOP contractor shall ensure compliance with the privacy and security laws,
regulations and guidance for the host nation.
2.2.3.6 The
contractor shall instruct providers to establish an alternate plan
for communicating with the patient (i.e., 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.
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 telehealth services. The
TOP contractor shall instruct providers that host nation’s privacy
and security laws, regulations and guidance for the use and disclosure
of PHI apply to all telehealth services.
2.2.4 Conditions of Payment
2.2.4.1 For TRICARE payment to be authorized
for synchronous telehealth 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 telehealth services, both
the patient and healthcare provider must be present on the connection
and participating.
2.2.4.3 TRICARE allows payment for
asynchronous telehealth 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 telehealth services,
interpretive or other clinical services
must be rendered by the consulting provider to the referring provider.
2.3 Reimbursement for Telemedicine
/Telehealth2.3.1 Distant Site
2.3.1.1 The
payment amount for synchronous telehealth 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 50 US, District of Columbia, Puerto Rico, and US Territories,
the services must be within a provider’s scope of practice under
all applicable TOP requirements and the
privacy and security laws, regulations and guidance of the 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 telehealth 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. TRICARE uses the Medicare fee set for Q3014. 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 (i.e., 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 telehealth services,
providers will use CPT or Healthcare Common Procedure
Coding System (HCPCS) codes
with a GT or 95 modifier
for distant site and Q3014 for originating site to distinguish telehealth services.
In addition, Place of Service (POS) 02 code
may be reported in conjunction with GT or 95 modifier. However, POS
02 is not required to be reported through
the end of the Coronavirus 2019 (COVID-19) pandemic if a more appropriate
code is necessary for correct billing, include POS code equal to
what it would have been had the service been furnished in person. By
coding and billing the GT or 95 modifier
with a covered telehealth procedure
code, the distant site provider certifies that the beneficiary was
present at an eligible originating site when the telehealth service
was furnished.
2.3.2.4 For billing asynchronous telehealth services,
providers will use CPT or HCPCS codes with a GQ modifier.
In addition, POS 02 may be
reported in conjunction with the GQ modifier. However, POS 02 is
not required to be reported through the end of the
COVID-19 pandemic for telehealth claims if a more
appropriate POS code is necessary for
correct billing, include POS code equal to what it
would have been had the service been furnished in person.