2.1 Telemedicine/Telehealth
2.1.1 Scope of Coverage
2.1.1.1 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/Telehealth
2.3.1 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.