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.