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TRICARE Policy Manual 6010.63-M, April 2021
Medicine
Chapter 7
Section 22.1
Telemedicine/Telehealth
Issue Date:  April 17, 2003
Authority:  32 CFR 199.4 and 32 CFR 199.14
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-3, May 3, 2024
1.0  DESCRIPTION
1.1  Telemedicine telehealth refers to the use of information and telecommunications technology to provide medically and psychologically necessary and appropriate diagnostic and treatment services across distances. The term “telehealth” is often used interchangeably with “telemedicine”, although telehealth typically refers to a broader range of services. The Military Health Systems (MHS) uses the terms “virtual health”, “telehealth”, and “telemedicine” interchangeably. Overall, telemedicine telehealth facilitates the exchange of medical information between providers and/or providers and patients through electronic means. Medical information includes but is not limited to medical images, output data from medical devices, and verbal diagnostic information. The telemedical telehealth interaction may involve a variety of technologies, including live real-time two-way audio and video modalities (e.g., clinical video-teleconferencing or (VTC) between patients at the “originating site” and providers at the “distant site”). Telemedicine Telehealth may be conducted provided in many clinical specialties including, but not limited to, telemental health and teleprimary primary care, specialty care, tele-critical care and behavioral health. For more information on the telehealth contractor network requirements see the TRICARE Operations Manual (TOM), Chapter 27, Section 1, and see https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf for telehealth definitions.
1.2  Synchronous telemedicine telehealth services involve interactive, electronic information exchange in at least two directions in the same time period. A common type of synchronous encounter is clinical VTC. Clinical VTC supports the delivery of health care at a distance via real-time, two-way transmission of digitized video images between two or more locations. Providers and/or providers and patients can exchange medical information via clinical VTC for the purpose of obtaining an expert opinion, diagnostic support regarding the care of a patient, and/or direct patient care.
1.3  Asynchronous, or store and forward, telemedicine telehealth encounters transmit medical images, or other medical information in one direction at a time via electronic communications. Common types of asynchronous services include teleconsultations involving radiology, pathology, cardiology, and dermatology. Teleconsultation supports the delivery of health care at a distance via the asynchronous transmission of electronic medical information and associated or stand-alone digital images or video over a secure connection between health care providers for the purpose of obtaining an expert opinion or diagnostic support regarding the care of a patient. In the process of teleconsultation, the remote consultant does not interact directly with the patient. The consultant prepares and transmits comments, recommendations, or an official interpretation back to the referring provider for their review and consideration. A teleconsultation is not a traditional patient referral whereby patient care is transferred to the consultant.
1.4  Remote Physiological Monitoring (RPM) of physiological parameters is a telehealth service that involves synchronous and asynchronous modalities. Medically necessary RPM is covered when ordered by a TRICARE authorized-provider and when certain coverage criteria are met.
2.0  POLICY
2.1  Telemedicine/Telehealth
2.1.1  Scope of Coverage.
2.1.1.1  TheFor services 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) 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 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  AnyTRICARE shall ensure that any applicable referral and/or preauthorization requirements that apply for services under the TRICARE Program also apply when such services are delivered via telemedicine telehealth.
2.1.3  Ancillary services (e.g.i.e., laboratory tests, Durable Medical Equipment (DME)) may will be ordered/prescribed in conjunction with a telemedicine telehealth visit to the same extent as during an in-person visit. All ancillary services that are ordered or prescribed must will conform to TRICARE regulation(s) and state law(s) at both the originating site and the distant site. All ancillary orders or prescriptions must will be medically or psychologically necessary and appropriate and prescribed by a licensed clinician who is directly involved in the patient’s current telemedicine telehealth episode of care.
2.1.4  All prescriptions for pharmaceuticals must will conform to TRICARE regulation(s) and states law(s) at both the originating site and the distant site. Prescription(s) for pharmaceutical(s) must will be medically or psychologically necessary and appropriate and prescribed by a licensed clinician who is directly involved in the patient’s current telemedicine telehealth episode of care.
2.2  General Telemedicine Telehealth Requirements
The following requirements, criteria, and limitations are applicable to the provisions of medically or psychologically necessary and appropriate care delivered via telemedicine telehealth.
2.2.1  Technical Requirements
2.2.1.1  VideoconferencingClinical VTC Platforms
Video conferencingClinical VTC platforms used for telemedicine telehealth services must will have the appropriate verification, confidentiality, and security parameters necessary to be properly utilized for this purpose and must will 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 of the 50 United States (U.S.), District of Columbia, and U.S. 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 (e.g.i.e., 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 telehealth.
2.2.1.2  Connectivity
TelemedicineTelehealth services provided through personal computers or mobile devices that use internet-based videoconferencing software programs must will 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 telehealth services being delivered. Telemedicine The contractor shall not provide telehealth services shall not be provided if this functional requirement is not met.
2.2.1.3  Privacy and Security
The contractor shall following these guidelines shall be followed to ensure the privacy and security of telemedicine telehealth services:
•  ProvidersThe contractor shall ensure providers of telemedicine telehealth services shall ensure use audio and video transmissions used that are secured using point-to-point encryption that meets recognized standards.
•  ProvidersThe contractor shall ensure providers of telemedicine telehealth services shall do not utilize use 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 will include more than two sites/patients as participants in that session with the consent of all participants (e.g.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 The contractor shall use cloud services unable that are able to achieve compliance shall not be used for PHI or confidential data.
•  For telehealth services performed outside of the 50 U.S., District of Columbia, and U.S. territories including the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth of 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.
2.2.2  Asynchronous “Store and Forward” Services
Asynchronous, or “store and forward” telemedicine 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 telemedicine telehealth, as well as physician interpretation of electrocardiogram and electroencephalogram readings that are transmitted electronically. Other examples for use of telemedicine 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 telemedicine telehealth services to follow telemedicine 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 United States (U.S.), District of Columbia and U.S. territories, this would includes all applicable TRICARE Overseas Program (TOP) and host nation requirements including privacy and security laws, regulations and guidance.
2.2.3.2  The contractor shall instruct providers rendering telemedicine telehealth services to follow professional discipline and national practice guidelines when practicing via telemedicine telehealth, and any modifications to applicable clinical practice guidelines for the telemedicine 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  TheFor synchronous telehealth services, the contractor shall instruct providers rendering telemedicine telehealth services to implement means for verification of provider and patient identity for synchronous telemedicine telehealth services. For telemedicine telehealth services where the originating site is an authorized institutional provider, the verification of both professional and patient identity may will occur at the host facility. For telemedicine telehealth services where the originating site does not have an immediately available health professional (e.g.i.e., the patient’s home), the telemedicine telehealth provider shall provide the patient (or legal representative) with the provider’s qualifications, licensure information, and, when applicable, registration number (e.g.i.e., National Provider Identification (NPI)). The patient shall provide two-factor authentication.
2.2.3.4  TheFor synchronous telehealth services, the contractor shall instruct providers that provider and patient location must will 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 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 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 (e.g.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 telehealth services to resume, all technological requirements of this policy must will 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 telehealth services. The TOP contractor shall instruct providers that the 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 telemedicine 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 will be used.
2.2.4.2  As a condition of payment for synchronous telemedicine telehealth services, both the patient and health care provider must will be present on the connection and participating.
2.2.4.3  TRICARE allows payment for asynchronous telemedicine 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 telemedicine telehealth services, interpretive and other clinical services must will 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 telemedicine telehealth services provided via an interactive telecommunication system by a TRICARE authorized provider at the distant site shall be equal to 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 equal to 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 will 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 U.S., District of Columbia, Puerto Rico, and U.S. territories the services must will 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 contractor shall charge beneficiaries for any applicable copay or cost-sharing. The contractor shall apply the copayment amount shall be the same as if the service was provided without the use of an interactive telecommunications system.
2.3.2  Originating Site Facility
2.3.2.1  For covered synchronous telemedicine telehealth services delivered via an interactive telecommunications system, the payment for the originating site facility fee (Q3014) will be equal to 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). 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 this updates in accordance with the annual CMAC updates.
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.i.e., physician’s office), or a TRICARE-authorized institutional provider. Facility The contractor shall not apply a 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 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 telemedicine telehealth services. In addition, Place of Service (POS) code 02 is to may be reported in conjunction with GT or 95 modifier. However, POS code 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 telemedicine telehealth procedure code, the distant site provider certifies that the beneficiary was present at an eligible originating site when the telemedicine telehealth service was furnished.
2.3.2.4  For billing asynchronous telemedicine telehealth services, providers will use CPT or HCPCS codes with a GQ modifier. In addition, POS code 02 is to may be reported in conjunction with the GQ modifier. Place of Service Code However, POS code 02 is not required to be reported through the COVID-19 pandemic for telehealth claims if a more appropriate Place of Service Code POS code is necessary for correct billing, include the POS codes equal to what it would have been had the service been furnished in person.
3.0  Exclusions
3.1  Christian Science services. To be considered for coverage under TRICARE, the beneficiary must will be present physically when a Christian Science service is rendered.
3.2  Services otherwise excluded under the TRICARE Program are also excluded from being delivered via telemedicine telehealth.
3.3  Telephone services. Audio-only telephone services excluded by 32 CFR 199.4(g)(52) do not meet the definition of interactive telecommunications systems and are excluded, unless otherwise allowed in response to the Coronavirus 2019 (COVID-19) pandemic in Chapter 1, Section 15.1.
3.4  Facility fee payment is excluded when the originating site is the patient’s home or location other than where the authorized TRICARE provider typically provides services (i.e., office, clinic).
4.0  EFFECTIVE DATES
4.1  August 1, 2003.
4.2  March 13, 2020, for exceptions to use of POS 02 code during the COVID-19 pandemic.
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