2.1 Telemedicine
/Telehealth2.1.1 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 follow
ing 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
/Telehealth2.3.1 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.