2.1 Telemedicine/Telehealth
2.1.1 Scope of Coverage
2.1.1.1 For 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)
codes are listed below:
• 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,
are covered.
2.1.2 TRICARE
shall ensure that anyThe contractor shall
apply applicable referral or and preauthorization requirements that
apply for services under the TRICARE Program also apply when
such services are delivered via telehealth.
2.1.3 AncillaryProviders
may order or prescribe ancillary services (i.e., laboratory
tests, Durable Medical Equipment (DME)) will 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 will conform to TRICARE regulation(s) and
state law(s) at both the originating site and the distant site.
All The contractor shall ensure all ancillary
orders or prescriptions will be are 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 will conform to TRICARE regulation(s)
and states law(s) at both the originating site and the distant site.
Prescription(s)The provider may prescribe
pharmaceuticals in conjunction with a telehealth visit to the same
extent as during an in-person visit. The contractor shall ensure
the provider submits prescription(s) for pharmaceutical(s) will
be that are 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 apply to the
provisions of medically or psychologically necessary
and appropriate care delivered via telehealth. The contractor
is responsible for the oversight of these requirements, criteria,
and limitations that apply to TRICARE-authorized providers.
2.2.1 Technical Requirements
2.2.1.1 Clinical VTC Platforms
Clinical VTC platforms used for
telehealth services will have the appropriate verification, confidentiality,
and security parameters necessary to be properly utilized for this
purpose and 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 (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 will shall provide such services
at a bandwidth and with sufficient resolutions to ensure the quality
of the image or audio received is sufficient for the type of telehealth
services being delivered. The contractor shall not
provide telehealth services if this functional requirement is not
met.
2.2.1.3 Privacy
and Security
The contractor
shall
use the follow
ing these guidelines
to ensure the privacy and security of telehealth services:
• The contractor
shall ensure providers Providers of
telehealth services use shall
ensure audio and video transmissions that used are
secured using point-to-point encryption that meets recognized standards.
• The contractor
shall ensure providers Providers of
telehealth services do shall not
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 will 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. The contractor shall use cloud Cloud services that
are able unable 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 TOP contractor shall apply the privacy
and security laws, regulations and guidance of the host nation apply.
• Enforcement of
the HIPAA rules is the responsibility of the The Office
of Civil Rights (OCR) will enforce the HIPAA rules.
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 theU.S., District of Columbia and
U.S. territories, this includes the
TOP contractor shall follow 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 telehealth services 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, the contractor
shall instruct the provider to determine 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 shall 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 contractor shall instruct providers rendering telehealth services
to implement means for verification of provider and patient identity
for synchronous telehealth services. For telehealth services where
the originating site is an authorized institutional provider, the
verification of both professional and patient identity will 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 will provide
two-factor authentication.
2.2.3.4 For synchronous telehealth services,
the contractor shall instruct providers that to
document provider and patient location will
be documented in the medical record as required for
the appropriate payment of services for synchronous telemedicine
services. Documentation will include The
contractor shall instruct the provider to document elements
such as city/town, state, and ZIP Code (or country for overseas
services).
2.2.3.5 The contractor shall instruct
providers that to conduct transmission
and storage of data associated with asynchronous telehealth services is
conducted over a secure network and is
compliant comply 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 The contractor shall
instruct providers to develop the alternate plan at
the outset of treatment. In order for the The
contractor shall instruct the provider to only resume telehealth
services to resume, if all the technological
requirements of this policy will be are 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 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 telehealth services between a provider and patient, the
contractor shall instruct the provider to use 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) will
be used.
2.2.4.2 As a condition of payment for
synchronous telehealth services, the contractor shall
instruct the provider that both the patient and health
care provider will shall 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, the contractor shall instruct the
consulting provider to render interpretive and other
clinical services 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
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 shall be
a TRICARE authorized provider and the service will shall 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 will shall 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 contractor shall charge beneficiaries
for any applicable copay or cost-sharing. The contractor shall apply
the charge a copayment amount that
is 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 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. 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 the contractors shall
implement this 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. The contractor shall not apply pay a
facility fee payment when a patient’s
home is the originating site.
2.3.2.3 When billing for synchronous
telehealth services, the contractor shall instruct the providers will to 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, the provider may report a Place
of Service (POS) code 02 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 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, the contractor shall instruct the providers
will to use CPT or HCPCS codes
with a GQ modifier. In addition, the provider
may report POS code 02 may
be reported in conjunction with the GQ modifier.
However, POS code 02 is not required to be reported
through the COVID-19 pandemic for telehealth claims if a more appropriate
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.