Section 140.403 Telehealth Services

TITLE 89: SOCIAL SERVICES

CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

SUBCHAPTER d: MEDICAL PROGRAMS

PART 140 MEDICAL PAYMENT

SECTION 140.403 TELEHEALTH SERVICES

Section 140.403

Telehealth Services

a)         Definitions

1)         "Asynchronous Store and Forward

Technology" means the transmission of a patient's medical information from

an originating site to the provider at the distant site.  The provider at the distant

site can review the medical case without the patient being present.  An asynchronous

telecommunication system in single media format does not include telephone

calls, images transmitted via facsimile machines and text messages without

visualization of the patient (electronic mail).  Photographs visualized by a telecommunication

system must be specific to the patient' s medical condition and adequate for

furnishing or confirming a diagnosis and/or treatment plan.  Dermatological

photographs (for example, a photograph of a skin lesion) may be considered to

meet the requirement of a single media format under this provision.

2)         "Distant Site" means the location

at which the provider rendering the service is located.

3)         "Encounter Clinic" means a

Federally Qualified Health Center, Rural Health Clinic or Encounter Rate Clinic,

as defined in 89 Ill. Adm. Code 140.461.

4)         "Facility Fee" means the

reimbursement made to the following originating sites for the telehealth

service:  physician's office, podiatrist's office, local health departments,

community mental health centers, licensed hospital outpatient departments as

defined in 89 Ill. Adm. Code 148.25(d) and substance abuse treatment centers

licensed by the Department of Human Services-Division of Alcoholism and

Substance Abuse (DASA).

5)         "Interactive Telecommunication

System" means multimedia communications equipment that includes, at a

minimum, audio and video equipment permitting two-way, real-time interactive

communication between the patient and the distant site provider

48.25(d) and substance abuse treatment centers

licensed by the Department of Human Services-Division of Alcoholism and

Substance Abuse (DASA).

5)         "Interactive Telecommunication

System" means multimedia communications equipment that includes, at a

minimum, audio and video equipment permitting two-way, real-time interactive

communication between the patient and the distant site provider.  Telephones, facsimile

machines, and electronic mail systems do not meet the definition of an interactive

telecommunication system.

6)         "Originating Site" means the

location at which the participant receiving the service is located.

7)         "Telecommunication System" means

an asynchronous store and forward technology and/or an interactive telecommunication

system that is used to transmit data between the originating and distant sites.

8)         "Telehealth" means services

provided via a telecommunication system.

9)         "Telemedicine" means the use of a

telecommunication system to provide medical services for the purpose of

evaluation and treatment when the patient is at one medical provider location

and the rendering provider is at another location.

10)         "Telepsychiatry" means the use

of a telecommunication system to provide psychiatric services for the purpose

of evaluation and treatment when the patient is at one medical provider

location and the rendering provider is at another location.

b)         Requirements

for Telehealth Services

1)         Telemedicine

A)        A physician or other licensed health care

professional must be present at all times with the patient at the originating site.

B)        The distant site provider must be a

physician, physician assistant, podiatrist or advanced practice nurse who is

licensed by the State of Illinois or by the state where the patient is located.

C)        The originating and distant site provider

must not be terminated, suspended or barred from the Department's medical programs

sent at all times with the patient at the originating site.

B)        The distant site provider must be a

physician, physician assistant, podiatrist or advanced practice nurse who is

licensed by the State of Illinois or by the state where the patient is located.

C)        The originating and distant site provider

must not be terminated, suspended or barred from the Department's medical programs.

D)        Medical data may be exchanged through a telecommunication

system.

E)        The interactive telecommunication system

must, at a minimum, have the capability of allowing the consulting distant site

provider to examine the patient sufficiently to allow proper diagnosis of the

involved body system.  The system must also be capable of transmitting clearly

audible heart tones and lung sounds, as well as clear video images of the

patient and any diagnostic tools, such as radiographs.

2)         Telepsychiatry

A)        A physician, licensed health care

professional or other licensed clinician, mental health professional (MHP),

or qualified mental health professional (QMHP), as defined in 59 Ill. Adm. Code

132.25, must be present at all times with the patient at the originating site.

B)        The distant site provider must be a

physician licensed by the State of Illinois or by the state where the patient

is located and must have completed an accredited general psychiatry residency

program or an accredited child and adolescent psychiatry residency program.

C)        The originating and distant site provider

must not be terminated, suspended or barred from the Department's medical programs.

D)        The distant site provider must personally

render the telepsychiatry service.

E)        Telepsychiatry services must be rendered

using an interactive telecommunication system.

F)         Group psychotherapy is not a covered telepsychiatry

service

ram.

C)        The originating and distant site provider

must not be terminated, suspended or barred from the Department's medical programs.

D)        The distant site provider must personally

render the telepsychiatry service.

E)        Telepsychiatry services must be rendered

using an interactive telecommunication system.

F)         Group psychotherapy is not a covered telepsychiatry

service.

c)         Reimbursement

for Telehealth Services

1)         Originating Site Reimbursement

A)        A facility fee shall be paid to providers as

defined in subsection (a)(4) of this Section.

B)        Local education agencies may submit telehealth

services as a certified expenditure.

C)        Providers who receive reimbursement for a

patient's room and board are not eligible for reimbursement as an originating site.

D)        Clinics reimbursed under the prospective

payment system shall be eligible for a medical encounter as set forth in

subsection (c)(3) of this Section.

2)         Reimbursement for Rendering Provider at the

Distant Site

A)        Participating providers shall be reimbursed

for the appropriate AMA Current Procedural Terminology (CPT) code for the telehealth

service rendered.

B)        Nonparticipating providers may be reimbursed

by the originating site provider, but will not be eligible for reimbursement

from the Department.

3)         Clinic Reimbursement

A)        An encounter clinic serving as the originating

site shall be reimbursed for its medical encounter as defined in Section 140.462.

The clinic is responsible for reimbursement to the distant site provider.

B)        An encounter clinic serving as the distant site

shall be reimbursed as follows:

i)          If the originating site is another encounter

clinic, the distant site encounter clinic shall receive no reimbursement from

the Department

site shall be reimbursed for its medical encounter as defined in Section 140.462.

The clinic is responsible for reimbursement to the distant site provider.

B)        An encounter clinic serving as the distant site

shall be reimbursed as follows:

i)          If the originating site is another encounter

clinic, the distant site encounter clinic shall receive no reimbursement from

the Department.  The originating site encounter clinic is responsible for

reimbursement to the distant site encounter clinic; and

ii)         If the originating site is not an encounter

clinic, the distant site encounter clinic shall be reimbursed for its medical

encounter.  The originating site provider will receive a facility fee as

defined in subsection (a)(4) of this Section.

d)         Record

Requirements for Telehealth Services

1)         Medical records documenting the telehealth

services provided must be maintained by the originating and distant sites and

shall include, but not be limited to, the following:

A)        The records required in Section 140.28;

B)        The name and license number of the licensed

health care professional or other licensed clinician present with the patient

at the originating site;

C)        The name and license number of the provider

at the distant site and, if the service involves telepsychiatry, documentation

that the physician has completed an approved general psychiatry residency

program or an approved child and adolescent psychiatry residency program;

D)        The

locations of the originating and distant sites;

E)        The date and the beginning and ending times

of the telehealth service; and

F)         The medical necessity for the telehealth

service.

2)         When the originating site is an encounter clinic,

records from the distant site must also be maintained

program or an approved child and adolescent psychiatry residency program;

D)        The

locations of the originating and distant sites;

E)        The date and the beginning and ending times

of the telehealth service; and

F)         The medical necessity for the telehealth

service.

2)         When the originating site is an encounter clinic,

records from the distant site must also be maintained.

3)         Appropriate steps must be taken by the originating

and distant site staff to assure patient confidentiality, based on technical

advances in compliance with all federal and state privacy and confidentiality

laws.

4)         The type of interactive telecommunication system

utilized at the originating and distant sites shall be documented.

5)         The billing records related to the use of

the telecommunication system shall be maintained as provided in Section 140.28.

e)

Telehealth

Requirements During a Public Health Emergency. Notwithstanding any other

provision of this Part, and to protect the public health in connection with a

public health emergency, the Department will reimburse medically necessary and

clinically appropriate telehealth services that meet the requirements of this

subsection (e) for dates of service on or after March 9, 2020 until the Department

determines any or all of the services or flexibilities permitted under this

subsection (e) are no longer necessary.

This determination will be

based upon federal or State disaster declarations, Executive Orders of the

Governor, termination of disaster-related flexibilities granted by federal

agencies, or feedback from stakeholders.

1)

Telehealth services are medically necessary and clinically appropriate

services covered under the Medical Assistance Program (see Section 140.3), and

provided in accordance with federal law and regulations, that are delivered

through a communication or technology system (see subsection (e)(5)) to a

patient at an originating site by a provider located at a distant site

ack from stakeholders.

1)

Telehealth services are medically necessary and clinically appropriate

services covered under the Medical Assistance Program (see Section 140.3), and

provided in accordance with federal law and regulations, that are delivered

through a communication or technology system (see subsection (e)(5)) to a

patient at an originating site by a provider located at a distant site. The

Department will also reimburse for the following services that do not meet the

definition of "telehealth services" during this public health

emergency, including:

A)

Notwithstanding

the restriction on services provided via phone in Section 140.6(m) and this

Section, brief communication technology-based service, e.g. virtual check-in

that uses audio-only real-time telephone interactions or synchronous, two-way

audio interactions that are enhanced with video or other kinds of data

transmission. Virtual check-ins must be rendered by a physician, advanced

practice registered nurse, physician assistant, or other qualified health-care

professional who can report evaluation and management (E/M) services, provided

to an established patient, not originating from a related E/M service provided

within the previous 7 days nor leading to an E/M service or procedure within

the next 24 hours or soonest available appointment.

The

Department will reimburse for this service at the rate established on the

Department's fee schedule. Federally Qualified Health Centers, Rural Health

Clinics, and Encounter Rate Clinics may also receive reimbursement for this

service at the rate established on the Department's fee schedule.

B)        Notwithstanding the restriction

on services provided via phone in Section 140.6(m) and this Section, online

patient portal or "E-visit" services are non-face-to-face

patient-initiated communications using online patient portals. These services

can only be reported when the billing practice has an established relationship

with the patient

established on the Department's fee schedule.

B)        Notwithstanding the restriction

on services provided via phone in Section 140.6(m) and this Section, online

patient portal or "E-visit" services are non-face-to-face

patient-initiated communications using online patient portals. These services

can only be reported when the billing practice has an established relationship

with the patient. For these encounters, the patient must generate the initial

inquiry and communications can occur over a 7-day period. The patient must verbally

consent to receive virtual check-in services. The Department will reimburse for

HCPCS codes G2061, G2062 and G2063 and CPT codes 99421, 99422 and 99423 at the

rate established on the Department's fee schedule. Federally Qualified Health

Centers, Rural Health Clinics, and Encounter Rate Clinics may also receive

reimbursement for this service at the rate established on the Department's fee

schedule.

C)

Notwithstanding

the restriction on services provided via phone in Section 140.6(m) and this

Section, the Department will reimburse for all behavioral health services

(substance use disorder and mental health disorder) detailed in Section 140.453

(except for Mobile Crisis Response and Crisis Stabilization as defined in Section

140.453(d)(3)) and behavioral health services (substance use disorder and

mental health disorder) contained on an applicable Department fee schedule

provided using

audio-only real-time telephone

interactions, or video interaction in accordance with subsection (e)(5). The

Department will reimburse for these services at the same rate paid for services

provided on site.

2)         The distant site provider is

any enrolled provider, operating within its scope of practice, and with the

appropriate license or certification.

3)         Telehealth services are

delivered to a patient that is located at an originating site

tion in accordance with subsection (e)(5). The

Department will reimburse for these services at the same rate paid for services

provided on site.

2)         The distant site provider is

any enrolled provider, operating within its scope of practice, and with the

appropriate license or certification.

3)         Telehealth services are

delivered to a patient that is located at an originating site. Any site that

allows for the patient to use a communication or technology system as defined

in subsection (e)(5) may be an originating site, including a

patient's place of residence located within the State of

Illinois or other temporary location within or outside the State of Illinois.

4)

An

originating site will be eligible for a facility fee when it is a

certified eligible facility or provider organization

that

acts as the location of the patient at the time a telehealth service is

rendered, including but not limited to: substance use treatment programs

licensed by the Department of Human Services' Division Substance Use Prevention

and Recovery (SUPR),

Supportive Living

Program providers, Hospice providers, Community Integrated Living Arrangement

(CILA) providers, and

providers who receive

reimbursement for a patient's room and board.

5)         To be eligible for

reimbursement, the telehealth service must be delivered using:

A)        An "interactive

telecommunication system" or "telecommunication system" as

described in subsection (a); or

B)

A communication

system where information exchanged between the physician or other qualified

health care practitioner and the patient during the course of the synchronous

telehealth service is of an amount and nature that would be sufficient to meet

the key components and requirements of the same service when rendered via

face-to-face interaction.

6)

Reimbursement

for telehealth services will be made at the same rate paid for face-to-face

services

n the physician or other qualified

health care practitioner and the patient during the course of the synchronous

telehealth service is of an amount and nature that would be sufficient to meet

the key components and requirements of the same service when rendered via

face-to-face interaction.

6)

Reimbursement

for telehealth services will be made at the same rate paid for face-to-face

services

. Reimbursement for the services described in subsections (e)(1)(A)

and (B) will be at the rate established on the Department's fee schedule.

Reimbursement for the services described in subsection (e)(1)(C) will be made

at the same rate paid for services provided on site.

7)         The distant site provider and

originating site provider eligible for a facility fee must maintain adequate

documentation of the telehealth services provided in accordance with the record

requirements of subsection (d).

8)

A

physician or other licensed health care professional is not required to be present

at all times with the patient at the originating site.