Section 140.413 Limitation on Physician Services

Section 140

TITLE 89: SOCIAL SERVICES

CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

SUBCHAPTER d: MEDICAL PROGRAMS

PART 140 MEDICAL PAYMENT

SECTION 140.413 LIMITATION ON PHYSICIAN SERVICES

Section 140.413  Limitation

on Physician Services

a)         When provided in accordance with the specified limitations and

requirements, the Department shall pay for the following services:

1)         Termination of Pregnancy.  All abortion service claims must be

accompanied by an HFS 2390 Abortion Payment Application.  The Department will

pay for abortion services when:

A)        The

pregnancy results from rape or incest;

B)        In the physician's professional judgment, the pregnancy

threatens the life of the mother; or

C)        The service is performed for any other reason.

2)         Sterilization

A)        Therapeutic sterilization – only when the procedure is either a

necessary part of the treatment of an existing illness, or is medically

indicated as an accompaniment of an operation on the female genitourinary

tract.  Mental incapacity does not constitute an illness or injury that would

authorize this procedure.

B)        Nontherapeutic sterilization – only for recipients age 21 or

older and mentally competent. The physician must obtain the recipient's

informed written consent in a language understandable to the recipient before

performing the sterilization and must advise the recipient of the right to

withdraw consent at any time prior to the operation.  The operation shall be

performed no sooner than 30 days and no later than 180 days following the date

of the recipient's written informed consent, except in cases of premature

delivery or emergency abdominal surgery.  An individual may consent to be

sterilized at the time of premature delivery or emergency abdominal surgery if

at least 72 hours have passed since informed consent was given.

3)         Morbid Obesity.  Effective October 1, 2012, surgery for morbid

obesity is covered only with prior approval by the Department

ormed consent, except in cases of premature

delivery or emergency abdominal surgery.  An individual may consent to be

sterilized at the time of premature delivery or emergency abdominal surgery if

at least 72 hours have passed since informed consent was given.

3)         Morbid Obesity.  Effective October 1, 2012, surgery for morbid

obesity is covered only with prior approval by the Department.  The Department

shall approve payment for this service only in those cases in which the

physician determines that obesity is exogenous in nature, the recipient has had

the benefit of other therapy with no success, endocrine disorders have been

ruled out, and the body mass index (BMI) is 40 or higher, or 35 to 39.9 with

serious medical complications.  The medical record must contain the following

documentation of medical necessity:

A)        Documentation

of review of systems (history and physical);

B)        Client

height, weight and BMI;

C)        Listing

of co-morbidities;

D)        Patient

participation in a six month consecutive medically supervised weight loss

program working in conjunction with a registered dietician and or physician

within two years prior to the surgery, with at least four documented visits

within the consecutive six months;

E)        Current

and complete psychiatric evaluation indicating the patient is an appropriate

candidate for weight loss surgery; and

F)         Documentation

of nutritional counseling.

4)         Psychiatric Services

A)        Treatment – when the services are provided by a physician who

has been enrolled as an approved provider with the Department.

B)        Consultation – only when necessary to determine the need for

psychiatric care.  Services provided subsequent to the initial consultation

must comply with the requirements for treatment.

C)        Group

Psychotherapy – payment may be made for up to two group sessions per week, with

a maximum of one session per day

ian who

has been enrolled as an approved provider with the Department.

B)        Consultation – only when necessary to determine the need for

psychiatric care.  Services provided subsequent to the initial consultation

must comply with the requirements for treatment.

C)        Group

Psychotherapy – payment may be made for up to two group sessions per week, with

a maximum of one session per day.  The following conditions must be met for

group psychotherapy:

i)          documentation

maintained in the patient's medical record must indicate the person

participating in the group session has been diagnosed with a mental illness as

defined in the International Classification of Diseases (ICD-9-CM) or, upon

implementation, International Classification of Diseases, 10

th

Revision, Clinical Modification (ICD‑10‑CM), or the Diagnostic and

Statistical Manual of Mental Disorders (DSM IV).  The allowable diagnosis code

ranges will be specified in the Handbook for Practitioners Rendering Medical

Services;

ii)         beginning

1/1/10, the entire group psychotherapy service is directly performed by a

physician licensed to practice medicine in all its branches who has completed

an approved general psychiatry residency program or is providing the service as

a resident or attending physician at an approved or accredited residency

program;

iii)        the

group size does not exceed 12 patients, regardless of payment source;

iv)        the

minimum duration of a group session is 45 minutes;

v)         the

group session is documented in the patient's medical record by the rendering

physician, including the session's primary focus, level of patient

participation, and begin and end times of each session;

vi)        the

group treatment model, methods, and subject content have been selected on

evidence-based criteria for the target population of the group and follows

recognized practice guidelines for psychiatric services;

vii)       the

group session is provided in accordance with a clear written description of

ry focus, level of patient

participation, and begin and end times of each session;

vi)        the

group treatment model, methods, and subject content have been selected on

evidence-based criteria for the target population of the group and follows

recognized practice guidelines for psychiatric services;

vii)       the

group session is provided in accordance with a clear written description of

goals, methods and referral criteria; and

viii)      Effective July 1, 2012, group psychotherapy is not covered for

recipients who are residents in a facility licensed under the Nursing Home Care

Act [210 ILCS 45] or the Specialized Mental Health Rehabilitation Act of 2013 [210

ILCS 49].

5)         Home Services.  Services provided to a recipient in his or her

home – only when the recipient is physically unable to go to the physician's

office.

6)         Services provided to recipients in group care facilities by a

physician other than the attending physician – only for emergency services

provided when the attending physician of record is not available or when the

attending physician has made referral with the recipient's knowledge and

permission.

7)         Services provided to recipients in a group care facility by a

physician who derives a direct or indirect profit from total or partial

ownership (or from other types of financial investment for profit in the

facility) – only when occasioned by an emergency due to acute illness or

unavailability of essential treatment facilities in the vicinity for short-term

care pending transfer, or when there is no comparable facility in the area.

8)         Maternity Care

sician who derives a direct or indirect profit from total or partial

ownership (or from other types of financial investment for profit in the

facility) – only when occasioned by an emergency due to acute illness or

unavailability of essential treatment facilities in the vicinity for short-term

care pending transfer, or when there is no comparable facility in the area.

8)         Maternity Care.  Payment shall be made for pre-natal and

post-natal care only when the following conditions are met:

A)        the physician, whether based in a hospital, clinic or

individual practice, retains hospital delivery privileges, maintains a written

referral arrangement with another physician who retains such privileges, or has

been included in the Maternal and Child Health Program as a result of having entered

into an appropriate Healthy Moms/Healthy Kids Program provider agreement;

B)        the written referral agreement is kept on file and is available

for inspection at the physician's place of business, and details procedures for

timely transfer of medical records; and

C)        maternal services are delivered in a manner consistent with the

quality of care guidelines published by the American College of Obstetricians

and Gynecologists in its Guidelines for Women's Health Care (2014) and

Guidelines for Perinatal Care (2017), available at 409 12

th

Street,

S.W., Washington D.C. 20024-2188, or at https://www.acog.org.

9)         Physician Services to Children under Age 21

A)        Payment shall be made only when the physician meets one or more

of the following conditions

the American College of Obstetricians

and Gynecologists in its Guidelines for Women's Health Care (2014) and

Guidelines for Perinatal Care (2017), available at 409 12

th

Street,

S.W., Washington D.C. 20024-2188, or at https://www.acog.org.

9)         Physician Services to Children under Age 21

A)        Payment shall be made only when the physician meets one or more

of the following conditions.  The physician:

i)          has admitting privileges at a hospital;

ii)         is certified or is eligible for certification in pediatrics

or family practice by the medical specialty board recognized by the American

Board of Medical Specialties;

iii)        is employed by or affiliated with a Federally Qualified

Health Center;

iv)        is a member of the National Health Service Corps;

v)         has been certified by the Secretary of the Department of

Health and Human Services as qualified to provide physician services to a child

under 21 years of age;

vi)        has current, formal consultation and referral arrangements

with a pediatrician or family practitioner for the purposes of specialized

treatment and admission to a hospital.  The written referral agreement is kept

on file and is available for inspection at the physician's place of business,

and details procedures for timely transfer of medical records; or

vii)       has entered into a Maternal and Child Health provider

agreement or has otherwise been transferred in from the Healthy Moms/Healthy

Kids Program;

B)        The physician shall certify to the Department the way in which

he or she meets the criteria of subsection (a)(9)(A); and

C)        Services to children shall be delivered in a manner consistent

with the standards of the American Academy of Pediatrics and rules published by

the Illinois Department of Public Health (77 Ill. Adm. Code 630, Maternal and

Child Health Services; 77 Ill. Adm. Code 665, Child Health Examination Code; 77

Ill. Adm. Code 675, Hearing Screening; 77 Ill. Adm. Code 685, Vision

Screening)

and

C)        Services to children shall be delivered in a manner consistent

with the standards of the American Academy of Pediatrics and rules published by

the Illinois Department of Public Health (77 Ill. Adm. Code 630, Maternal and

Child Health Services; 77 Ill. Adm. Code 665, Child Health Examination Code; 77

Ill. Adm. Code 675, Hearing Screening; 77 Ill. Adm. Code 685, Vision

Screening).

10)        Hysterectomy.  Only if the individual has been informed,

orally and in writing, that the hysterectomy will render her permanently

incapable of reproducing and the individual has signed a written acknowledgment

of receipt of the information.  The Department will not pay for a hysterectomy that

would not have been performed except for the purpose of rendering an individual

permanently incapable of reproducing.

11)        Selected Surgical Procedures.  Includes:

A)        tonsillectomies or adenoidectomies;

B)        hemorrhoidectomies;

C)        cholecystectomies;

D)        disc surgery/spinal fusion;

E)        joint cartilage surgery/meniscectomies;

F)         excision of varicose veins;

G)        submucous resection/rhinoplasty/repair of nasal system;

H)        mastectomies for non-malignancies; and

I)         surgical procedures that generally may be performed in an

outpatient setting (see Section 140.117), but only if the Department authorizes

payment. The Department will in some instances require that a second physician

agree that the surgical procedure is medically necessary prior to approving

payment for one of these procedures.  The Department will require a second

opinion when the attending physician has been notified by the Department that

he or she will be required to obtain prior approval for payment for the

surgeries listed.  (See Sections 140.40 through 140.42 for prior approval

requirements.)  The Department will select physicians for this requirement

based on the recommendation of a peer review committee that has reviewed the

utilization pattern of the physician

attending physician has been notified by the Department that

he or she will be required to obtain prior approval for payment for the

surgeries listed.  (See Sections 140.40 through 140.42 for prior approval

requirements.)  The Department will select physicians for this requirement

based on the recommendation of a peer review committee that has reviewed the

utilization pattern of the physician.

12)        Mammography Screening and Related Services.  Described in 305

ILCS 5/5-5.

13)        Pap Tests and Prostate-Specific Antigen Tests.  Coverage is

provided for the following:

A)        An annual cervical smear or Pap smear test for women.

B)        An annual digital rectal examination and a prostate-specific

antigen test, upon the recommendation of a physician licensed to practice

medicine in all its branches, for:

i)          asymptomatic men age 50 and over;

ii)         African-American men age 40 and over; and

iii)        men age 40 and over with a family history of prostate cancer.

14)        Coronary Artery By-Pass Grafts.  Effective July 1, 2012, coronary

artery by-pass grafts are covered only with prior approval by the Department.

15)        Tobacco

Cessation Counseling. Face-to-face tobacco cessation counseling only for

pregnant and up to 60‑day postpartum women age 21 and over. The tobacco

cessation counseling services:

A)        Must

be provided by or under supervision of a physician, or by any other health care

professional who is legally authorized to furnish those services under State

law, and who is authorized to provide Medicaid covered services other than

tobacco cessation services.

B)        Are

limited to a maximum of three quit attempts, with four individual face-to-face

counseling sessions per quit attempt, per calendar year.

C)        Must

be properly documented in the patient's medical record and include the total

time spent and what was discussed during the counseling session, including

cessation techniques, resources available and follow-up

co cessation services.

B)        Are

limited to a maximum of three quit attempts, with four individual face-to-face

counseling sessions per quit attempt, per calendar year.

C)        Must

be properly documented in the patient's medical record and include the total

time spent and what was discussed during the counseling session, including

cessation techniques, resources available and follow-up.  Distinct

documentation to support this service is required if reported in conjunction

with another evaluation and management service.

D)        Rendered

to participants under age 21 are not subject to the limitations in this

subsection (a)(15).

16)

Gender-affirming Surgeries, Services and Procedures

A)        Gender-affirming

surgeries, services and procedures are covered only with prior approval by the

Department for individuals who are 21 years of age or older. In order for prior

approval to be granted for genital surgeries, letters from two qualified medical

providers must be submitted, including one from a Licensed Practitioner of the

Healing Arts (LPHA), as defined in Section 140.453(b)(3)(A) through (D) and (F),

and one from either the individual's primary care physician or the physician

managing the individual's gender-related healthcare. In order for prior approval

to be granted for non-genital surgeries, one letter from either the

individual's primary care physician or the physician managing the individual's

gender-related healthcare must be submitted.  The qualified medical provider or

providers must have independently assessed the individual and must be referring

the individual for the surgery

's gender-related healthcare. In order for prior approval

to be granted for non-genital surgeries, one letter from either the

individual's primary care physician or the physician managing the individual's

gender-related healthcare must be submitted.  The qualified medical provider or

providers must have independently assessed the individual and must be referring

the individual for the surgery. Together, the letter or letters must establish:

i)          That

the individual:

●

has a diagnosis of gender dysphoria;

●

has received hormone therapy

appropriate to the individual's gender goals, which shall be for a minimum of

12 months in the case of an individual seeking genital surgery, unless that

therapy is medically contraindicated or the individual is otherwise unable to

take hormones;

●

has lived continuously for at

least 12 months in the gender role that is congruent with their gender

identity, in the case of an individual seeking genital surgery;

●

has completed an assessment by

an LPHA, as defined in Section 140.453(b)(3)(A) through (D) and (F), which must

include education and counseling of treatment options and implications; and

psychotherapy, if indicated;

●

if a significant medical or

mental health condition is present that would be a contraindication to the

gender-affirming surgery, service or procedure, it must be reasonably

well-controlled; and

●

has the capacity to make a

fully informed decision and to consent to the treatment;

ii)         That

the medical provider has communicated with the individual's other medical

providers regarding the proposed surgery, service or procedure;

iii)        The

medical necessity of the surgery, service or procedure; and

iv)        Recommendations

for post-operative care.

B)        The

Department will cover all gender-affirming surgeries, services and procedures

that are medically necessary to treat a particular individual's gender

dysphoria and are listed on the Department's fee schedule and in the

Practitioner Handbook

r procedure;

iii)        The

medical necessity of the surgery, service or procedure; and

iv)        Recommendations

for post-operative care.

B)        The

Department will cover all gender-affirming surgeries, services and procedures

that are medically necessary to treat a particular individual's gender

dysphoria and are listed on the Department's fee schedule and in the

Practitioner Handbook. Gender-affirming surgeries, services and procedures

shall include, but are not limited to, breast/chest surgeries, genital

surgeries, and related therapies.

C)

If prior approval is for genital surgery, the

surgery must be performed by a urologist, gynecologist, or plastic or general

surgeon who is board-certified in the practitioner's area of expertise and has

demonstrated specialized competence in gender-based genital reconstruction as

indicated by documented supervised training or post-graduate training in the

field of gender-based genital reconstruction.

D)        Surgeries

resulting in sterilization must meet all requirements of subsection (a)(2);

surgeries performed for the purpose of treating gender dysphoria are considered

therapeutic sterilizations for purposes of this Section.

E)        Notwithstanding

the age limitation in subsection (a)(16)(A), payment for gender-affirming

surgeries, services and procedures for patients under 21 years of age will be

made in specific cases if medical necessity is demonstrated and prior approval

is received.

b)         In cases in which a physical examination by a second physician

is needed, the Department will notify the recipient and designate a physician

to perform the examination.  Physicians will be subject to this requirement for

six months, after which a request can be submitted to the peer review committee

to consider removal of the prior approval requirement.