Ill. Admin. Code tit. 89 § 140.403

Current through Register Vol. 48, No. 49, December 6, 2024

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. 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.

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.

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. 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.

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. 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. 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. 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. 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.

Ill. Admin. Code tit. 89, § 140.403

Added at 34 Ill. Reg. 903, effective January 29, 2010

Amended at 44 Ill. Reg. 13678, effective 8/7/2020

Amended at 45 Ill. Reg. 10996, effective 8/27/2021