Provider Notice issued 01/12/10

Expansion of Telehealth Services

Rulemaking regarding the department’s policies for telehealth services have been adopted and become effective January 29, 2010. Effective with dates of service January 29, 2010, and after, the department will be expanding the covered services and locations for telehealth. The expanded services will include telemedicine as well as telepsychiatry. This expansion is designed to improve participant access to specialists, while supporting the quality of care they receive.

Previously, telehealth services were limited to medical evaluations between hospitals only.  Under the telehealth expansion, physicians, advanced practice nurses, podiatrists, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Encounter Rate Clinics (ERCs) will be allowed to render telemedicine services. In addition, telepsychiatry will be covered, when the physician rendering the service has completed either a general psychiatric residency program or a child/adolescent psychiatric residency program. Physicians that would like to provide telepsychiatry services as a Distant Site provider must complete and return the HFS 3882, Psychiatric Residency Certification referenced in the April 28, 2009, Informational Notice posted on the department’s Web site. at:

Attached to this notice are documents explaining the new telehealth policy. One document is specific to individual practitioners/other providers, one is specific to encounter clinics and the others provide billing examples. Under the expansion, the site where the patient is located will be designated as the Originating Site and the site where the provider rendering the telehealth service is located will be designated as the Distant Site. The department will reimburse one provider as the Originating Site and one or more providers at the Distant Site depending on the patient’s medical needs.

Your participation in our programs is greatly appreciated. Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs

Illinois Department of Healthcare and Family ServicesTelehealth Services Policy for Individual Practitioners/Providers

Telehealth is defined as the use of a telecommunication system to provide medical services between places of lesser and greater medical capability and/or expertise, for the purpose of evaluation and treatment. Medical data exchanged can take the form of multiple formats: text, graphics, still images, audio and video. The information or data exchanged can occur in real time (synchronous) through interactive video or multimedia collaborative environments or in near real time (asynchronous) through “store and forward” applications.

Under the department’s telehealth policy, providers will be paid as either an Originating Site or Distant Site. The following is an overview of the department’s telehealth policies for individual practitioners/other providers.

Originating Site

The Originating Site is the site where the patient is located. The Originating Site shall be reimbursed a facility fee of $25.00 per telehealth service. Originating Site providers shall bill HCPCS Procedure Code Q3014 (Telehealth originating site facility fee) in order to receive reimbursement for the Facility Fee.

For telemedicine services, a physician or other licensed healthcare professional must be present at all times with the patient at the Originating Site.

For telepsychiatry services, a physician, licensed healthcare professional or other licensed clinician, mental health professional (MHP), or qualified mental health professional (QMHP), as defined in 59 IL Admin Code 132.25, must be present at all times with the patient at the Originating Site.

The following provider locations are eligible to receive reimbursement as an Originating Site: physician’s office, podiatrist’s office, local health departments, community mental health centers and outpatient hospitals.

Distant Site

The Distant Site is the site where the provider rendering the telehealth service is located. Providers rendering telemedicine and telepsychiatry services at the Distant Site shall be reimbursed the department’s rate for the Current Procedural Terminology (CPT) code for the service rendered. The appropriate CPT code must be billed with modifier GT (via interactive audio/video telecommunication systems).

Enrolled Distant Site providers may not seek reimbursement from the department for their services when the Originating Site is an encounter clinic. The Originating Site encounter clinic is responsible for reimbursement to the Distant Site provider.

Nonenrolled providers rendering services as a Distant Site provider shall not be eligible for reimbursement from the department, but may be reimbursed by the Originating Site provider.

For telemedicine services, the provider rendering the service at the Distant Site can be a physician, podiatrist or advanced practice nurse (APN) who is licensed by the State of Illinois or by the state where the participant is located. Services rendered by an APN can be billed under the collaborating physician’s NPI, or if the APN is enrolled, under the APN’s NPI. When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

For telepsychiatry services, the provider rendering the service at the Distant Site must be a physician licensed by the State of Illinois, or by the state where the patient is located, who has completed an approved general psychiatry residency program or a child and adolescent psychiatry residency program.

To be eligible for reimbursement for telepsychiatry services, physicians must have an HFS 3882, Psychiatric Residency Certification form, on file with the department. Claims received from Distant Site providers who do not have an HFS 3882 on file with the department will be rejected. The rejection error message will be T98 – Telepsychiatry Provider Invalid. Group psychotherapy is not a covered telepsychiatry service.

Illinois Department of Healthcare and Family Services Telehealth Services Policy for Encounter Clinics

Telehealth is defined as the use of a telecommunication system to provide medical services between places of lesser and greater medical capability and/or expertise, for the purpose of evaluation and treatment. Medical data exchanged can take the form of multiple formats: text, graphics, still images, audio and video. The information or data exchanged can occur in real time (synchronous) through interactive video or multimedia collaborative environments or in near real time (asynchronous) through “store and forward” applications.

Under the department’s telehealth policy, providers will be paid as either an Originating Site or Distant Site. The following is an overview of the department’s telehealth policies for encounter clinics.

Originating Site

The Originating Site is the site where the patient is located. An encounter clinic serving as the Originating Site shall be reimbursed their medical encounter. The encounter clinic must bill procedure code T1015 with the appropriate Current Procedural Terminology (CPT) code and modifier GT (via interactive audio/video telecommunication systems) for the service rendered by the Distant Site in the detail lines on the claim. In addition, the Distant Site rendering provider’s name and NPI must also be reported on the claim. The Originating Site encounter clinic must ensure and document that the Distant Site provider meets the department’s requirements for telehealth and telepsychiatry services, since the clinic is responsible for reimbursement to the Distant Site provider.

For telemedicine services, a physician or other licensed healthcare professional must be present at all times with the patient at the Originating Site.

For telepsychiatry services, a physician, licensed healthcare professional or other licensed clinician, mental health professional (MHP), or qualified mental health professional (QMHP), as defined in 59 IL Admin Code 132.25, must be present at all times with the patient at the Originating Site.

Distant Site

The Distant Site is the site where the provider rendering the telehealth service is located. The Distant Site shall be reimbursed as follows:

• If the Originating Site is an encounter clinic, the Distant Site provider or encounter clinic may not seek reimbursement from the department for their services. The Originating Site encounter clinic is responsible for reimbursing the Distant Site encounter clinic; or

• If the Originating Site is not an encounter clinic, the Distant Site encounter clinic shall be reimbursed their medical encounter. The Distant Site encounter clinic must bill T1015 and the appropriate Current Procedural Terminology (CPT) code and modifier GT (via interactive audio/video telecommunication systems) for the service rendered in the detail lines on the claim. In addition, the rendering provider’s name and NPI must also be reported on the claim.

For telemedicine services, the provider rendering the service at the Distant Site can be a physician, podiatrist or advanced practice nurse (APN) who is licensed by the State of Illinois or by the state where the participant is located.

For telepsychiatry services, the provider rendering the service at the Distant Site must be a physician licensed by the State of Illinois, or by the state where the patient is located, who has completed an approved general psychiatry residency program or a child and adolescent psychiatry residency program. Group psychotherapy is not a covered telepsychiatry service.

Billing Examples for Telemedicine Services

Example 1:

Originating Site – Physician’s office
Bill HCPCS Code Q3014
Reimbursement is $25.00

 

Distant Site – Podiatrist’s office
Bill the appropriate CPT code with modifier GT
Reimbursement will be the fee schedule rate for the CPT code billed.

Example 2:  

Originating Site – Local Health Department
Bill HCPCS Code Q3014
Reimbursement is $25.00

 

Distant Site – APN’s office
Bill the appropriate CPT code with modifier GT
Reimbursement will be the fee schedule rate for the CPT code billed.

Example 3:      

Originating Site – Physician’s office
Bill HCPCS Code Q3014
Reimbursement is $25.00

 

Distant Site – Local Health Department
Not a valid provider – there is no billable service

Example 4:      

Originating Site – Encounter clinic
Bill the encounter HCPCS Code T1015 and any appropriate detail code(s) with modifier GT
Reimbursement will be the facility’s medical encounter rate

 

Distant Site – Encounter clinic
There is no billable service; the Originating Encounter clinic is responsible for payment to the Distant Encounter clinic provider

Example 5:      

Originating Site – Encounter clinic
Bill the encounter HCPCS Code T1015 and any appropriate detail code(s) with modifier GT
Reimbursement will be the facility’s medical encounter rate

 

Distant Site – Physician’s office
There is no billable service; the Originating Encounter clinic is responsible for payment to the Distant Encounter clinic provider

Example 6: 

Originating Site – Physician’s office
Bill HCPCS Code Q3014
Reimbursement is $25.00

 

Distant Site – Encounter clinic
Bill the encounter HCPCS Code T1015 and any appropriate detail code(s) with modifier GT
Reimbursement will be the facility’s medical encounter rate. The rendering provider’s name and NPI must also be reported on the claim

Billing Examples for Telepsychiatry Services

Example 1:      

Originating Site – Physician’s office
Bill HCPCS Code Q3014
Reimbursement is $25.00

 

Distant Site – Physician who has completed an approved general or child/adolescent psychiatry residency program
Bill the appropriate CPT code for services provided
Reimbursement will be the fee schedule rate for the CPT code billed

Example 2:      

Originating Site – Encounter clinic
Bill the encounter HCPCS Code T1015 and any appropriate detail code(s) with modifier GT
Reimbursement will be the facility’s medical encounter rate

 

Distant Site – Encounter clinic
There is no billable service; the Originating Encounter clinic is responsible for payment to the Distant Encounter clinic provider
Provider rendering the service must be a physician who has completed an approved general or child/adolescent psychiatry residency program

Example 3:      

Originating Site – Physician’s office
Bill HCPCS Code Q3014
Reimbursement will be $25.00

 

Distant Site – Encounter clinic
Bill the encounter HCPCS Code T1015 and any appropriate detail code(s) with modifier GT
Provider rendering the service must be a physician who has completed an approved general or child/adolescent psychiatry residency program  
Reimbursement will be the facility’s medical encounter rate

Example 4:      

Originating Site – Encounter clinic
Bill the encounter HCPCS Code T1015 and any appropriate detail code(s) with modifier GT
Reimbursement will be the facility’s medical encounter rate

 

Distant Site – Physician’s office
There is no billable service; the Originating Encounter clinic is responsible for payment to the Distant Encounter clinic provider.
Provider rendering the service must be a physician who has completed an approved general or child/adolescent psychiatry residency program