Provider Notice issued 06/26/14

Change in Coverage of Group Psychotherapy

The purpose of this notice is to advise providers of the requirements that must be met for group psychotherapy services rendered in a Federally Qualified Health Center (FQHC), or a Rural Health Clinic (RHC) setting. This notice supersedes the informational notice issued on January 30, 2013.

Effective with dates of service February 1, 2013, and after, the department will pay for up to two group psychotherapy sessions for a participant in a rolling 7-day period, with a maximum of one session per day. Documentation shall be maintained in the patient's medical record and must indicate the person participating in the group session has been diagnosed with a mental illness as defined in the International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM) or, upon implementation, International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), or the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). 

Beginning February 1, 2013, the entire group of psychotherapy services must be directly performed by one of the following practitioners:

• 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;

• an Advanced Practice Nurse holding a current certification in Psychiatric and Mental Health Nursing as set forth in 68 Ill. Adm. Code 1305.Appendix A;

• one of the following providers in an FQHC or RHC:

• Psychologist;

• Licensed Clinical Social Worker;

• Licensed Clinical Professional Counselor; or

• Licensed Marriage and Family Therapist.

Group Session Requirements

The group must not exceed 12 patients, regardless of payment source and the minimum duration of the group session is 45 minutes.  Also, the group session must be documented in the patient's medical record by the rendering practitioner, including the session's primary focus, level of patient participation, and begin and end times of each session.

The group treatment model, methods and subject content must have been selected on evidence-based criteria for the target population of the group and shall follow recognized practice guidelines for psychiatric services.  In addition, the group session must be provided in accordance with a clear written description of goals, methods and referral criteria.

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 [210 ILCS 48].

Enrollment

Physicians and Advanced Practice Nurses (APN) rendering group psychotherapy services at an FQHC or at an RHC must be enrolled as a provider in the Illinois Medicaid Program.  Physicians must complete a Form HFS 3882 (pdf) and APNs must complete a form HFS 3411C (pdf) to be eligible to render these services. Forms for enrollment may be accessed at the HFS Provider Enrollment website.

An FQHC or a RHC that will be providing group psychotherapy services rendered by Licensed Clinical Professional Counselors (LCPC) or rendered by LMFT or rendered by both will be assigned Category of Service (COS) 088 on the Centers/Clinics provider file.  In order to receive COS 088, the FQHC and the RHC must submit the professional license of the LCPC and/or the LMFT to the Provider Participation Unit along with a letter stating that group psychotherapy services will be provided with the date of the initiation of these services.  This letter must be dated and signed by the authorized representative of the FQHC or the RHC.

If the FQHC or the RHC has an LCPC on staff and previously has submitted to the Provider Participation Unit the professional license of the LCPC, then COS 088 has already been assigned to the Centers/Clinics provider file.  If this same FQHC or RHC will now be employing an LMFT to render group psychotherapy services as well, then the Center/Clinic must comply with letter and professional license submission as outlined above with the letter being dated and signed by the authorized representative of the FQHC or the RHC.

It is the responsibility of the FQHC and the RHC to submit to the Provider Participation Unit copies of all renewed professional licenses.  It is also the responsibility of the FQHC and the RHC to advise the Provider Participation Unit in writing if group psychotherapy services will be terminated with the effective date of such termination being indicated in the letter.  This letter must be dated and signed by the authorized representative of the FQHC or the RHC.

Questions regarding the completion of enrollment forms or letters should be directed to the Provider Participation Unit at (217) 782-0538.  Mail applications or letters/licenses to:

Illinois Department of Healthcare and Family Services

Provider Participation Unit

P. O. Box 19114

Springfield, Illinois 62794-9114

Billing Information

To receive reimbursement for services rendered by a physician or APN, providers must bill procedure code T1015. To receive reimbursement for services rendered by a psychologist, LCSW, LCPC or LMFT, providers must bill procedure code T1015 and the appropriate modifier listed below: 

• Licensed Clinical Social Worker - T1015 with AJ modifier

• Licensed Clinical Psychologist - T1015 with AH modifier

• Licensed Clinical Professional Counselor - T1015 with HO modifier

• Licensed Marriage and Family Therapists – T1015 with HO modifier

Timely Filing Override Information

Claims for any dates of service past the 180 day timely filing must be submitted to HFS on a paper claim form (HFS 2360) and provide a cover letter stating the reason they are requesting a time override to the following address. The instructions for preparation of the HFS 2360 can be found in the Handbook for Providers of Encounter Clinic Services, Chapter D-200, Appendix 1. Please note that the information on the instructions for HFS 2360, Box 30 is incorrect. Box 30 must contain the 10-digit Provider’s NPI not the 12-digit Provider Identification Number.

Healthcare and Family Services

Bureau of Professional and Ancillary Services

Attn: Practitioner Billing Consultant

P.O. Box 19115

Springfield, Illinois 62794-9115

Any questions regarding this notice may be directed to a medical assistance consultant in the Bureau of Professional and Ancillary Services at 1-877-782-5565, option 3, option 1.

Theresa A. Eagleson, Administrator

Division of Medical Programs