Ill. Admin. Code tit. 89, § 140.462 - Covered Services in Clinics
Payment shall be made to clinics for the following types of services when provided by, or under the direction of, a physician:
a) Hospital-Based Organized Clinics. Covered
services are those described in 89 Ill. Adm. Code 148.
b) Encounter Rate Clinics
1) With respect to those encounter rate
clinics that qualify as Maternal and Child Health providers, as described in
Section
140.924,
covered services are those described in Section
140.922.
2) With respect to all other encounter rate
clinics, covered services are medical services that provide for the continuous
health care needs of persons who elect to use this type of service, including
dental services that will be billed as separate encounters for dates of service
on or after January 1, 2011.
3)
Group psychotherapy services must meet the guidelines set forth in Section
140.413(a)(4)(C).
c) Rural Health Clinics
Those core services for which the clinic or center may bill an encounter as described in 42 CFR 440.90 (2000) are as follows:
1) Physician's Services, including covered
services of nurse practitioners, nurse midwives and physician-supervised
physician assistants. Group psychotherapy services must meet the guidelines set
forth in Section
140.413(a)(4)(C).
2) Group Psychotherapy Services - 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:
A) 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 9th Revision, Clinical
Modification (ICD-9-CM) or, upon implementation, International Classification
of Diseases, 10th 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;
B) beginning February 1, 2013, the entire
group of psychotherapy services must be directly performed by one of the
following practitioners:
i) 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;
ii) an Advanced Practice
Registered Nurse holding a current certification in Psychiatric and Mental
Health Nursing as set forth in 68 Ill. Adm. Code 1305.Appendix A;
iii) Psychologist;
iv) Licensed Clinical Social
Worker;
v) Licensed Clinical
Professional Counselor; or
vi)
Licensed Marriage and Family Therapist;
C) the group size does not exceed 12
patients, regardless of payment source;
D) the minimum duration of the group session
is 45 minutes;
E) the group session
is 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;
F) 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;
G) the group
session is provided in accordance with a clear written description of goals,
methods and referral criteria; and
H) 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 ].
3) Other
services for which a separate encounter may be billed include dentist and
behavioral health services as defined in Section
140.463(a).
4) Medically-necessary services and supplies
furnished by or under the direction of a physician or dentist within the scope
of licensed practice that have been included in the cost report but neither
fee-for-service nor encounter billings may be billed. Some examples of these
services include:
A) medical case
management;
B) laboratory
services;
C) occupational
therapy;
D) patient
transportation;
E) pharmacy
services;
F) physical
therapy;
G) podiatric
services;
H) speech and hearing
services;
I) x-ray
services;
J) health
education;
K) nutrition
services;
L) optometric
services.
5) A rural
health clinic (RHC) that adds behavioral health services or dental services on
or after October 1, 2001, must notify the Department in writing. These services
are to be billed as an encounter with a procedure code that appropriately
identifies the service provided.
6)
Any service that is no longer provided on or after October 1, 2001, or any new
service added on or after October 1, 2001, must be communicated to the
Department in writing prior to billing for the services.
7) Effective January 1, 2001, the Medicare,
Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) precludes
fee-for-service billings for any RHC services with the exception of services
identified in subsections (c)(8) and (c)(9).
8) Effective July 1, 2012 through June 30,
2013, a physician or APRN may submit fee-for-service billings for implantable
contraceptive devices administered in an RHC. Reimbursement for the implantable
contraceptive devices shall be made in accordance with the following:
A) To the extent that the implantable device
was purchased under the 340B Drug Pricing Program, the device must be billed at
the RHC's actual acquisition cost;
B) The RHC must be listed as the payee on the
claim;
C) Reimbursement shall be
made at the RHC 's actual acquisition cost or the rate on the Department's
practitioner fee schedule, whichever is applicable;
D) This reimbursement shall be separate from
any encounter payment the RHC may receive for implanting the device.
9) Effective July 1, 2013, an RHC
may submit fee-for-service billings for Long Acting Reversible Contraceptives
(LARCs). For dates of service October 1, 2014 and after, an RHC may submit
fee-for-service billing for non-surgical transcervical permanent contraceptive
devices. Reimbursement for the implantable contraceptive device shall be made
in accordance with the following:
A) To the
extent that the LARCs or transcervical permanent contraceptive devices were
purchased under the 340B Drug Pricing Program, the device must be billed at the
RHC's actual acquisition cost;
B)
Reimbursement shall be made at the RHC 's actual acquisition cost or the rate
on the Department's practitioner fee schedule, whichever is
applicable;
C) This reimbursement
shall be separate from any encounter payment the RHC may receive for implanting
the device.
10) Tobacco
cessation counseling services may be billed as an encounter if furnished by a
provider as defined in Section
140.413(a)(15)
within the designated coverage limitations.
d) Federally Qualified Health Centers
Those core services for which the clinic or center may bill an encounter as described in 42 CFR 440.90 (2000) are as follows:
1) Physician's services, including covered
services of nurse midwives, nurse practitioners and physician-supervised
physician assistants. Group psychotherapy services must meet the guidelines set
forth in Section
140.413(a)(4)(C).
2) Group Psychotherapy Services - 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:
A) 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 9th Revision, Clinical
Modification (ICD-9-CM) or, upon implementation, International Classification
of Diseases, 10th 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;
B) beginning February 1, 2013, the entire
group of psychotherapy services must be directly performed by one of the
following practitioners:
i) 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;
ii) 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;
iii) Psychologist;
iv) Licensed Clinical Social
Worker;
v) Licensed Clinical
Professional Counselor; or
vi)
Licensed Marriage and Family Therapist;
C) the group size does not exceed 12
patients, regardless of payment source;
D) the minimum duration of the group session
is 45 minutes;
E) the group session
is 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;
F) 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;
G) the group
session is provided in accordance with a clear written description of goals,
methods and referral criteria; and
H) 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 ].
3) Other
services for which separate encounters may be billed include:
A) dental services provided by a dentist or a
dental hygienist, as defined and in accordance with the Illinois Dental
Practice Act, working under the general supervision of a dentist and employed
by a federally qualified health center; and
B) behavioral health services as defined in
Section
140.463(a).
4) Medically-necessary services
and supplies furnished by or under the direction of a physician or dentist
within the scope of licensed practice have been included in the cost report but
neither fee-for-service nor encounter billings may be billed. Some examples of
these services include:
A) medical case
management;
B) laboratory
services;
C) occupational
therapy;
D) patient
transportation;
E) pharmacy
services;
F) physical
therapy;
G) podiatric
services;
H) optometric
services;
I) speech and hearing
services;
J) x-ray
services;
K) health
education;
L) nutrition
services.
5) A federally
qualified health center (FQHC) that adds behavioral health services or dental
services on or after October 1, 2001, must notify the Department in writing.
These services are to be billed as an encounter with a procedure code that
appropriately identifies the service.
6) Any service that is no longer provided on
or after October 1, 2001, or any new service added on or after October 1, 2001,
must be communicated to the Department in writing.
7) Effective January 1, 2001, the Medicare,
Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) precludes
fee-for-service billings for any FQHC services provided with the exception of
services identified in subsections (d)(8) and (d)(9).
8) Effective July 1, 2012 through June 30,
2013, a physician or APRN may submit fee-for-service billings for implantable
contraceptive devices administered in an FQHC. Reimbursement for the
implantable contraceptive devices shall be made in accordance with the
following:
A) To the extent that the
implantable device was purchased under the 340B Drug Pricing Program, the
device must be billed at the FQHC's actual acquisition cost;
B) The FQHC must be listed as the payee on
the claim;
C) Reimbursement shall
be made at the FQHC's actual acquisition cost or the rate on the Department's
practitioner fee schedule, whichever is applicable;
D) This reimbursement shall be separate from
any encounter payment the FQHC may receive for implanting the device.
9) Effective July 1, 2013, an FQHC
may submit fee-for-service billings for LARCs. For dates of service October 1,
2014 and after, an FQHC may submit fee-for-service billing for non-surgical
transcervical permanent contraceptive devices. Reimbursement for the
implantable contraceptive device shall be made in accordance with the
following:
A) To the extent that the LARCs or
transcervical permanent devices were purchased under the 340B Drug Pricing
Program, the device must be billed at the FQHC's actual acquisition
cost;
B) Reimbursement shall be
made at the FQHC's actual acquisition cost or the rate on the Department's
practitioner fee schedule, whichever is applicable;
C) This reimbursement shall be separate from
any encounter payment the FQHC may receive for implanting the device.
10) Tobacco cessation counseling
services may be billed as an encounter if furnished by a provider as defined in
Section
140.413(a)(15)
within the designated coverage limitations.
e) School Based/Linked Health Clinics
(Centers)
Covered services are the following services, when delivered in a school based/linked health center setting as described in Section 140.461(f):
1) Basic medical services: well child or
adolescent exams, consisting of a comprehensive health history, complete
physical assessment, screening procedures and age appropriate anticipatory
guidance; immunizations; EPSDT services; diagnosis and treatment of acute
illness and injury; basic laboratory tests; prescriptions and dispensing of
commonly used medications for identified health conditions, in accordance with
Medical Practice and Pharmacy Practice Acts; and acute management and on-going
monitoring of chronic conditions, such as asthma, diabetes and seizure
disorders.
2) Reproductive health
services: gynecological exams; diagnosis and treatment of sexually transmitted
diseases; family planning; prescribing and dispensing of birth control or
referral for birth control services; pregnancy testing; treatment or referral
for prenatal and postpartum care; and cancer screening.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.