Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois

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D E F G H I J K L M N Code is billable by encounter rate clinic only. Vaccine is supplied through the Vaccines For Children (VFC) program. The department reimburses for the administrative cost (practice expense) of the vaccine only, for ages 0-18 years, as shown in the Unit Price column. Vaccine is not available through the VFC. The department reimburses for the vaccine when it is medically necessary. Vaccine is supplied for children, but not adults, through the VFC. The department reimburses for the administrative cost (practice expense) of the vaccine only, for ages 0-18 years, as shown in the Unit Price column, and for the vaccine for adults, ages 19 years and older, as shown in the State Max column when medically necessary. CLIA “A” rate for the full test. CLIA “W” rate for the waived test. Covered only for blood lead draws as a Healthy Kids service for ages 0-20 years, and must be billed with the U1 modifier as documentation that the service meets this description. Prior approval required for surgeon and assistant surgeon. Anesthesia services for these codes must be billed using the anesthesia five-digit procedure code. Number of eyes tested should be billed using the days/units field; quantity is either 1 or 2. Age restricted to 9-26 years. Vaccine is supplied through the VFC Program for ages 9-18 years. The department reimburses VFC-enrolled providers for administrative cost (practice expense) as shown in the unit price column. The department reimburses for the vaccine for ages 19-26 years, and ages 9-26 years for non-VFC providers as shown in the State Max column. Additional information is provided at . Prior approval required for physician-purchased and administered drug. Prior approval guidelines are provided at . P Add-on applies only when the Primary Care Physician provides services. 2
Q State maximum amount now includes the Maternal Child Health Add-on amount for all providers. Prog Cov Eff Date HP APL NDC Ind Surg Ind Program Coverage Effective Date Hand Price Indicator Ambulatory Procedure Listing NDC indicator Surgery Indicator M1 (26) Modifier 1 (26) M2 (TC) Modifier 2 (TC) 02-Title XIX coverage only (limited Transitional Assistance coverage) 04-Medicaid covered services 09-Qualified Medicare Beneficiary (QMB) coverage only (See Chap 100 Section 120.12, posted on our website at . Effective date of codes added on or after 01/01/07 or date of change in payment policy. If “Y”, special pricing methodology is applied. Anesthesia: Claims may be submitted electronically or on paper following the billing guidelines posted on our website at . Medical/surgical procedure: Claims must be submitted on paper. The name of the procedure and total number of times performed must be submitted in the description field and the procedure note must be attached. To bill quantities: The number listed in the days/units field must be “1” and the actual quantity must be included in the description/note field. Drugs: May be submitted electronically or on paper. The claim must contain the name of the drug, strength of the drug, and the amount given in the description/note field and must be billed according to NDC billing guidelines available on our website at . To bill quantities: The number listed in the days/units field must be “1” and the actual quantity must be included in the description/note field. Column has been removed to allow addition of more pertinent information. APL information may be viewed on our website at . If “Y”, the 11-digit NDC must be billed according to NDC billing guidelines available on our website at . B = Obstetrical service N = Not considered surgical I = Incidental. Procedure may not pay separately when billed with other surgical codes. M = Major. Reimbursement for procedure includes 30- day postoperative care. Rate paid for the professional component of the procedure. Rate paid for the technical component of the procedure. 3
Page 1: Healthcare and Family Services Prac
Page 5 and 6: MODIFIERS RECOGNIZED IN PROCESSING
Page 7 and 8: HO Masters degree level; added 0601
Page 9 and 10: Health Care and Family Services Rev
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Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois

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