Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois
Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois
Assist Surg Assistant Surgeon “Y” indicates services of an assistant at surgery may be paid. CoSurg Co-Surgeon “Y” indicates services of a co-surgeon may be paid. Unit Price Price for each unit when multiple quantities are billable or base amount payable for ages 0-20 years when followed by “©”. Max Qty Maximum Quantity The maximum quantity payable for the code. To bill quantities when the maximum quantity is greater than 1: Submit number of units performed or dispensed on a single date of service in the days/units field To bill quantities when the maximum quantity is 1, note field is blank, and HP is “N”: For bilateral procedures, submit the procedure code, use modifier “RT” and show quantity “1” in days/units field and in the subsequent service section submit the procedure code, use modifier “LT”, and show quantity “1” in days/units field. For multiples that are not bilateral, claims must be submitted on paper. Submit the procedure code on one service section, and in the next service section submit the unlisted procedure code for any quantity beyond the first, listing total # and name of additional procedures in the description field, and attach documentation of all State Max Add-ons State Maximum Surgical addon Child add-on Adult add-on procedures performed. The maximum allowable reimbursement (reflects combined professional and technical components where applicable). or base amount payable for ages 21 years and older when followed by “(A)”. Surg: The amount added to the state maximum when the procedure is performed in the practitioner’s office. This amount covers such items as casting and surgical supplies. Child: The amount added to the state maximum for services rendered to ages 0-20 years. Preventive medicine and Evaluation and Management code add-ons are payable only to Primary Care Providers. Adult: The amount added to the state maximum for services rendered to ages 21 years and older. Preventive medicine and Evaluation and Management code add-ons are payable only to Primary Care Providers. 4
MODIFIERS RECOGNIZED IN PROCESSING ILLINOIS HEALTHCARE AND FAMILY SERVICE CLAIMS MODIFIER DESCRIPTION Updated 04/01/09 HOW PAYMENT IS AFFECTED 25 Significant, separately identifiable E&M service same physician same day May allow E&M payment separate from another service 26 Professional component Pays professional component only (*see practitioner fee schedule, Notes A, B, C) 50 Bilateral procedure Bill procedure code one time with modifier and quantity "1" to indicate bilaterals performed (*see practitioner fee schedule, Note B) 51 Multiple procedures Applies only to billing multiple NDCs (**see Informational Notice to Physicians dated 12-21-07) 52 Reduced services Goes to hand pricing, requires attachment of additional information 53 Discontinued procedure Not payable; bill only for services completed 59 Distinct procedural service Applies to Medicare crossovers only 62 Two surgeons Each surgeon is paid at 50% state maximum 73 Discontinued outpatient procedure prior to anesthesia administration Not payable; bill only for services completed 74 Discontinued outpatient procedure after anesthesia administration Not payable; bill only for services completed 76 Repeat procedure by same physician Applies only to billing multiple NDCs (**see Informational Notice to Physicians dated 12-21-07) 80 Assistant surgeon Payment is based on minutes billed 81 Minimum assistant surgeon Payment is based on minutes billed 82 Assistant surgeon when qualified resident surgeon not available Payment is based on minutes billed 90 Reference (outside) laboratory Not payable for APL or inpatient procedures 91 Repeat clinical diagnostic laboratory test Applies to Medicare crossovers only AH Clinical psychologist Billable only by FQHC and RHC AJ Clinical social worker Billable only by FQHC and RHC AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery Payment is based on minutes billed AT Acute Treatment Sterilization permit not required when procedure performed for acute reason and not for sterilization purposes Processes separately from same CPT with different eyelid E1 Upper left eyelid modifier
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- Page 3: Q State maximum amount now includes
- Page 7 and 8: HO Masters degree level; added 0601
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MODIFIERS RECOGNIZED IN PROCESSING ILLINOIS<br />
HEALTHCARE AND FAMILY SERVICE CLAIMS<br />
MODIFIER DESCRIPTION<br />
<strong>Updated</strong> <strong>04</strong>/<strong>01</strong>/<strong>09</strong><br />
HOW PAYMENT IS AFFECTED<br />
25 Significant, separately identifiable E&M service same physician same day May allow E&M payment separate from another service<br />
26 Pr<strong>of</strong>essional component<br />
Pays pr<strong>of</strong>essional component only (*see practitioner fee schedule,<br />
Notes A, B, C)<br />
50 Bilateral procedure<br />
Bill procedure code one time with modifier and quantity "1" to<br />
indicate bilaterals performed (*see practitioner fee schedule, Note<br />
B)<br />
51 Multiple procedures<br />
Applies only to billing multiple NDCs (**see Informational Notice to<br />
Physicians dated 12-21-07)<br />
52 Reduced services<br />
Goes to hand pricing, requires attachment <strong>of</strong> additional<br />
information<br />
53 Discontinued procedure Not payable; bill only for services completed<br />
59 Distinct procedural service Applies to Medicare crossovers only<br />
62 Two surgeons Each surgeon is paid at 50% state maximum<br />
73 Discontinued outpatient procedure prior to anesthesia administration Not payable; bill only for services completed<br />
74 Discontinued outpatient procedure after anesthesia administration Not payable; bill only for services completed<br />
76 Repeat procedure by same physician<br />
Applies only to billing multiple NDCs (**see Informational Notice to<br />
Physicians dated 12-21-07)<br />
80 Assistant surgeon Payment is based on minutes billed<br />
81 Minimum assistant surgeon Payment is based on minutes billed<br />
82 Assistant surgeon when qualified resident surgeon not available Payment is based on minutes billed<br />
90 Reference (outside) laboratory Not payable for APL or inpatient procedures<br />
91 Repeat clinical diagnostic laboratory test Applies to Medicare crossovers only<br />
AH Clinical psychologist Billable only by FQHC and RHC<br />
AJ Clinical social worker Billable only by FQHC and RHC<br />
AS<br />
Physician assistant, nurse practitioner, or clinical nurse specialist services for<br />
assistant at surgery<br />
Payment is based on minutes billed<br />
AT Acute Treatment<br />
Sterilization permit not required when procedure performed for<br />
acute reason and not for sterilization purposes<br />
Processes separately from same CPT with different eyelid<br />
E1 Upper left eyelid<br />
modifier
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