Practitioner Fee Schedule Key - Illinois Department Of Healthcare And Family Services Page 3
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5Fee Schedule Key
Column HEADING
Column Description
HCPCS
CPT-4 or HCPCS procedure code.
Note
Special billing information applies to the code.
A
Professional and technical components are each reimbursed at 50% of the state maximum.
Professional and technical components are each reimbursed at 50% of the state maximum,
B
rounded to the nearest cent.
C
Reimbursements for professional and technical components split at a rate other than 50%.
D
Code is billable by encounter rate clinic only. Reimbursement for 90845 and T1015 is the
provider-specific encounter rate. Reimbursement for S5190 is $0.00.
E*
Vaccine is supplied through the Vaccines For Children (VFC) program for children age 0
through 18 with Title XIX (19) eligibility, but not for adults or children age 0 through 18 with Title
XXI (21) or state-funded eligibility.
F*
Vaccine is not available through the VFC program. Additional Unit Price reimbursement is not
applicable.
•
H
Reimbursements for professional and technical components split at the rates shown in
Columns M1 and M2
•
Multiples are allowed up to the posted Max Qty
•
I*
Enter name of vaccine in Note Field (Loop 2400 of 837P)
•
Vaccine restricted to females age 9 through 25 years
•
Vaccine is supplied through the VFC program for children age 9 through18 years with Title
XIX (19) eligibility
•
Obstetric/Gynecology providers are reimbursed for the vaccine product for ages 9 through
25 as shown in the State Max column
•
J
Covered only when specimen is obtained and submitted to IDPH for processing for blood
lead analysis as a Healthy Kids service for ages 0-20 years
•
Must be billed with the U1 modifier as documentation that the service meets this
description
•
Billing guidelines are available in
Chapter A-200 Practitioner Handbook and appendix.
K
Prior approval required for surgeon and assistant surgeon. Anesthesia services for these
codes must be billed using the five-digit anesthesia procedure code.
•
M*
Enter name of vaccine in Note Field (Loop 2400 of 837P)
•
The EPSDT indicator is required to identify as a preventive service
•
Vaccine restricted to age 9 through 26 years
•
Vaccine is supplied through the VFC program for children age 9 through 18 years with Title
XIX (19) eligibility
•
Obstetric/Gynecology providers are reimbursed for the vaccine product for ages 9 through
25 as shown in the State Max column
N
Prior approval required for practitioner-purchased and administered drug.
Prior approval
guidelines.
P
Add-on is payable only to the PCP or affiliate within the same group.
Q
State maximum amount includes the Maternal Child Health Add-on amount for all providers.
•
R
Covered only for ages 0 through 20 years
•
Reimbursement for professional and technical components splits at a rate other than 50%
S
Additional amount paid to any provider for the component performed:
•
Global add-on = $51.66
•
Professional component add-on = $10.33
•
Technical component add-on = $41.33
T
A $12.00 dispensing fee is allowed for 340B enrolled providers when billed with the “UD”
modifier.
*Dispensing fees were reduced by $1.00 for dates of service May 1, 2015 – June 30, 2015
U
A $35.00 dispensing is fee allowed when billed with the “UD” modifier for highly effective birth
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