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control methods purchased through the 340B federal Drug Pricing Program.

*The $35.00 dispensing fee is allowed to 340B providers for the following procedure codes:

•

J3490 when billing Depo-SubQ Provera 104mg Injection

•

J8499 when billing Emergency Contraceptives (ECPs), effective June 1, 2016

*Dispensing fees were reduced by $1.00 for dates of service May 1, 2015 – June 30,

2015.

Smoking cessation counseling services for pregnant and post-partum women in addition to

children 2-21 years under Early and Periodic Screening, Diagnostic and Treatment (EPSDT).

Reimbursable only to a designated eligible/approved facility by the Department. The CPT code

must be billed by the eligible/approved rendering practitioner with the FP modifier, and the

facility must be designated as the billing provider/payee on the claim.

Claim must be submitted on paper with a copy of the invoice showing the practitioner’s

acquisition cost for the item attached.

For private stock vaccines administered to children age 0 through 18 with Title XXI (21) or

state-funded eligibility refer to the applicable billing guidelines and examples provided in the A-

200 Practitioner Handbook & Appendices or the

D-200 Encounter Clinic Handbook &

Appendices, and on the

Non-Institutional Providers Resources webpage

Prog Cov

04-Medicaid covered services.

(Program

09-Qualified Medicare Beneficiary (QMB) coverage only.

Coverage)

Eff Date

Effective date of codes added on or after 01/01/07 or date of change in payment policy.

(Effective Date)

If “Y”, special pricing methodology is applied:

(Hand Priced

Anesthesia codes: system priced according to

Chapter A-200

and Appendix.

Indicator)

Practitioner purchased and administered drugs: The number listed in the days/units field

must be “1”. Claims may be submitted electronically or on paper. The name of the drug,

strength of the drug, and the amount given must be shown in the description/note field and

must be billed according to NDC billing guidelines available in

Chapter A-200 Practitioner

Handbook and

appendix.

Medical/surgical procedures: The number listed in the days/units field must be “1”. Claims

must be submitted on paper. The specific name of the procedure and the total number of

times performed must be submitted in the description/note field, and the procedure note must

be attached.

Provider Type 061 Independent laboratory billing on the HFS 2211: Claims must be

submitted on paper. The specific name of the procedure and total number of times performed

must be submitted in the description/note field, and the test report(s) must be attached.

NDC Ind

If “Y”, the 11-digit NDC must be billed according to NDC billing guidelines available in

Chapter

A-200 Practitioner Handbook and appendix.

(NDC indicator)

N or blank = Not considered surgical.

Surg Ind

I = Incidental. Procedure may not pay separately when billed with visit or other surgical

(Surgery Indicator)

codes.

M = Major. Reimbursement for procedure includes 30-day postoperative care.

AV (Anesthesia

Value assigned by the Department and used in the calculation of anesthesia rates.

Value)

M1 (Modifier 1) 26

Rate paid for the professional component of the procedure.

M2 (Modifier 2) TC

Rate paid for the technical component of the procedure.

Assist Surg

“Y” indicates services of an assistant at surgery may be paid.

(Assistant Surgeon)

CoSurg (Co-

“Y” indicates services of a co-surgeon may be paid.

Surgeon)

Unit Price

Price for each unit when multiple quantities are billable or base amount payable for ages 0-20

years when followed by “C”.

Max Qty

The maximum number of units payable for the code.

(Maximum

Quantity)

State Max

The maximum allowable reimbursement (reflects combined professional and technical

Practitioner Fee Schedule Key - Illinois Department Of Healthcare And Family Services Page 4

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