Illinois Department of Healthcare and Family Services ...

Illinois Department of Healthcare and Family Services Practitioner Fee Schedule Effective 12/31/2017 Updated 01/31/2018

**The 2018 code additions and deletions are not included on this fee schedule. A revised version with 2018 code additions and deletions is forthcoming pending coverage and reimbursement determination. Please note the appearance of a code on this fee schedule does not guarantee payment. Services for which medical necessity is not clearly established are not covered by the Department's Medical Programs. See Chapter 100, Topic 104 and Chapter A-200, Section 204 for additional exclusions. Updates are based on periodic modifications to the HCPCS/CPT code set. CPT codes and descriptions only are copyright 2015 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. National Correct Coding Institute (NCCI) edits apply. *2.7% rate reductions shown in a separate column do not apply to: Physicians, Dentists, Advanced Practice Nurses, Community Mental Health Providers, FQHCs, RHCs, ERCs, LEAs, DORs Schools,

School-based Clinics, Local Health Departments and Early Intervention.

Procedure Code

Note

Prog Cov

Eff Date

HP

NDC Ind

Surg Ind

AV

M1 (26)

M2 Asst Co(TC) Surg Surg

Unit price

Max Qty

00100 00102 00103 00104 00120 00124 00126 00140 00142 00144 00145 00147 00148 00160 00162 00164 00170 00172 00174 00176 00190 00192 00210 00211 00212 00214 00215 00216 00218 00220 00222

04

Y

04

Y

04

Y

04 04/01/15 N

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04 01/01/09 Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

04

Y

I3 M3 M5 N M4 I3 I3 M5 M5 M5 M5 M5 I3 M4 M4 I4 I5 M5 M4 M4 M4 M4 M9 M9 M4 M9 M9 M9 M9 M 11 M9

State Max

44.40

Add-On Surg Child Adult

Rate reduced by 2.7%

Unit price

State Max

43.20

School-based Clinics, Local Health Departments and Early Intervention.

Procedure Code

Note

Prog Cov

Eff Date

HP

NDC Ind

Surg Ind

AV

M1 (26)

M2 Asst Co(TC) Surg Surg

Unit price

Max Qty

00300

04

Y

M3

00320

04

Y

M6

00322

04

Y

M3

00326

04

Y

M4

00350

04

Y

M 15

00352

04

Y

M5

00400

04

Y

I3

00402

04

Y

M4

00404

04

Y

M4

00406

04

Y

M4

00410

04

N

I

00450

04

Y

M3

00454

04

Y

I3

00470

04

Y

M4

00472

04

Y

M7

00474

04

Y

M5

00500

04

Y

M9

00520

04

Y

M4

00522

04

Y

I4

00524

04

Y

M4

00528

04

Y

M4

00529

04

Y

N5

00530

04

Y

M5

00532

04

Y

I3

00534

04

Y

M5

00537

04

Y

I5

00539

04

Y

M 11

00540

04

Y

M 11

00541

04

Y

M 11

00542

04

Y

M 11

00546

04

Y

M7

00548

04

Y

M 11

00550

04

Y

M3

00560

04

Y

M 20

00561

04

Y

M 20

00562

04

Y

M 20

00563

04

Y

M 20

00566

04

Y

M 20

00567

04 01/01/09 Y

M 20

00580

04

Y

M 20

State Max

112.40

Add-On Surg Child Adult

Rate reduced by 2.7%

Unit price

State Max

109.37

School-based Clinics, Local Health Departments and Early Intervention.

Procedure Code

Note

Prog Cov

Eff Date

HP

NDC Ind

Surg Ind

AV

M1 (26)

M2 Asst Co(TC) Surg Surg

Unit price

Max Qty

00600

04

Y

M8

00604

04

Y

M8

00620

04

Y

M8

00625

04 01/01/07 Y

M 10

00626

04 01/01/07 Y

N 10

00630

04

Y

M7

00632

04

Y

M4

00635

04

Y

I3

00640

04

Y

M8

00670

04

Y

M7

00700

04

Y

M4

00702

04

Y

I3

00730

04

Y

M4

00740

04

Y

M4

00750

04

Y

M3

00752

04

Y

M3

00754

04

Y

M3

00756

04

Y

M6

00770

04

Y

M 15

00790

04

Y

M6

00792

04

Y

M 12

00794

04

Y

M6

00796

04

Y

M 12

00797

04

Y

M5

00800

04

Y

M4

00802

04

Y

M3

00810

04

Y

M4

00820

04

Y

M4

00830

04

Y

M3

00832

04

Y

M3

00834

04

Y

M3

00836

04

Y

M3

00840

04

Y

M4

00842

04

Y

I4

00844

04

Y

M6

00846

04

Y

M5

00848

04

Y

M6

00851

04 01/01/12 Y

M4

00860

04

Y

M4

00862

04

Y

M5

State Max

Add-On Surg Child Adult

Rate reduced by 2.7%

Unit price

State Max

School-based Clinics, Local Health Departments and Early Intervention.

Procedure Code

Note

Prog Cov

Eff Date

HP

NDC Ind

Surg Ind

AV

M1 (26)

M2 Asst Co(TC) Surg Surg

Unit price

Max Qty

00864

04

Y

M7

00865

04

Y

M6

00866

04

Y

M9

00868

04

Y

M5

00870

04

Y

M5

00872

04

Y

M3

00873

04

Y

M3

00880

04

Y

M4

00882

04

Y

M5

00902

04

Y

M4

00904

04

Y

M3

00906

04

Y

M3

00908

04

Y

M6

00910

04

Y

M3

00912

04

Y

M3

00914

04

Y

M5

00916

04

Y

M5

00918

04

Y

M3

00920

04

Y

M3

00921

04

Y

M3

00922

04

Y

M3

00924

04

Y

M4

00926

04

Y

M3

00928

04

Y

M4

00930

04

Y

M3

00932

04

Y

M3

00934

04

Y

M4

00936

04

Y

M4

00938

04

Y

M3

00940

04

Y

I3

00942

04

Y

M3

00944

04

Y

M5

00948

04

Y

I3

00950

04

Y

I3

00952

04

Y

I3

01112

04

Y

I3

01120

04

Y

M3

01130

04

Y

I3

01140

04

Y

M 11

01150

04

Y

M 11

State Max

Add-On Surg Child Adult

Rate reduced by 2.7%

Unit price

State Max

School-based Clinics, Local Health Departments and Early Intervention.

Procedure Code

Note

Prog Cov

Eff Date

HP

NDC Ind

Surg Ind

AV

M1 (26)

M2 Asst Co(TC) Surg Surg

Unit price

Max Qty

01160

04

Y

M3

01170

04

Y

M3

01173

04

Y

M3

01180

04

Y

M3

01190

04

Y

M3

01200

04

Y

M5

01202

04

Y

M3

01210

04

Y

M3

01212

04

Y

M8

01214

04

Y

M3

01215

04

Y

I3

01220

04

Y

M3

01230

04

Y

M4

01232

04

Y

M3

01234

04

Y

M6

01250

04

Y

M3

01260

04

Y

M 10

01270

04

Y

M 10

01272

04

Y

M5

01274

04

Y

M5

01320

04

Y

M3

01340

04

Y

M3

01360

04

Y

M4

01380

04

Y

M3

01382

04

Y

M3

01390

04

Y

M4

01392

04

Y

M4

01400

04

Y

M3

01402

04

Y

M3

01404

04

Y

M3

01420

04

Y

I3

01430

04

Y

M5

01432

04

Y

M5

01440

04

Y

M5

01442

04

Y

M5

01444

04

Y

M5

01462

04

Y

M3

01464

04

Y

M3

01470

04

Y

M4

01472

04

Y

M3

State Max

Add-On Surg Child Adult

Rate reduced by 2.7%

Unit price

State Max

School-based Clinics, Local Health Departments and Early Intervention.

Procedure Code

Note

Prog Cov

Eff Date

HP

NDC Ind

Surg Ind

AV

M1 (26)

M2 Asst Co(TC) Surg Surg

Unit price

Max Qty

01474

04

Y

M3

01480

04

Y

M3

01482

04

Y

M3

01484

04

Y

M3

01486

04

Y

M3

01490

04

Y

I3

01500

04

Y

M 10

01502

04

Y

M5

01520

04

Y

M 10

01522

04

Y

M5

01610

04

Y

M3

01620

04

Y

M3

01622

04

Y

M3

01630

04

Y

M3

01634

04

Y

M5

01636

04

Y

M 11

01638

04

Y

M3

01650

04

Y

M5

01652

04

Y

M 15

01654

04

Y

M 10

01656

04

Y

M 10

01670

04

Y

M 10

01680

04

Y

I3

01682

04

Y

I3

01710

04

Y

M3

01712

04

Y

M3

01714

04

Y

M3

01716

04

Y

M3

01730

04

Y

M3

01732

04

Y

M3

01740

04

Y

M3

01742

04

Y

M3

01744

04

Y

M3

01756

04

Y

M3

01758

04

Y

M3

01760

04

Y

M3

01770

04

Y

M5

01772

04

Y

M5

01780

04

Y

M5

01782

04

Y

M3

State Max

Add-On Surg Child Adult

Rate reduced by 2.7%

Unit price

State Max

School-based Clinics, Local Health Departments and Early Intervention.

Procedure Code

Note

Prog Cov

Eff Date

HP

NDC Ind

Surg Ind

AV

M1 (26)

M2 Asst Co(TC) Surg Surg

Unit price

Max Qty

01810

04

Y

M3

01820

04

Y

M3

01829

04

Y

M3

01830

04

Y

M3

01832

04

Y

M3

01840

04

Y

M5

01842

04

Y

M5

01844

04

Y

M5

01850

04

Y

M 10

01852

04

Y

M3

01860

04

Y

M3

01916

04

Y

I3

01920

04

Y

M3

01922

04

Y

I3

01924

04

Y

M3

01925

04

Y

M3

01926

04

Y

I3

01930

04

Y

M5

01931

04

Y

M8

01932

04

Y

M6

01933

04

Y

M9

01935

04 01/01/08 Y

M5

01936

04 01/01/08 Y

M5

01951

04

Y

I3

01952

04

Y

I3

01953

04

Y

I3

01958

04

Y

M4

01960

09

Y

M4

01961

04

Y

M5

01962

04

Y

M5

01963

04

Y

M5

01965

04

Y

M3

01966

04 07/01/08 Y

M3

01967

04

Y

M3

01968

04

Y

M3

01969

04

Y

M3

01991

04

Y

I3

01992

04

Y

I3

01996

04

N

I

01999

04

Y

M3

State Max

Add-On Surg Child Adult

Rate reduced by 2.7%

Unit price

State Max

14.25

13.87

School-based Clinics, Local Health Departments and Early Intervention.

Procedure Code

Note

Prog Cov

Eff Date

HP

NDC Ind

Surg Ind

AV

M1 (26)

M2 Asst Co(TC) Surg Surg

Unit price

Max Qty

10021

04

N

I3

10022

04

N

I3

10030

04 01/01/14 N

I4

Y

10035

04 01/01/16 N

I3

Y

10036

A 04 01/01/16 N

I3

Y

10040

04

N

I3

10060

04

N

I3

10061

04

N

I3

10080

04

N

I3

10081

04

N

I4

10120

04

N

I3

10121

04

N

I3

10140

04

N

I3

10160

04

N

I3

10180

04

N

I3

Y

11000

04

N

I3

11001

04

N

I3

11004

04

N

M3

YY

11005

04

N

M3

YY

11006

04

N

M3

YY

11008

04

N

M3

YY

11010

04

N

I3

11011

04

N

I3

11012

04

N

I3

11042

04 01/01/10 N

I3

11043

04 07/01/12 N

I3

11044

04 07/01/12 N

M3

11045

04 01/01/11 Y

I3

11046

04 01/01/11 Y

I3

Y

11047

04 01/01/11 Y

I3

Y

11055

04

N

I3

11056

04 04/01/14 N

I3

11057

04 04/01/14 N

I3

11100

04

N

I3

11101

04

N

I3

11200

04

N

I3

11201

04

N

I3

11300

04

N

I3

11301

04

N

I3

11302

04

N

I3

State Max

49.80 56.70 95.05 53.40 23.93 35.20 36.00 66.50 70.65 131.80 39.05 77.60 41.50 35.95 130.55 77.70 20.85 154.43 154.43 154.43 154.43 127.60 157.90 218.40 70.55 170.55 219.35

Surg

Add-On Child Adult

Rate reduced by 2.7%

Unit price

State Max

48.46 55.17 92.48 51.96 23.28 34.25 35.03 64.70 68.74 128.24 38.00 75.50 40.38 34.98 127.03 75.60 20.29 150.26 150.26 150.26 150.26 124.15 153.64 212.50 68.65 165.95 213.43

22.15 13.93 18.21 50.20 22.15 35.65 15.20 21.10 29.20 37.50

17.00 17.00

21.55 13.55 17.72 48.84 21.55 34.69 14.79 20.53 28.41 36.49

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