Provider Notice issued 12/28/10

Chapter A-200, Handbook for Practitioners Rendering Medical Services - Update Regarding Billing for Vaccinations

The purpose of this bulletin is to remove the H1N1 billing instructions that are included in Appendix A-8, Page 2. H1N1 is now included as part of the influenza vaccine, therefore practitioners should follow the vaccination billing instructions in Appendix A-8, Page 1.

If you do not have access to the Internet, or need a paper copy, printed copies are available upon written request. You need to specify a physical street address to ensure delivery. Submit your written request or fax to:

Illinois Department of Healthcare and Family Services

Provider Participation Unit
Post Office Box 19114
Springfield, Illinois 62794-9114
Fax Number: 217-557-8800
E-mail the Provider Participation Unit

Instructions for Updating Handbook

Appendix A-8 Vaccination Billing Instructions

Remove HFS Appendix A-8 (1-2) and replace with HFS Appendix A-8 (1)

Appendix A-8

Vaccinations Billing Instructions

Children 0 through 18 years of age

Example #1 A well-child examination is performed, and routine vaccinations are administered at the same time. The well-child examination is submitted using the appropriate CPT Code for the preventive medicine visit. Vaccinations are billed using the CPT Codes for the specific vaccines. The department reimburses for the visit at the fee schedule rate, for the VFC vaccine administrative services at $6.40, and for the non-VFC vaccine at the fee schedule rate.

Example #2 A child presents solely to receive a vaccine available through VFC. The salaried staff member administers the vaccine. The office visit is submitted using the CPT Code for a minimal level office or other outpatient visit for evaluation and management not requiring the presence of a physician. The vaccination is billed using the CPT Code for the specific vaccine. The department reimburses for the visit at the fee schedule rate and for the VFC vaccine administrative services at $6.40.

Adults 19 years of age or older

Example #3 An office visit for an adult is performed for reasons other than receiving an immunization. A vaccine is then recommended and administered. The office visit is submitted using the CPT Code for the appropriate level office or other outpatient visit for evaluation and management. The vaccination is billed using the CPT Code for the specific vaccine. The department reimburses for the visit at the fee schedule rate and for the cost of the vaccine at the fee schedule rate.

Example #4 An adult presents solely to receive a vaccine. The salaried staff member administers the vaccine. The office visit is submitted using the CPT Code for the minimal level office or other outpatient visit for evaluation and management not requiring the presence of a physician. The vaccination is billed using the CPT Code for the specific vaccine. The department reimburses for the visit at the fee schedule rate and for the cost of the vaccine at the fee schedule rate.