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Elizabeth M. Whitehorn, Director

Provider Notice issued 08/09/2023

 

Date: August 9, 2023 
​To: Enrolled Pharmacies; Physicians; Physician Assistants; and Advanced Practice Registered Nurses
​Re: Pharmacists Billing for Evaluation and Management Procedure Codes Related to Hormonal Contraceptive Assessment

This notice informs pharmacies that the Department of Healthcare and Family Services (HFS) has opened additional procedure codes that may be billed for pharmacists providing hormonal contraceptive assessment and consultation services. This applies to the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organization (MCO) plans.

By provider notice dated October 31, 2022, the Department of Healthcare and Family Services (HFS) notified providers that patient care services provided by a pharmacist for hormonal contraceptive assessment and consultation would be covered at 85% of the physician rate. HFS identified CPT procedure code 99401 - Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes, for billing. Modifier FP must be billed in conjunction with procedure code 99401.

Effective retroactive to August 1, 2022, pharmacies may bill on behalf of pharmacists for one of the following Evaluation and Management procedure codes with the FP modifier, in addition to 99401, for the assessment component of the family planning service:

99202

Office or other outpatient visit for the evaluation and management of a new patient; 15-29 minutes

99203

 

      ;30-44 minutes

99211

Office or other outpatient visit for the evaluation and management of an established patient; less than 10 minutes

99212

      ;10-19 minutes

All other policies contained in the October 31, 2022, provider notice remains the same.

Pharmacists are encouraged to dispense hormonal contraceptives in three-month supplies when possible. As a reminder, Public Act 102-0103 allowing pharmacists to dispense hormonal contraceptives states that a pharmacist and pharmacy must maintain appropriate records. In case of HFS audit, providers must be able to supply adequate documentation to support the services provided.

Payment

Pharmacist rates for the CPT procedure codes are identified in a separate Pharmacist Fee Schedule on the Department’s website.

 

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or to the applicable HCI MCO plan.

 

Kelly Cunningham, Administrator
Division of Medical Programs