Provider Notice issued 10/17/2024

This notice informs providers that the Department of Healthcare and Family Services (HFS) has received federal approval for genetic counselors licensed under 68 Ill. Admin. Code Part 1251 to enroll as Medicaid providers and submit claims for their services. This approval is effective for dates of service beginning April 1, 2024.

Previously, genetic counseling services could be performed by genetic counselors, but the services had to be submitted under the name and National Provider Identifier (NPI) of an enrolled physician. To align with the procedure code definition and billing instructions in the CPT codebook, genetic counselors must now enroll separately in the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) system and submit claims as the rendering practitioner.

Provider Enrollment

Genetic counseling services are reimbursable for those enrolled in the IMPACT provider enrollment system. Genetic counselors should review the IMPACT Account Activation Instructions for New External IMPACT Users.

In IMPACT, a genetic counselor must select an Enrollment Type of either:

1.)   Rendering/Servicing Provider – An individual provider who will be rendering services to Medicaid customers but will not be submitting claims directly to the State for reimbursement. Enrolling as a Rendering Provider requires that you associate with a Group Practice or Facility, Agency, Organization (FAO) as a billing provider in the IMPACT system and does not allow you to bill for yourself.

2.)  Regular Individual/Sole Proprietor – A provider that owns his/her own practice. A Sole Proprietor may receive payments directly or associate to Billing Providers and/or Billing Agents. If you enroll as a Sole Proprietor, you can still also associate with a Group Practice or FAO as your Billing Provider(s) and they may bill on your behalf, but you are not required to do so. You can use this enrollment to work as part of an organization and/or bill for yourself.

National Provider Identifier (NPI)

Genetic counselors must have an NPI in order to enroll. Information about obtaining an NPI is located on the Centers for Medicare & Medicaid Services (CMS) website.

Billable Procedure Code

Fee Schedule

Procedure code 96040 will be identified with an explanatory note in a future update of the Practitioner Fee Schedule that it is to be billed only by genetic counselors. To accommodate the billing transition, physicians may continue to bill 96040 on behalf of a licensed genetic counselor until their associated genetic counselor is enrolled, but no later than February 1, 2025.

Effective with service dates beginning February 1, 2025, physicians who provide genetic counseling services must use the appropriate Evaluation and Management procedure codes, per CPT guidelines.  

Taxonomy Code
Taxonomy code for genetic counseling services:  170300000X

Ordering/Referring/Prescribing Claim Edits
Genetic counseling services do not require a referring provider.

Claim Submission/Claim Format
Services are billed electronically on the 837 Professional transaction. Information regarding electronic 837P transactions may be found in the Chapter 300 Companion Guide. Claims may also be submitted via direct data entry within the MEDI system. 

Telehealth
The telehealth delivery method is allowable utilizing modifier GT (Via Audio and Video Telecommunications Systems) or 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system) and place of service 02 (Telehealth Provided Other than in Patient’s Home) or 10 (Telehealth Provided in Patient’s Home), as applicable.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 or the applicable HealthChoice Illinois managed care organization.

Kelly Cunningham, Administrator
Division of Medical Programs