(Diagnostic/Evaluation Purposes Only for Early Intervention)

Service Description

Service Description: Medical services only for diagnostic and evaluation purposes means services provided by a licensed physician or a multidisciplinary team (if needed) under the direction of a licensed physician to determine a child's developmental status and need for services. Medical diagnostic services may be appropriate when 1) the child's record documents that other evaluations have failed to determine the child's eligibility for services and the child is likely to be determined eligible if additional developmental diagnostic services are provided, or 2) to establish a diagnosis which would potentially meet the eligibility parameters for services. Medical referrals may be required if the need for medical testing is identified. Consultation with other medical providers, if needed, is considered a part of the diagnostic evaluation and should not be billed separately. The evaluation report must conform to the Service Report Guidelines (see ATTACHMENT 1: EARLY INTERVENTION SERVICE REPORT GUIDELINES/FORMAT) which require in part a statement of the child's eligibility, developmental status, and intervention recommendations for use in development of the Plan.

Services must be consistent with the provider's qualifications and licensure. Team members must be individually enrolled to provide Early Intervention Services under their respective disciplines and have an authorization under their discipline to provide and bill for this service. Team members should use the codes found under their respective disciplines for billing purposes.

The only other medical or health-related services which are covered by EI (other than the above diagnostic/evaluation medical services) are defined under "Nursing" and "Health Consultation". Medical and health services do not include the following:

  1. services that are-
    1. Surgical in nature (such as cleft palate surgery, surgery for club foot, or the shunting of hydrocephalus); or
    2. Purely medical in nature (such as hospitalization for management of congenital heart ailments, or the prescribing of medicine or drugs for any purpose).
  2. Devices necessary to control or treat a medical condition.
  3. Medical-health services (such as immunizations and regular "well-baby" care) that are routinely recommended for all children.

Qualified Staff: A system enrolled Physician licensed by the state in which he or she provides EI services to Illinois children. (See ATTACHMENT 5: REQUIREMENTS FOR PROFESSIONAL AND ASSOCIATE LEVEL EARLY INTERVENTION CREDENTIALING AND ENROLLMENT TO BILL.)

Billable Activities Evaluation to determine the child's developmental status and need for EI

With Authorization: services. Early Intervention will pay for one (1) medical Diagnostic Evaluation

prior to the initial service plan or one (1) encounter during the initial Service Plan. Early Intervention will pay for one (1) Medical Diagnostic Evaluation prior to each annual Service Plan after the expiration of the initial Service Plan.

Do not provide services without having an authorization in hand. Services provided without a pre-approved authorization are not guaranteed for payment.

Medical Service (Diagnostic / Evaluation Purposes Only)

Procedure Codes Unit of Service Description Rate
99274 N/A Medical Diagnostic Evaluation $201.46