La. Admin. Code tit. 40 § I-5125

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5125 - Special Instructions

A. Procedure Codes Not Listed in Rules

1. If a procedure is performed which is not listed in the maximum reimbursement allowance, the health care provider must use an appropriate CPT code descriptor. The provider must submit a narrative report to the carrier to explain why it was medically necessary to use a particular procedure code or descriptor not contained in the maximum reimbursement allowance. The codes used in this schedule are 1994 CPT codes.

2. The CPT contains codes for unlisted procedures which end in "99." These codes should only be used when there is no procedure code which accurately describes the service rendered. A special report is required as these services are reimbursed by report.

3. Services must be coded with valid five digit procedure codes.

B. Modifiers

1. Modifier codes must be used by providers to identify procedures or services that are modified due to specific circumstances.

2. Modifiers listed in the CPT must be added to the procedure code when the service or procedure has been altered from the basic procedure described by the descriptor.

3. When Modifier-22 is used to report an unusual service, a report explaining the medical necessity of the situation must be submitted with the claim to the carrier. It is not appropriate to use Modifier-22 for routine billing.

4. The use of modifiers does not imply or guarantee that a provider will receive reimbursement as billed. Reimbursement for modified services or procedures must be based on documentation of medical necessity and must be determined on a case by case basis.

5. The modifier 95 appended to a code indicates it was performed by telemedicine/telehealth methods. Services should be reimbursed the same amount as the exact same codes without the modifier as long as the Emergency Rule exist. If carrier requires a Place of Service (POS) code for telemedicine/telehealth, code 02 may be used.

C. By Report (BR)

1. BR refers to the method by which the reimbursement for a procedure is determined by the carrier when a service or procedure is performed by the provider that does not have an established maximum reimbursement allowance.

2. Reimbursement for procedure codes listed as BR must be determined by the carrier based on documentation which is submitted to the carrier by the provider in a special report attached to the claim form. Information in this report must include, as appropriate:

a. the pertinent history and physical findings;

b. diagnostic tests and interpretation;

c. therapeutic procedures;

d. treatment for concurrent medical conditions;

e. the final diagnosis/diagnoses;

f. identification of, or an estimate of the time required for follow-up care;

g. summary of treatment plan;

h. copies of operative reports, consultation reports, progress notes, office notes or other applicable documentation;

i. description of equipment necessary to provide the service.

3. Reimbursement by the carrier of BR procedures should be based upon the following:

a. review of the submitted documentation;

b. recommendation of the C/SIE's medical consultant;

c. the C/SIE's review of the prevailing charges for like procedures based upon data which is specific for Louisiana charges.

4. Bundled Code. These codes are marked BR, and are not payable because the service is included in the payment for other services.

D. Pathology. If no indication is given in the fee schedule to differentiate between professional and technical components for the MFA, the standard would be 15 percent of the total allocated for the technical component and 85 percent for the professional component.

E. Adjunct of Subsidiary Codes. Certain codes, by the nature of their description have already been reduced, as they are never to be billed as primary procedures. These codes should be reimbursed at the listed value when billed with other procedures.

F. Dispensing Physician Services

1. Reimbursement to a physician for dispensing medications, drugs or chemicals is limited to physicians who are licensed through the State Board of Medical Examiners for dispensing such.

2. Payments shall be made in accordance with the Pharmacy Reimbursement Schedule, Chapter 29.

La. Admin. Code tit. 40, § I-5125

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), Amended by the Louisiana Workforce Commission, Office of Workers' Compensation, LR46, Amended by the Louisiana Workforce Commission, Office of Workers' Compensation Administration, LR 461400 (10/1/2020).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.