Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 31 - Vision Care Services, Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-3119 - Maximum Allowable Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Maximum allowable reimbursement lists the
				  maximum payment allowed for vision items described by HCPCS codes. Payment will
				  be the least of:
1. the provider's usual and
				  customary fee;
2. a pre-negotiated
				  amount between the provider and carrier/self-insured employer; or
3. the amount indicated in the maximum
				  allowable reimbursement schedule.
State of Louisiana
Office of Workers' Compensation Schedule of
								Maximum Allowances for Vision Services and Supplies
HCPCS
Description
Purchase
New
V2020
Frames; Purchases
$74
V2025
Deluxe Frame
B.R.
V2100
Sphere; Single Vision
$50
V2101
Sphere; Single Vision
$58
V2102
Sphere; Single Vision
$60
V2103
Spherocylinder; Single Vision
$38
V2104
Spherocylinder; Single Vision
$54
V2105
Spherocylinder; Single Vision
$57
V2106
Spherocylinder; Single Vision
$59
V2107
Spherocylinder; Single Vision
$65
V2108
Spherocylinder; Single Vision
$59
V2109
Spherocylinder; Single Vision
$59
V2110
Spherocylinder; Single Vision
$61
V2111
Spherocylinder; Single Vision
$63
V2112
Spherocylinder; Single Vision
$86
V2113
Spherocylinder; Single Vision
$78
V2114
Spherocylinder; Single Vision
$100
V2115
Lenticular; (Myodisc); per Lens
$101
V2118
Aniseikonic Lens; Single Vision
$85
V2121
Lenticular lens, per lens, single
$93
V2199
Not Otherwise Classified
B.R.
V2200
Sphere; Bifocal
$66
V2201
Sphere; Bifocal
$66
V2202
Sphere; Bifocal
$92
V2203
Spherocylinder; Bifocal
$65
V2204
Spherocylinder; Bifocal
$69
V2205
Spherocylinder; Bifocal
$74
V2206
Spherocylinder; Bifocal
$83
V2207
Spherocylinder; Bifocal
$66
V2208
Spherocylinder; Bifocal
$91
V2209
Spherocylinder; Bifocal
$77
V2210
Spherocylinder; Bifocal
$87
V2211
Spherocylinder; Bifocal
$80
V2212
Spherocylinder; Bifocal
$89
V2213
Spherocylinder; Bifocal
$120
V2214
Spherocylinder; Bifocal
$125
2215
Lenticular (Myodisc); per Lens
$93
V2216
Lenticular; Nonaspheric; per Lens
$91
V2217
Lenticular; Aspheric Lens; Bifocal
$108
V2218
Aniseikonic; per Lens; Bifocal
$105
V2219
Bifocal Seg Width over 28mm
$59
V2220
Bifocal Add over 3.25d
$60
V2221
Lenticular lens, per lens, bifocal
$109
V2299
Specialty Bifocal (by report)
B.R.
V2300
Sphere; Trifocal
$81
V2301
Sphere; Trifocal
$104
V2302
Sphere; Trifocal
$101
V2303
Spherocylinder; Trifocal
$76
V2304
Spherocylinder; Trifocal
$82
V2305
Spherocylinder; Trifocal
$116
V2306
Spherocylinder; Trifocal
$124
V2307
Spherocylinder; Trifocal
$91
V2308
Spherocylinder; Trifocal
$92
V2309
Spherocylinder; Trifocal
$94
V2310
Spherocylinder; Trifocal
$98
V2311
Spherocylinder, Trifocal
$109
V2312
Spherocylinder; Trifocal
$101
V2313
Spherocylinder; Trifocal
$105
V2314
Spherocylinder; Trifocal
$111
V2315
Lenticular; (Myodisc); per Lens
$118
V2316
Lenticular Nonaspheric; per Lens
$111
V2317
Lenticular; Aspheric Lens
$138
V2318
Aniseikonic Lens; Trifocal
$156
V2319
Trifocal Seg Width over 28mm
$75
V2320
Trifocal Add over 3.25d
$84
V2321
Lenticular lens, per lens, trifocal
$145
V2399
Specialty Trifocal (by report)
B.R.
V2410
Variable Asphericity Lens
$147
V2430
Variable Asphericity Lens; Bifocal
$141
V2499
Variable Sphericity Lens
B.R.
V2500
Contact Lens; PMMA; Spherical
$125
V2501
Contact Lens; PMMA; Toric or
Prism
$134
V2502
Contact Lens PMMA; Bifocal
$154
V2503
Contact Lens PMMA; Color Vision
$145
V2510
Contact Lens; Gas Permeable
$171
V2511
Contact Lens; Gas Permeable; Toric
$186
V2512
Contact Lens; Gas Permeable
$277
V2513
Contact Lens; Gas Permeable
$252
V2520
Contact Lens Hydrophilic
$128
V2521
Contact Lens Hydrophilic; Toric
$193
V2522
Contact Lens Hydrophillic; Bifocal
$262
V2523
Contact Lens Hydrophilic; Extended
$181
V2530
Contact Lens; Scleral; per Lens
$277
V2531
Contact lens, scleral, gas permeable, per lens
$783
V2599
Contact Lens; Other Type
B.R.
V2600
Hand Held Low Vision Aids
B.R.
V2610
Single Lens Spectacle Mounted
B.R.
V2615
Telescopic and Other Compound
Lens
B.R.
V2623
Prosthetic Eye; Plastic; Custom
$1,384
V2624
Polishing Artificial Eye
$78
V2625
Enlargement of Ocular Prosthesis
$374
V2626
Reduction of Ocular Prosthesis
$259
V2627
Scleral Cover Shell
$1,412
V2628
Fabrication and Fitting
$367
V2629
Prosthetic Eye; Other Type
B.R.
V2630
Anterior Chamber Intraocular Lens
$534
V2631
Iris Supported Intraocular Lens
$534
V2632
Posterior Chamber Intraocular Lens
$453
V2700
Balance Lens; per Lens
$52
V2702
Deluxe lens feature
B.R.
V2710
Slab off Prism; Glass or Plastic
$78
V2715
Prism; per Lens
$19
V2718
Press-on Lens; Fresnell Prism
$41
V2730
Special Base Curve
$33
V2744
Tint; Photochromatic; per Lens
$20
V2745
Addition to lens; tint, any color, solid, gradient
								or equal, excludes photochromatic, any lens material, per lens
$13
V2750
Anti-Reflective Coating; per Lens
$26
V2755
UV Lens; per Lens
$27
V2756
Eye glass case
$6
V2760
Scratch Resistant Coating
$17
V2761
Mirror coating, any type, solid, gradient or
								equal, any lens material, per lens
B.R.
V2762
Polarization, any lens material, per lens
B.R.
V2770
Occluder Lens; per Lens
$29
V2780
Oversize Lens; per Lens
$15
V2781
Progressive lens, per lens
B.R.
V2782
Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79
								glass, excludes polycarbonate, per lens
$71
V2783
Lens, index greater than or equal to 1.66 plastic
								or greater than or equal to 1.80 glass, excludes polycarbonate, per lens
$80
V2784
Lens, polycarbonate or equal, any index, per lens
$52
V2785
Processing; Transp Corneal Tissue
B.R.
V2786
Specialty occupational multifocal lens, per lens
B.R.
V2787
Astigmatism correcting function of intraocular
								lens
B.R.
V2790
Amniotic membrane for surgical reconstruction, per
								procedure
B.R.
V2797
Vision supply, accessory and/or service component
								of another hcpcs vision code
B.R.
V2799
Vision Service; Miscellaneous
B.R.