reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5111 - Billing Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The HCFA
				  1500 Form is to be used by health care providers except dentist, pharmacy,
				  hospital (unless otherwise stated), and for home and vehicle modifications for
				  billing services provided to workers' compensation claimant. Do not use any
				  other form. A sample HCFA 1500 Claim Form and detailed instruction for proper
				  completion of the form follows.
B.
				  Bills for services rendered should be sent directly to the party responsible
				  for reimbursement. Please do not send your bills directly to the Office of
				  Workers' Compensation as this will delay your payments.
C. Instructions for use of HCFA 1500 Form:
1. provide the claimant's full name and
				  address;
2. indicate the Social
				  Security number; this cuts down on errors and helps correlate the billing to
				  the appropriate file;
3. identify
				  correct date of injury, if possible;
4. complete name and address of the employer,
				  not just an individual's name;
5.
				  name of the insurance carrier;
6.
				  the attending physician should indicate the date the claimant's disability
				  should begin;
7. the attending
				  physician should list all diagnoses and claimant's complaints;
8. the date of the visit, the service(s) or
				  procedure(s) performed and charges;
9. provider's complete name and
				  address;
10. provider's
				  identification number, i.e., tax identification number (TIN) or Social Security
				  number.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5113 - Coding System

Current through Register Vol. 50, No. 6, June 20, 2024
A. Diagnosis
				  Coding.
The International Classification of Diseases, Tenth
				  Revision
(ICD-10-CM) is the basis of diagnosis coding. These are the
				  disease codes in the international classification, tenth revision, clinical
				  modifications published by the U.S. Department of Health and Human
				  Resources.
B. Helpful Hints for
				  Diagnosis Coding
1. To ensure accurate
				  payment, always report the primary diagnosis code on the claim form.
2. Each diagnosis code should be reported
				  when services for multiple diagnosis are filed on the same claim
				  form.
3. All digits of the
				  appropriate ICD-10-CM code(s) should be reported.
4. The date of accident should always be
				  reported if the ICD-10-CM code is for an accident diagnosis.
5. It is important to provide a complete
				  description of the diagnosis if an appropriate ICD-10-CM code cannot be
				  located.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5115 - Surgery Guidelines

Current through Register Vol. 50, No. 6, June 20, 2024
A. General
				  Guidelines
1. Global Surgery. The
				  reimbursement allowances for surgical procedures are based on a global
				  reimbursement concept that covers performing the basic service and the normal
				  range of care required before and after surgery. The global reimbursement
				  includes:
a. the initial evaluation or
				  consultation by a surgeon will be paid separately. The pre-operative policy
				  will include all pre-operative visits, in or out the hospital, by the surgeon
				  beginning the day before the surgery;
b. local anesthesia, such as infiltration,
				  digital or topical anesthesia;
c.
				  normal, uncomplicated follow-up care for the time periods indicated in the
				  follow-up days column to the right of each procedure code. The number in that
				  column establishes the days during which no additional reimbursement is allowed
				  for the usual care provided following surgery, absent complications or unusual
				  circumstances. Follow-up days are specified by procedures. The day of surgery
				  is day one when counting follow-up days;
d. the global fee will include services such
				  as dressing changes, local incisional care, removal of operative packs, removal
				  of cutaneous sutures, staples, lines, wires, tubes, drains, casts and splints;
				  insertion, irrigation and removal of urinary catheters, routine peripheral
				  intravenous lines nasogastric and rectal tubes, and change and removal of
				  tracheostomy tubes.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5119 - Deposition/Witness Fee Limitation

Current through Register Vol. 50, No. 6, June 20, 2024
A. Any
				  health care provider who gives deposition shall be allowed a witness fee.
				  Procedure Code 99075 must be used to bill for a deposition. Reimbursement for a
				  deposition should be a specific amount mutually agreed upon and in writing, in
				  advance of the event. Fees may be at an hourly rate or a flat rate. Disputes
				  over these fees will be resolved in the same manner and subject to the same
				  procedures as established for dispute resolution of claims for workers'
				  compensation benefits.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5121 - Missed Appointments

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  provider shall not receive payment for a missed appointment unless the
				  appointment was arranged by the carrier or the employer. If the carrier or
				  employer fails to cancel the appointment not less than 72 hours prior to the
				  time of the appointment and the provider is unable to arrange for a substitute
				  appointment for that time, the provider may bill the carrier for the missed
				  appointment.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5123 - Copies of Records and Reports

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Health care providers must submit copies of records and reports to carriers,
				  employers, claimants or their attorney and the Office of Workers' Compensation
				  Administration upon request. Providers can facilitate the timely processing of
				  claims and payment for services by submitting appropriate documentation to the
				  carrier/self-insured employer when requested.
B. Health care providers are entitled to
				  recover a reasonable amount, not to exceed $1 per page, to cover the cost of
				  copying documents which have been requested by the carrier.
1. Certain procedure code descriptors require
				  the submission of records and/or reports with the claim form. There is no
				  reimbursement of copy charges to the provider for these required records and
				  reports.
2. Documentation which is
				  submitted by the provider, but was not specifically requested by the carrier,
				  is not allowed a copy charge.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5125 - Special Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
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.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5127 - Physical Medicine

Current through Register Vol. 50, No. 6, June 20, 2024
A. Practicing
				  Physical and Occupational Therapists
1. To
				  bill for physical therapist and/or occupational therapist services under
				  workers' compensation, a practicing therapist must be:
a. currently licensed in the state of
				  Louisiana as a physical therapist or as an occupational therapist;
b. if billing for physical or occupational
				  therapy procedures, you must provide your physical therapist or occupational
				  therapist license number. These procedures will not be reimbursed unless a
				  current Louisiana license number is provided;
c. services must be billed using the
				  appropriate national CPT codes as listed in this manual.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5129 - Allergy and Clinical Immunology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Procedure Codes 95004-95199 must be billed for allergy testing and allergy
				  immunotherapy.
B. When billing for
				  allergy tests, enter the appropriate CPT procedure code in Item 24-D of the
				  HCFA 1500 Form.
1. Enter the total number of
				  tests performed in Item 24-G.
2.
				  Enter the total amount charged for the procedure code in Item 24-F.
3. Allergy skin testing is reimbursed on a
				  per test basis.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5131 - Biofeedback

Current through Register Vol. 50, No. 6, June 20, 2024
A. Biofeedback
				  training may be reimbursed when it is medically necessary. A written plan of
				  care which includes objectives, the estimated length of treatment and stated
				  goals must be submitted to the carrier/self-insured employer for approval prior
				  to the services being provided.
B.
				  The reimbursement of biofeedback is limited to providers currently licensed or
				  certified to provide biofeedback services. Providers include:
1. physicians currently licensed in Louisiana
				  who are certified by or meet certification requirements of the Biofeedback
				  Certification Institute of America;
2. physical therapists and occupational
				  therapists, licensed through the license laws of Louisiana, and biofeedback
				  therapists, certified by the Biofeedback Certification Institute of America,
				  who are employed by physicians. Billings for these biofeedback services
				  provided by these therapists must be submitted by the employer (physician). The
				  appropriate license or certification number must be placed in Item 24-K on the
				  HCFA 1500 Billing Form to receive reimbursement for these procedures.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5133 - Injections

Current through Register Vol. 50, No. 6, June 20, 2024
A. Subcutaneous,
				  Intramuscular and Intravenous
1. Procedure
				  Codes 90700-90749 are reimbursed by report only. The report must include the
				  name of the medication strength and volume injected.
2. When multiple drugs are administered from
				  the same syringe, Modifier-51 must be added to the procedure codes for the
				  second and subsequent drugs.
3.
				  Reimbursement for multiple drugs administered from the same syringe must be at
				  the provider's usual charge or the maximum reimbursement allowable, whichever
				  is less for the first drug, and the provider's charge or 50 percent of the
				  maximum reimbursement allowable, whichever is less for each additional
				  drug.
4. Reimbursement for
				  injections includes the cost of the drug, the charge for the administration of
				  the drug and the cost of the supplies used to administer the drug.
5. Reimbursement for anesthetic agents, such
				  as Xylocaine and Carbocaine, when used for infiltration, is included in the
				  reimbursement for the basic procedure performed and must not be separately
				  reimbursed.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5135 - Evaluation and Management

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Examination, evaluations, treatments, conferences with or concerning patients,
				  and similar medical services necessitate wide variations in the skill, effort,
				  time, responsibility and medical knowledge required for the diagnosis and
				  treatment of work-related illnesses and on the job injuries. The various types
				  of physician visits have been categorized into different levels of service in
				  the CPT.
B. Reimbursement may be
				  made for only one visit per physician per patient per day at the highest level
				  of care provided.
C. When billing
				  for visit and consultations, providers must use the appropriate CPT procedure
				  code that best describes the service rendered.
D. Consultation Services (Procedure Codes
				  99241-99275).
1. A consultation includes
				  services rendered by a physician whose opinion or advice is requested by
				  another physician or other appropriate source for the further evaluation and/or
				  management of the patient.
a. A consultant
				  may initiate diagnostic or therapeutic services at the request of the attending
				  physician.
b. When the
				  documentation supports a consultative service, reimbursement must be at the
				  appropriate consultative level.
c.
				  A copy of the consultation report must be submitted with the bill in order for
				  reimbursement to be made.
d. The
				  reimbursement for a consultation includes payment for the report. Separate
				  reimbursement must not be made for the report.
e. When a physician performs consultative
				  services and subsequently becomes the treating physician for either total or
				  partial care, reimbursement for the consultative services should not be denied
				  by the carrier. The subsequent services must be billed and reimbursed under the
				  appropriate visit codes, not consultation codes.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5137 - Neurologic and Neuromuscular Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. General
1. Neurologic services are typically
				  consultation services and any of the levels of consultation (Procedure Codes
				  99241-99263) may be appropriate. However, when one is the attending physician
				  for or partial care, the appropriate evaluation and management level of service
				  must be billed.
2. Diagnostic
				  studies (nerve conduction tests, electromyograms, electroencephalograms, etc.)
				  are reimbursable in addition to the office visit or consultative
				  service.
3. Diagnostic study
				  includes both a technical component (equipment, technical personnel, supplies,
				  etc.) and a professional component (interpreting test results, written reports,
				  etc.).
4. Billing of the five-digit
				  CPT neurological and neuromuscular procedure codes indicate that the complete
				  service (professional and technical components) is being billed. Reimbursement
				  is the lesser of the provider's charge or the MRA for the procedure.
5. When the professional and technical
				  components are performed by two different health care providers, the total
				  reimbursement for both components must not exceed the listed MRA.
a. The physician bills for the test
				  interpretation and written report by adding Modifier-26 to the five-digit
				  procedure code. The reimbursement is the lesser of the provider's charge or the
				  MRA listed for the five digit procedure code plus Modifier-26.
b. The health care provider who performs the
				  technical component bills for the technical component by adding Modifier-90 to
				  the five digit procedure code. The reimbursement for the technical component is
				  the lesser if the provider's charge or the difference between the MRA for the
				  total procedure and the MRA for the five-digit procedure code plus
				  Modifier-90.
c. When a procedure
				  coded does not list a separate amount for the professional component,
				  reimbursement for the professional component must not exceed 85 percent of the
				  total MRA. The reimbursement for the technical component must not exceed 15
				  percent of the total MRA.
6. When the diagnostic services are provided
				  at a hospital or ambulatory surgical center, the hospital or ambulatory
				  surgical center bills for the technical services and the physician bills for
				  the professional component only, using Modifier-26.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5139 - Psychiatry

Current through Register Vol. 50, No. 6, June 20, 2024
A. General
1. Psychiatric evaluations may be provided as
				  independent medical examinations (IMEs) when requested by the
				  carrier/self-insured employer.
2.
				  Psychiatric evaluations may be provided as consultations when requested by a
				  physician and when authorized by the carrier/self-insured employer.
3. Upon authorization by the
				  carrier/self-insured employer psychiatric treatment may be provided when
				  documentation submitted by the physician to the carrier/self-insured employer
				  substantiates the medical necessity of the treatment and includes the estimated
				  length of treatment.
4.
				  Reimbursement for a routine medical visit rendered by the same physician on the
				  same day as psychiatric therapy is included in the reimbursement for the more
				  comprehensive service.
5. Hypnosis
				  may be reimbursed when it is an integral part of a plan for the treatment of
				  post-traumatic stress disorders arising from on-the-job injuries.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5141 - Soft Tissue Injury Care

Current through Register Vol. 50, No. 6, June 20, 2024
A. Initial
				  Visits
1. Initial (new patient) treatment for
				  soft tissue injuries must be billed under the appropriate medical (office)
				  visit code.
2. When a cast or
				  strapping is applied during initial visit, supplies and materials used such as
				  stockinette, plaster, fiberglass, ace bandages, etc., may be itemized and
				  billed separately using Procedure Code 99070.
3. Replacement casting and strapping codes
				  (29000-29799) must not be used for initial care.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5143 - Thermography

Current through Register Vol. 50, No. 6, June 20, 2024
A. General
				  Information
1. When medically necessary,
				  thermographic testing may be used as an assistive device in the diagnosis of
				  many different conditions.
2. When
				  a request for authorization for thermography is received, carriers must ensure
				  that a specially trained, qualified physician is to perform the test and that
				  written documentation of medical necessity is obtained, when necessary, to
				  substantiate the service.
3. As
				  with all diagnostic tests, thermography should be ordered with discretion by
				  the attending physician and authorized with discretion by the
				  carrier.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5145 - Carrier Responsibilities for Reimbursement Determinations

Current through Register Vol. 50, No. 6, June 20, 2024
A. Medical
				  Consultant. Carriers must utilize the expertise of physicians or other health
				  care professionals in making determinations pertaining to acceptable, safe
				  medical care and treatment and appropriate reimbursement for services rendered.
				  The consultants should have expertise in the areas for which medical or other
				  treatment determinations are made.
B. Carriers must not change, alter, delete or
				  obscure procedure codes.
1. When a carrier
				  questions a procedure code reported by a provider, the carrier must contact the
				  provider for clarification prior to reimbursing a claim. This may result in the
				  carrier requesting additional documentation or a copy of the office or progress
				  note to substantiate the service in question from the provider.
2. If after contacting the provider a carrier
				  determines that available provider documentation does not support the level of
				  service billed the carrier may reimburse the provider at the appropriate level
				  but must ensure that an explanation of medical benefits specifically denotes
				  the action taken and explains the reimbursement made for the service in
				  question.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5147 - Explanation of Medical Benefits (EOMB)

Current through Register Vol. 50, No. 6, June 20, 2024
A. Carriers must provide an explanation of
				  medical benefits (EOMB) to health care providers whenever the carrier's
				  reimbursement differs from the amount billed by the provider. The EOMB must be
				  provided with the reimbursement check.
1. A
				  carrier must use the listed EOMB codes and descriptors to explain why a
				  provider's charge has been reduced or disallowed.
2. A carrier may develop additional EOMB
				  codes, if necessary, to explain the adjustment of a claim, but must furnish to
				  the provider a written explanation of each EOMB code used.
3. The EOMB must contain appropriate
				  identifying information so the provider can relate a specific reimbursement to
				  the applicable claimant, the procedure billed and the date of
				  service.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5149 - Reconsideration of Disputed Reimbursements

Current through Register Vol. 50, No. 6, June 20, 2024
A. When, after examination of the EOMB, a
				  health care provider is dissatisfied with a carrier's payment of a bill for
				  medical services, a reconsideration may be requested by the provider.
1. A provider must make a written request for
				  reconsideration within 60 days from receipt of the EOMB, accompanied by a copy
				  of the bill in question, the carrier's EOMB and any supporting documentation to
				  substantiate the medical necessity of the service and the diagnosis
				  provided.
2. The carrier must
				  process a reconsideration within 60 days of receipt.
a. The carrier must review and re-evaluate
				  the original bill and accompanying documentation using its own medical
				  consultant if necessary.
b. The
				  carrier must notify the provider within 60 days of the results of the
				  reconsideration, explain the reason(s) for their decision and cite the specific
				  policy upon which their final adjustment was made.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5151 - Out-of-State, On-the-Job Injuries or Work-Related Illness Treated in Louisiana

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
				  patient may receive medical services in Louisiana for injuries incurred in an
				  out-of-state accident.
1. If the patient is
				  receiving treatment under the Workers' Compensation Law of another state, this
				  manual may not apply.
2. If the
				  patient is receiving care and treatment in Louisiana pursuant to the Louisiana
				  Act, the reimbursement is subject to the requirements and amount of this manual
				  regardless of the site of injury.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5153 - In State Medical Treatment

Current through Register Vol. 50, No. 6, June 20, 2024
A.
1. Each employer shall furnish all necessary
				  drugs, supplies, hospital care and services, medical and surgical treatment,
				  and any nonmedical treatment recognized by the laws of this state as legal. All
				  such care, services, and treatment shall be performed at facilities within the
				  state when available.
2. When
				  billing for out-of-state services, supporting documentation is necessary to
				  show that the service being provided cannot be performed within the state, or
				  it is closer to patient's domicile to have services performed out of
				  state.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5155 - Maintenance of Schedule

Current through Register Vol. 50, No. 6, June 20, 2024
A. Maintenance
				  of the schedules requires that a database of applicable charges be accumulated
				  by the carrier/self-insured employer. This database will be utilized to profile
				  the charges by each appropriate code.
B. Information Required. In order to update
				  the schedule, each carrier/self-insured employer shall submit the following
				  information for claims incurred in the preceding period. This information shall
				  be submitted to the OWCA upon request. Failure to do so may subject the payor
				  to penalties. The information required for calculation of the reimbursement
				  schedule will include:
Field Name
Length
Type
CPT/HCPCS
5
Alpha/Numeric
Modifier
2
Alpha/Numeric
Unit/Days
3
Numeric
Amount Charged
10
Numeric
Amount Paid
10
Numeric
C.
				  Communication Format. The above information shall be submitted in the following
				  format.
1. Magnetic tape:
a. tape 9-tract, 8.5-inch to 10.5-inch reels
				  with silver mylar reflector (standard reels) with write-ring removed;
b. recording density-1600 or 6250 bytes per
				  inch;
c. recording code-Extended
				  Binary Coded Decimal Interchange Code (EBCDIC);
d. header record must identify submitter and
				  position of each field in the record;
e. tape must have a leading tape mark and an
				  end of file mark;
f. the external
				  label must identify the submitter, the date submitted, the tape number with
				  identification of the total number of tapes submitted and a descriptive
				  narrative of the information contained within the records.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5157 - Maximum Reimbursement Allowances

Current through Register Vol. 50, No. 6, June 20, 2024
A. Table 1
Click Here To View
					 Image
B. Table 2
Click Here To View
					 Image
C. Table 3
Click Here To View
					 Image
AUTHORITY
					 NOTE: Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions › Section I-5315 - Coding System

Current through Register Vol. 50, No. 6, June 20, 2024
A. Resources:
1. CDT-1 manual:
Council on Dental Care Programs
American Dental Association
211 East Chicago Avenue
Chicago, Illinois 60611
(312) 440-2500
2. CPT manual:
AMA Order Dept.
Box 10946
Chicago, Illinois 60610
(800) 621-8335
3. ADA dental claim form:
Council on Dental Care Programs
American Dental Association
211 East Chicago Avenue
Chicago, Illinois 60611
(312) 440-2500
4. HCPCS Manual
MAP
671 Executive Drive
Willowbrook, Illinois 60521
(312) 440-2500
5. NDAS Manual
National Dental Advisory Service
P.O. Box 510949
Milwaukee, WI 53203
(800) 669-3337
6. Relative Values for Dentists
Relative Value Studies, Inc.
P.O. Box 6431
Denver, Colorado 80206
(303) 329-9787
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions › Section I-5317 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Only dental
				  services necessitated by an occupational injury or illness are covered. Such
				  services are provided as a result of damage to the teeth and/or dental work due
				  to a work injury or exposure. In addition, dental appliances and prosthetics
				  not originally purchased by the carrier/self-insured employer will be replaced
				  if damaged or broken in a work-related accident in accordance with the
				  provisions of
				  R.S.
				  23:1203.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions › Section I-5319 - Procedure Codes and Guidelines

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Current Dental Terminology (CDT) is a listing of descriptive terms and
				  identifying codes for reporting dental services and procedures and are used for
				  processing claims benefits. CDT was developed to provide a standard and
				  effective system of reporting dental services to third-party payers for
				  reimbursement. Each procedure or service is identified with a five-digit code.
				  By using these procedures, dental office staff can enhance the speed and
				  accuracy with which a claim may be paid. You should always include the
				  appropriate CDT code(s) when filing a claim.
B. Because medical nomenclature and
				  procedural coding is a rapidly changing field, certain codes may be added,
				  modified or deleted for the next year. Please ensure that your office is using
				  the most current edition of CDT and that you update your codes
				  annually.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions › Section I-5321 - Maximum Allowable Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Maximum Allowable Reimbursement lists the
				  maximum payment allowed for dental items described by appropriate codes.
				  Payment will be the least of:
1. the
				  seventieth percentile in the current edition of the National Dental Advisory
				  Service (NDAS) Comprehensive Fee Report, utilizing the average of geographic
				  multipliers for Louisiana as published in the NDAS report;
2. a pre-negotiated amount between the
				  provider and carrier/self-insured employer; or
3. the amount indicated in the maximum
				  allowable reimbursement schedule.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions › Section I-5329 - Special Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Procedure Codes Not Listed in Rules
1. If a
				  procedure is performed which is not listed in the maximum fee allowance, the
				  health care provider must use an appropriate CDT code descriptor. They 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 fee
				  allowance.
2. The CDT 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.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions › Section I-5341 - Annual Maintenance

Current through Register Vol. 50, No. 6, June 20, 2024
A. To
				  ensure that the maximum allowable reimbursement schedule is as fair as
				  possible, the Office of Workers' Compensation will require the
				  carriers/self-insured employers to submit the following information for claims
				  incurred in the preceding period.
1. This
				  information will be reviewed and any changes to the maximum allowable
				  reimbursement rates will be published.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter A - Definitions › Section I-5501 - Purpose; Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 purpose of these rules is to govern the practice and procedures before the
					 Workers' Compensation Court which is a statewide court having jurisdiction of
					 claims for workers' compensation benefits, the controversion of entitlement to
					 benefits and other relief under the Workers' Compensation Act. These rules are
					 designed to facilitate the equitable, expeditious and simple resolution of
					 workers' compensation disputed claims filed with the Court.
B. As used in these rules, unless otherwise
					 indicated the following words shall have the following meanings.
Claimant
-shall refer to the injured
						employee.
Court
-the Office of Workers'
						Compensation court within the Office of Workers' Compensation Administration of
						the Louisiana Department of Labor.
Director
-the director of the Office of
						Workers' Compensation Administration of the Louisiana Department of
						Labor.
Judge
-a workers' compensation
						judge.
Judicial District
-as referred to in
						R.S. 1310.4, any of the 10 locations of a workers' compensation district
						office, i.e. Shreveport, Monroe, Alexandria, Lake Charles, Lafayette, Baton
						Rouge, Covington, New Orleans, Harahan, Houma, and the parishes each
						encompass.
Mediator
-a workers' compensation
						mediator.
Office
-the Office of Workers'
						Compensation Administration of the Louisiana Department of Labor.
Petitioner
-shall, as the context
						requires, mean the employer, the insurance carrier, the group self-insurance
						fund, the health care provider, claimant, or a dependant of a
						claimant.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter B - Jurisdiction › Section I-5503 - Jurisdiction Authority

Current through Register Vol. 50, No. 6, June 20, 2024
A. Jurisdiction
					 over workers' compensation matters is conferred upon the Office of Workers'
					 Compensation Administration pursuant to Louisiana Constitution Article V,
					 §16. A.(1) and
					 R.S.
					 23:1310.3, et seq.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter B - Jurisdiction › Section I-5505 - Jurisdiction over Subject Matter and Persons

Current through Register Vol. 50, No. 6, June 20, 2024
A. Jurisdiction of the workers' compensation
					 judges shall be governed by
					 R.S.
					 23:1310.3.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter C - Commencement › Section I-5509 - Delay for Answering

Current through Register Vol. 50, No. 6, June 20, 2024
A. A defendant
					 shall file his answer within 15 days after service of the citation in
					 accordance with Code of Civil Procedure
					 Articles
					 1001,
					 1005 and
					 1006. The
					 defendant shall certify that a copy of the answer was sent to all parties to
					 the claim.
B. The filing of the
					 answer shall be deemed timely when the answer is filed as provided in
					 R.S.
					 23:1310.3.D.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter C - Commencement › Section I-5511 - Service

Current through Register Vol. 50, No. 6, June 20, 2024
A. Service of
					 process in a workers' compensation claim shall be as provided for in
					 R.S.
					 23:1310.3(C).
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter D - Venue › Section I-5515 - Proper Venue

Current through Register Vol. 50, No. 6, June 20, 2024
A. Proper venue in
					 a workers compensation claim shall be governed by
					 R.S.
					 23:1310.4.
B. When the claimant or his dependent is not
					 a party to the disputed claim, the petitioner shall have the right to select
					 the venue of necessary hearings by the workers' compensation judge as provided
					 in the Code of Civil Procedure.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter E - Recusal › Section I-5525 - Procedure for Recusal of a Workers' Compensation Judge

Current through Register Vol. 50, No. 6, June 20, 2024
A. Recusal of a workers' compensation judge
					 shall be governed by Code of Civil Procedure
					 Article
					 151.
B. A workers' compensation judge may recuse
					 himself, prior to a judgment being rendered, whether a motion for his
					 recusation has been filed by a party or not, in any cause in which a ground for
					 recusation exists.
C. If a judge
					 recuses himself pursuant to this Section, he shall provide in writing to the
					 Chief Judge the specific grounds under Code of Civil Procedure
					 Article
					 151 for which the recusal is ordered within
					 15 days of the rendering of the order of recusal.
D. On written application of a workers'
					 compensation judge, the chief judge shall immediately reassign the matter to
					 another workers' compensation judge in either the same workers' compensation
					 district office or another workers' compensation district office.
E. Any party to a workers' compensation claim
					 may file a written motion for recusal of the judge to whom the matter is
					 assigned specifying the grounds for recusal. This motion shall be filed prior
					 to trial or hearing unless the party discovers the facts constituting the
					 ground for recusal thereafter. In such case, the motion shall be filed
					 immediately after the facts are discovered, but in no case after judgment. If a
					 valid ground for recusation is set forth in the motion, the judge shall either
					 recuse himself or refer the matter to the chief judge. Upon receipt of the
					 motion the chief judge shall either try the motion or assign it to another
					 workers' compensation judge for trial. Trial of the motion shall be held in an
					 expedited manner and in no event later than 14 days following filing of the
					 motion.
F. If a valid ground for
					 recusation is not set forth in the motion, the judge shall deny the motion and
					 proceed with the trial of the cause. Any party aggrieved by any denial may file
					 an appeal in accordance with the provisions of
					 R.S.
					 23:1310.5.
G. Consolidated cases are to be considered as
					 one case within the meaning of this Section.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter F - Power and Authority › Section I-5533 - General

Current through Register Vol. 50, No. 6, June 20, 2024
A. Workers'
					 compensation judges shall have the power to enforce any lawful order and the
					 discretionary authority to use necessary sanctions, including dismissal, in
					 order to control the orderly process of the hearing, enforce orders, and these
					 rules.
B. All workers' compensation
					 judges shall be subject to the Code of Judicial Conduct, Civil Service Rules,
					 the Louisiana Code of Governmental Ethics and the Louisiana State Bar
					 Association Code of Professional Conduct.
C. All workers' compensation mediators shall
					 be subject to the Civil Service Rules, the Louisiana Code of Governmental
					 Ethics, and the Louisiana State Bar Association Code of Professional
					 Conduct.
D. A workers' compensation
					 judge or mediator shall not refer any claimant to an attorney for
					 representation in a workers' compensation matter except under the following
					 circumstances:
1. when ordered to appoint an
					 attorney for an unrepresented party by a court of competent
					 jurisdiction;
2. except as provided
					 in §5709.
					 B of these rules; or
3. when the judge has a reasonable belief
					 that the unrepresented party lacks capacity to represent himself.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter F - Power and Authority › Section I-5534 - Submission and Investigation of Complaints alleging Judicial Misconduct or Disability

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Complaints alleging misconduct or disability on the part of any workers'
					 compensation judge shall be submitted to the director in writing, and shall
					 include:
1. the complainants full name,
					 address, and telephone number;
2.
					 the judges name and assigned court;
3. a statement detailing the alleged
					 misconduct or disability, including all underlying facts and the names and
					 addresses of any persons having knowledge relevant to the complaint, and if
					 known, the particular judicial cannons, rules of professional conduct, Civil
					 Service rules, or other rules allegedly violated;
4. copies of any pleadings, orders,
					 judgments, or other documents relevant to the complaint;
5. if the alleged misconduct or disability
					 concerns a specific matter pending before the judge, the complainant shall list
					 all parties thereto and/or their counsel of record, and shall certify that a
					 copy of the complaint has been provided to them via facsimile, other electronic
					 transmission, or by certified mail.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter F - Power and Authority › Section I-5535 - Contempt

Current through Register Vol. 50, No. 6, June 20, 2024
A. Contempt of
					 court is any act or omission tending to obstruct or interfere with the orderly
					 administration of justice, or to impair the dignity of the court or respect for
					 its authority.
B. Contempt
					 proceedings in a workers' compensation proceeding shall be governed by
					 R.S.
					 23:1310.7.B. This procedure is favored and
					 shall be construed to accomplish the just, speedy, and orderly process of the
					 hearing.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter F - Power and Authority › Section I-5537 - Procedure

Current through Register Vol. 50, No. 6, June 20, 2024
A. The procedure
					 for contempt of court shall be as found in
					 R.S.
					 23:1310.7.
B. Form for Judges to Report Contempt
					 Findings
Click here to view
						Image
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						23:1310.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 55 - General Provisions › Subchapter G - Clerks › Section I-5539 - District Clerk; Pleadings Filed; Docket Books

Current through Register Vol. 50, No. 6, June 20, 2024
A. Each workers' compensation district and
					 the records management division shall have a clerk(s), who shall have the
					 authority to certify records of the office. The supervisor of the records
					 management division shall be the custodian of all records and documents for
					 that district or the office and no such records, documents, or paper shall be
					 withdrawn.
B. The manager of the
					 records management division shall be the custodian of all records and documents
					 for that district or offices and no such records, documents, or paper shall be
					 withdrawn.
C. The manager of the
					 records management division shall be the custodian of all records and documents
					 for that district or offices and no such records, documents, or paper shall be
					 withdrawn.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.