reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines › Subchapter B - Shoulder Injury Medical Treatment Guidelines › Section I-2319 - Initial Diagnostic Procedures

Current through Register Vol. 50, No. 6, June 20, 2024
A. The OWCA recommends the following
					 diagnostic procedures be considered, at least initially, the responsibility of
					 the workers' compensation carrier to ensure that an accurate diagnosis and
					 treatment plan can be established. Standard procedures that should be utilized
					 when initially diagnosing a work-related shoulder complaint are listed below.
1. History Taking and Physical Examination
					 (Hx and PE) are generally accepted, well-established and widely used procedures
					 that establish the foundation/basis for and dictates subsequent stages of
					 diagnostic and therapeutic procedures. List of medications patient is taking
					 should be included in every history, including over the counter medicines as
					 well as supplements. When findings of clinical evaluations and those of other
					 diagnostic procedures are not complementing each other, the objective clinical
					 findings should have preference. The medical records should reasonably document
					 the following:
a. History of Present Injury
i. Mechanism of injury. This includes details
					 of symptom onset and progression, and documentation of right or left
					 dominance;
ii. Relationship to
					 work. This includes a statement of the probability that the illness or injury
					 is work-related;
iii. Prior
					 occupational and non-occupational injuries to the same area including specific
					 prior treatment;
iv. History of
					 locking, clicking, weakness, acute or chronic swelling, crepitation, pain while
					 lifting or performing overhead work, dislocation or popping. Pain or catching
					 with overhead motion may indicate a labral tear. Night time pain can be
					 associated with specific shoulder pathology. Anterior joint pain, such as that
					 seen in throwing athletes, may indicate glenohumeral instability. Pain
					 radiating below the elbow, may indicate cervical disc problems or proximal
					 entrapment neuropathy.
v. Ability
					 to perform job duties and activities of daily living; and
vi. Exacerbating and alleviating factors of
					 the reported symptoms. The physician should explore and report on non-work
					 related as well as, work related activities.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines › Subchapter B - Shoulder Injury Medical Treatment Guidelines › Section I-2323 - Specific Diagnosis, Testing and Treatment

Current through Register Vol. 50, No. 6, June 20, 2024
A. Acromioclavicular joint
					 sprains/dislocations. An acute acromioclavicular (AC) joint injury is
					 frequently referred to as a shoulder separation. There are six classifications
					 of AC joint separation, which are based upon the extent of ligament damage and
					 bony displacement:
1. Description/Definition:
a. Type I - Sprain of the AC ligament and
					 capsule; x-ray usually normal.
b.
					 Type II - Sprains consisting of a ruptured AC ligament and capsule with
					 incomplete injury to the coracoclavicular (CC) ligament, resulting in mild AC
					 joint subluxation. X-ray shows clavicle slightly elevated.
c. Type III - Dislocation of the clavicle
					 above the acromion with complete tear of the AC ligament and/or CC ligaments;
					 abnormal stress x-rays.
d. Type IV.
					 - Dislocation consisting of a displaced clavicle that penetrates posteriorly
					 through or into the trapezius muscle. The sterno-clavicular joint may also be
					 dislocated.
e. Type V - Dislocation
					 consisting of complete separation of the AC and CC ligaments and dislocation of
					 the acromioclavicular joint with a large coracoclavicular interval.
f. Type VI - Dislocation consisting of a
					 displaced clavicle that penetrates inferior to the coracoid.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines › Subchapter B - Shoulder Injury Medical Treatment Guidelines › Section I-2328 - LWC-WC 1009. Disputed Claim for Medical Treatment

Current through Register Vol. 50, No. 6, June 20, 2024
E-Mail to: medicalservices@LWC.la.gov
Fax to: OWCA - Medical Services 1. Social Security No.
						__-__-__
ATTN: Medical Director 2. Date of Injury/Illness
						__-__-__
(225) 342-6556 3. Parts of Body Injury_________
Mail to: Medical Services 4. Date of Birth
						__-__-__
P.O. Box 94040 5. Date of This Request __-__-__
Baton Rouge, LA 70804 6. Claim Number
						____________
DISPUTED CLAIM FOR MEDICAL TREATMENT
NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS THERE ARE
						MEDICAL SERVICES IN DISPUTE AS PER
						R.S.
						23:1203.1 J AND THE FOLLOWING HAS
						OCCURRED:
A. The insurer has issued a
					 denial.
B. The insurer has issues
					 an approval with modification.
C.
					 The insurer's failure to act has resulted in a deemed denial.
D. The aggrieved party is seeking a variance
					 from the medical treatment schedule
DISPUTES RELATING TO COMPENSABILITY AND/OR CAUSATION ARE
						NOT ADDRESSED BY THE MEDICAL DIRECTOR.
GENERAL INFORMATION
Claimant files this dispute with the Office of Workers'
						Compensation Medical Services Director. This office must be notified
						immediately in writing of changes in address. An employee may be represented by
						an attorney, but it is not required.
7. This request is submitted by
___ Employee ____ Health Care Provider ___ Other
						________________
The following records/documents
MUST
be attached to this request.
						Failure to do so may result in the rejection of the request by the OWCA
						director:
A. Copies of all relevant
					 information must be included with this request as per LAC 40:I.2715
					 J.
B. If applicable, a copy of the
					 denial letter issued by the insurance carrier must be attached to this
					 request.
C. A copy of this request
					 with all supporting documentation must be mailed or emailed to all parties at
					 their designated fax or email address.
EMPLOYEE
EMPLOYEE'S
								  ATTORNEY
8. Name ___________________
9. Name
								  __________________
Street or Box _______________
Street or
								  Box ______________
City ______________________
City
								  _____________________
State __________ Zip _______
State
								  ________ Zip _________
Phone (____) ______________
Phone (____)
								  ______________
Fax (____) ______________
EMPLOYER
INSURER/ADMINISTRATOR
(circle one)
10. Name __________________
11. Name
								  _________________
Street or Box _______________
Street or
								  Box ______________
City ______________________
City
								  _____________________
State __________ Zip _______
State
								  ________ Zip _________
Phone (____) ______________
Phone (____)
								  ______________
Fax (____) ______________
Fax (____)
								  ______________
TREATING/REQUESTING
PHYSICIAN
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2505 - Hospital Inpatient Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Reimbursement for inpatient hospital
				  services will be limited to the lesser of covered billed charges or the per
				  diem amount. The per diem rate assigned to the Standard Metropolitan
				  Statistical Area in which the services are rendered will be applied to
				  inpatient days by type of service, either medical or surgical.* The
				  reimbursement amount will be reduced by charges for noncovered items and
				  services.
NOTE: *The diagnosis/procedure code requiring the greatest
					 resource consumption (severity) should be used to assign the correct
					 category.
B. Using the
				  following Per Diem Rate Schedule, the formula for calculating payment amount
				  is:
Per Diem Rate x Inpatient Days = per Diem Amount
1. If billed charges per diem amount, pay per
				  diem amount less noncovered charges.
2. If billed charges < per diem amount,
				  pay billed charges less noncovered charges.
Per Diem Rate Schedule
SMSA*
Medical per Diem
Surgical per Diem
Alexandria
$1212
$1628
Baton Rouge
$1125
$2015
Houma-Thibodaux
$ 908
$1697
Lafayette
$1009
$1655
Lake Charles
$ 946
$1645
Monroe
$1050
$1654
New Orleans
$1186
$2059
Nonmetropolitan
$ 771
$1570
Shreveport
$1198
$1629
*Please refer to Exhibit I for listing of
								hospitals within each SMSA.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2507 - Outpatient Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Outpatient hospital and ambulatory surgery services will be reimbursed at
				  covered charges less a 10 percent discount. The formula for calculating payment
				  amount is:
(Billed Charges) - (Noncovered Charges) = Covered Charges
					 x 0.90 = Payment Amount
B.
				  If a patient is admitted as an outpatient, however; is in the hospital
				  overnight, this will be considered outpatient services. When patient is in
				  hospital by midnight census of day two, this becomes an inpatient admission,
				  thus services are paid at per diem rate. In addition, all procedures which can
				  safely be performed as outpatient procedures shall be reimbursed as such.
				  (Reference the Utilization Review Procedures, Chapter 27).
C. For a hospital admission to be subject to
				  inpatient reimbursement, it must be medically necessary and not solely for the
				  convenience of the payor.
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 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2509 - Psychiatric and Chemical Dependency Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Inpatient. Reimbursement for inpatient
				  psychiatric and/or chemical dependency unit services will be limited to the
				  lesser of covered billed charges or the per diem amount.
1. The uniform statewide per diem rates will
				  be applied to inpatient days by type of service, either psychiatric or chemical
				  dependency.
2. The reimbursement
				  amount will be reduced by charges for noncovered items and services.
Per Diem Rate Schedule
Psychiatric Services
$799
Chemical Dependency Unit Services
$597
3.
				  Using the above per diems, the formula for calculating payment amount is the
				  same as that for acute care inpatient services found in
				  §2505.
				  B.1
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2511 - Rehabilitation Services Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Inpatient. Reimbursement for inpatient
				  rehabilitation facility services will be limited to the lesser of covered
				  billed charges or the per diem amount.
1. The
				  uniform statewide per diem rate will be applied to inpatient days by type of
				  facility, either hospital based or freestanding.
2. The reimbursement amount will be reduced
				  by charges for noncovered items and services.
Per Diem Rate Schedule
Hospital Based Rehabilitation Facility
$ 704
Freestanding Rehabilitation Facility
$1225
3.
				  Using the above per diems, the formula for calculating payment amount is the
				  same as that for inpatient hospital services found in
				  §2505.
				  B.1
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2513 - Skilled Nursing and Intermediate Facility Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Reimbursement for skilled nursing facility
				  or intermediate care (swing bed) facility services will be limited to the
				  lesser of covered billed charges or the per diem amount.
1. The uniform statewide per diem rates will
				  be applied to inpatient days by type of facility, either hospital-based or
				  freestanding.
2. The reimbursement
				  amount will be reduced by charges for noncovered items and services.
Per Diem Rate Schedules
Skilled Nursing Facility
Hospital Based
$294
Freestanding
$ 69
Intermediate Care Facility
Hospital Based
$224
Freestanding
$ 63
3.
				  Using the above per diems, the formula for calculating payment amount is the
				  same as that for inpatient hospital services found in
				  §2505.
				  B.1
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2515 - Hospice Services Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Hospice care services will be reimbursed
				  at the lesser of covered billed charges or the per diem, per shift, or per hour
				  rate.
1. The uniform statewide rates depicted
				  in the table below will be applied by type of facility, either hospital based
				  or freestanding.
2. The four
				  categories of service are defined by the intensity of care, the skill level of
				  the caregiver, and the place of service as follows.
a. Routine Home Care. The hospice is paid the
				  routine home care rate for each day the patient is under the care of the
				  hospice and not receiving one of the other categories of hospice care. This
				  rate is paid without regard to the volume or intensity of routine home care
				  services provided on any given day, and is also paid when the patient is
				  receiving hospital care for a condition unrelated to their terminal
				  condition.
b. Continuous Home Care.
				  Continuous home care is to be provided only during a period of crisis. A period
				  of crisis is a period in which a patient requires continuous care which is
				  primarily nursing care to achieve management of acute medical symptoms.
i. Nursing care must be provided by either a
				  registered nurse or a licensed practical nurse and a nurse must be providing
				  care for more than half of the period of care.
ii. A minimum of eight hours of care must be
				  provided during a 24 hour day which begins and ends at midnight. This care need
				  not be continuous.
iii. Continuous
				  home care is covered when it is provided to maintain an individual at home
				  during a medical crisis. If less skilled care is needed on a continuous basis
				  to enable the person to remain at home, this is covered as routine home
				  care.
c. Respite Care.
				  Respite care is short-term inpatient care provided to the individual only when
				  necessary to relieve the family members or other persons caring for the
				  individual at home. Respite care may be provided only on an occasional basis
				  and may not be reimbursed for more than five consecutive days at a time.
				  Payment for the sixth and any subsequent days is to be made at the routine home
				  care rate.
d. General Inpatient
				  Care. Payment at the inpatient rate is made when general inpatient care is
				  provided. None of the other fixed payment rates are applicable for a day on
				  which the patient receives hospice inpatient care.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2517 - Hospice Care Rate Schedule

Current through Register Vol. 50, No. 6, June 20, 2024
A. Schedule
Routine
*Continuous
Respite
General Inpatient
Hospital Based
$114
$28
$117
$504
Freestanding
$116
$29
$120
$513
*(Continuous Home Care is an hourly rate. All
								others are per diems)
B.
				  The formulas for calculating payment amount by category of service are:
1. routine home care, respite care and
				  general inpatient care:
Per Diem Rate x days = Per Diem Amount;
a. if billed charges per diem amount, pay per
				  diem amount less noncovered charges;
b. if billed charges < per diem amount,
				  pay billed charges less noncovered charge;
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2521 - Hospital Billing Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Introduction
1. The purpose of this document
				  is to facilitate the billing process for hospital services.
2. For an overview of the workers'
				  compensation program and policies covering treatment of compensable
				  work-related injuries and illnesses, please refer to the carrier/self-insured
				  employer.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2523 - Required Information for Billing Inpatient Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Itemization
1. Billing for hospital and other
				  institutional type services must be submitted on a UB-92 Form as developed and
				  implemented by the National Uniform Billing (UB-92) Committee. A copy of this
				  form is on the last page of this Section.
2. Please itemize inpatient charges with the
				  applicable UB-92 revenue codes. The use of all inclusive accommodation and
				  ancillary revenue codes is not acceptable. These codes may contain services
				  which are noncovered.
3. Invalid
				  revenue codes which are not assigned or defined in the UB-92 manual are not
				  allowed.
4. Sample UB-92 Form
Click Here To View
					 Image
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2525 - Inpatient Services Not Billable on the UB-92

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following inpatient services are not
				  billable on the UB-92 Form unless they are customarily billed in that manner:
1. durable medical equipment when charges
				  exceed $150;
2. orthotic/prosthetic
				  appliance when charges exceed $150 (Pacemakers and other surgically implanted
				  devices may be billed on UB-92);
3.
				  ambulance;
4.
				  psychiatric/psychological treatments and services;
5. therapeutic services;
6. professional services customarily billed
				  separately must be billed on the HCFA-1500 Claim Form; and
7. separate sets of billing instructions have
				  been developed for the following services:
a.
				  professional services (including chiropractor and physical therapy);
b. durable medical equipment and
				  supplies;
c. prosthetic and
				  orthotic equipment;
d. medical
				  transportation (ambulance);
e.
				  respiratory therapy; and
f.
				  nursing/home health and attendant services.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2527 - Inpatient Revenue Codes Not Billable on the UB-92

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following revenue codes must be billed
				  on the HCFA 1500 Form as professional services.
Revenue Code(s)
Description
290
Durable Medical Equipment (DME) General
								Classification (Except charge under $150)
291
DME-Rental
292
DME-Purchase
299
DME-Other Equipment
540-549
Ambulance Services
900-909
Psychiatric/Psychological Treatments
910-919
Psychiatric/Psychological Services
940-949
Therapeutic Services
960-989
Professional Fees
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 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2529 - Required Information for Billing Outpatient Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Itemization. Please itemize outpatient
				  charges with the applicable revenue codes. The use of all inclusive ancillary
				  revenue codes is not acceptable.
B.
				  Reports. Supporting documentation of services rendered may be attached to
				  billings for outpatient services. Such reports are:
1. emergency room reports;
2. operative reports, if surgery was
				  performed; and
3. discharge
				  summary, if surgery was performed.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2531 - Outpatient Services Not Billable on the UB-92

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following services are not billable on
				  the UB-92 Form unless they are customarily billed in that manner:
1. ambulance;
2. psychiatric/psychological treatments and
				  services;
3. therapeutic
				  services;
4. all professional
				  services including those provided by salaried personnel that are customarily
				  billed separately and those provided in connection with emergency room service.
				  These type of professional services must be billed on the HCFA-1500
				  Form;
5. outpatient clinic
				  services; and
6. all outpatient
				  durable medical and prosthetic/orthotic items.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2533 - Outpatient Revenue Codes Not Billable on the UB-92

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following revenue codes must be billed
				  on the HCFA 1500 Form.
Revenue Code(s)
Description
274
Medical/Surgical Supplies Prosthetics
277
Medical/Surgical Supplies Take Home Oxygen
290
Durable Medical Equipment (DME) General
								Classification
291
DME-Rental
292
DME-Purchase
299
DME-Other Equipment
500-539
Outpatient Services, Clinic, Free-Standing Clinic
								and Osteopathic Services
570-599
Home Health Services
540-549
Ambulance Services
550-559
Skilled Nursing
820-859
Dialysis Service
860-879
Not Assigned
880-889
Miscellaneous Dialysis Services
900-909
Psychiatric/Psychological Treatments
910-919
Psychiatric/Psychological Services
940-949
Therapeutic Services
960-989
Professional Fees
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 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2539 - Annual Maintenance

Current through Register Vol. 50, No. 6, June 20, 2024
A. To
				  ensure that the reimbursement for the procedures are as fair as possible, the
				  Office of Workers' Compensation will require the self insured employer or
				  carrier to submit the following information for claims incurred in the
				  preceding period. This information will be reviewed and any changes to the
				  maximum allowable reimbursement rates will be published.
B. Information Required. The information
				  required for calculation of the reimbursement schedule will include:
Information
Field Length
Type
FIP-Parish Code
3
Numeric
Provider Name
35
Alpha Numeric
Charge Amount
10
Numeric
Type of Service: Medical vs. Surgical*
30
Alpha
Length of Stay
4
Numeric
IP/OP indicator
1
Alpha
*The diagnosis/procedure code requiring the
								greatest resource consumption (severity) should be used to assign the correct
								category.
C.
				  Communication Format. The following is the current format, however, the Office
				  of Workers' Compensation will establish the format on an annual basis to
				  facilitate the review:
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. The external label must identify the submitter, the date
				  submitted, the tape number with identification of the total number of tapes
				  submitted and the 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 25 - Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2599 - Appendix A-F.I.P.S. Area Codes

Current through Register Vol. 50, No. 6, June 20, 2024
Appendix A
F.I.P.S. Area Codes
001 Acadia
003 Allen
005 Ascension
007 Assumption
009 Avoyelles
011 Beauregard
013 Bienville
015 Bossier
017 Caddo
019 Calcasieu
021 Caldwell
023 Cameron
025 Catahoula
027 Claiborne
029 Condordia
031 DeSoto
033 East Baton Rouge
035 East Carroll
037 East Feliciana
039 Evangeline
041 Franklin
043 Grant
045 Iberia
047 Iberville
049 Jackson
051 Jefferson
053 Jefferson Davis
055 Lafayette
057 Lafourche
059 LaSalle
061 Lincoln
063 Livingston
065 Madison
067 Morehouse
069 Natchitoches
071 Orleans
073 Ouachita
075 Plaquemines
077 Pointe Coupee
079 Rapides
081 Red River
083 Richland
085 Sabine
087 St. Bernard
089 St. Charles
091 St. Helena
093 St. James
095 St. John the Baptist
097 St. Landry
099 St. Martin
101 St. Mary
103 St. Tammany
105 Tangipahoa
107 Tensas
109 Terrebonne
111 Union
113 Vermillion
115 Vernon
117 Washington
119 Webster
121 West Baton Rouge
123 West Carroll
125 West Feliciana
127 Winn
998 Out-of-State
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 27 - Utilization Review Procedures › Section I-2701 - Statement of Policy

Current through Register Vol. 50, No. 6, June 20, 2024
A. It is the
				  intent of this rule to establish procedures and policies appropriate to the
				  fulfillment of the powers, duties, and functions of the director of the Office
				  of Workers' Compensation as set forth in
				  R.S.
				  23:1291 (Act 938 of the 1988 Regular
				  Session).
				  R.S.
				  23:1291 empowers the director of the Office
				  of Workers' Compensation:
1. "to resolve
				  disputes over the necessity, advisability, and cost of proposed or already
				  performed hospital care or services, medical or surgical treatment, or any
				  nonmedical treatment recognized by the laws of this state as legal.";
				  and
2. "to audit the specific
				  medical records of the patient under treatment by any health care provider who
				  has furnished services or treatment to a person covered by this Chapter, or the
				  records of any person or entity rendering care, services, or treatment or
				  furnishing drugs or supplies for the purpose of determining whether an
				  inappropriate reimbursement has been made."
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2703 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Managed care
				  activities are defined as a set of coordinated cost and utilization management
				  activities by the carrier/self-insured employer to assure appropriate payment
				  for health care services rendered to employees eligible for workers'
				  compensation benefits in the state of Louisiana.
1. Pre-admission certification review is the
				  cornerstone of utilization management. The pre-admission certification review
				  notice (i.e., telephone call or written notification) is the claimant's entry
				  into the benefits management system and triggers other utilization management
				  functions. During pre-admission certification review, all utilization
				  management activities can be coordinated. When cases are reviewed before
				  hospitalization, this activity works to promote appropriate lengths of stay,
				  discharge planning, and ambulatory care. The pre-admission certification
				  program reviews and certifies, before hospitalization, that a proposed hospital
				  admission is both medically necessary and appropriate. It is not a process of
				  substituting judgement for that of the physician, but rather making a
				  determination of what level of care is to be reasonable and necessary under the
				  provisions of the Louisiana Workers' Compensation Act.
2. The following managed care activities
				  required by the Louisiana Workers' Compensation Act are described:
				  pre-admission certification, admission certification, continued stay review
				  (including length of stay assignment), discharge planning, reporting standards
				  and dispute resolution, ambulatory surgery, and second surgical
				  opinion.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2705 - Pre-Admission Certification

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Pre-admission certification is the review and assessment of the medical
				  necessity and appropriateness of non-emergency hospital admissions before
				  hospitalization has occurred. The appropriateness of the site and the level of
				  care is assessed along with the timing of the proposed admission. Actual
				  payment for services is also contingent upon the carrier/self-insured
				  employer's verification of:
1. claimant's
				  entitlement to benefits at the time hospitalization actually occurs;
				  and
2. statutory coverage for the
				  care that is actually provided.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2709 - Discharge Planning

Current through Register Vol. 50, No. 6, June 20, 2024
Discharge planning is the process of assessing a patient's
					 need for treatment after hospitalization and effecting an appropriate and
					 timely discharge. The hospital has major responsibility for this function with
					 the carrier/self-insured employer promoting, monitoring, and assisting the
					 hospital.
A. Discharge Planning
				  Procedures
1. Discharge planning is primarily
				  the responsibility of the hospital.
2. The carrier/self-insured employer supports
				  discharge planning by identifying and referring patients who may need discharge
				  planning, by assisting the hospital with information on statutory coverage and
				  alternative providers, and by monitoring hospitals to assure that appropriate
				  discharge planning services are provided.
3. Discharge planning cases are identified
				  primarily by the hospital. These services may not be duplicated by the
				  carrier/self-insured employer if they are provided by the hospital. However, in
				  addition, the carrier/self-insured employer identifies cases through
				  pre-admission certification, admission review, continued stay review, and other
				  managed care activities.
4. The
				  carrier/self-insured employer requires appropriate hospital documentation on
				  cases processed through discharge planning.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2711 - Second Surgical Opinion

Current through Register Vol. 50, No. 6, June 20, 2024
A. When surgery
				  has been recommended by the treating physician, the carrier/self-insured
				  employer is entitled to obtain a second professional opinion from a physician
				  chosen by the carrier/self-insured employer. Regardless of the second surgical
				  opinion outcome, the claimant remains free to elect not to undergo surgery
				  after the consultation. The carrier/self-insured employer is responsible for
				  informing the claimant when a second surgical opinion is required and for
				  referring the claimant to a second surgical opinion physician. This Program is
				  designed to reduce unnecessary surgeries and to provide the claimant with
				  possible alternate courses of treatment so that he or she can make an informed
				  decision.
B. Second Surgical
				  Opinion Procedures
1. The following is a list
				  of surgical procedures that usually require a second opinion.
Spinal Surgery
Foot Surgery
Gastrectomy
Hemorrhoidectomy
Coronary Artery Bypass
Varicose Vein Surgery
Knee Surgery
Traumatic Cataract Surgery
Nasal Surgery
Joint Replacement
2.
				  The carrier/self-insured employer should have in place a process to waive
				  second surgical opinions on the basis of defined criteria.
3. The carrier/self-insured employer shall
				  develop manual procedures or develop an automated system for administering
				  program requirements, selecting consultants, documenting claimant compliance
				  with the program, and efficiently handling claimant and physician
				  contacts.
4. The second surgical
				  opinion consultation and any tests necessary for the second surgical opinion
				  consultant to render an opinion on the proposed surgery are to be paid by
				  carrier/self-insured employer.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2713 - Ambulatory Surgery

Current through Register Vol. 50, No. 6, June 20, 2024
A. Ambulatory
				  surgery refers to a program which recommends that specified surgical procedures
				  be performed on an outpatient basis. The program is designed to reduce
				  unnecessary hospitalizations and to shift care to less costly settings if
				  medically appropriate. The surgeon is responsible for following the specified
				  guidelines for procedures which should be performed in an outpatient
				  setting.
B. Ambulatory Surgery
				  Procedures
1. The following is a list of
				  surgical procedures and tests that are classified as primarily outpatient
				  procedures not requiring hospitalization under normal circumstances.
Arthroscopy
Brush Biopsy of Stomach
Blood Transfusions
Carpal Tunnel Release
Closed Reduction Nasal Fracture
Cystoscopy
Closed Reduction of Dislocation or Fracture
Dx Radiological Procedures in Absence of Acute
								Admittable Illness
Dx Ultrasound
Esophagoscopy
Exploration Tendon Sheath-Hand
Excision Lesion Tendon Sheath-Hand
Excision Lesion Tendon Sheath
Fiberoptic Bronchoscopy
Flex Fiberoptic Colonoscopy
Gastroscopy
Lid Reconstruction
Laryngoscopy/ Tracheoscopy
Large Bowel Endoscopy
Laparoscopy
Other Larynx Diagnostic Procedures
Other Fusion of Toe
Other Skin and Subcutaneous Incision/Drainage
Other Local Destruction of Skin
Peripheral Nerve Biopsy
Plastic Repair External Ear
Partial Ostectomy
Sinus Puncture for Lavage
Surgical Tooth Extraction
Small Bowel Endoscopy-via existing surgical ostomy
Skin Incision and Foreign Body Removal
Skin and Subcutaneous Biopsy
Skin Suture
Tooth Extraction
Turbinate Fracture
Tenotomy of Hand
Total Ostectomy-Digit
Turbinectomy by Diathermy/Cryosurgery
The Office of Workers' Compensation may expand
								this list pursuant to its rulemaking authority.
2.
				  The carrier/self-insured employer should not waive ambulatory surgeries except
				  on the basis of defined criteria, which must include at least the following:
a. presence of other documented medical
				  problems that make prolonged pre-operative or post-operative observation
				  medically necessary;
b. inability
				  to provide proper post-operative care at home; and
c. likelihood that another major surgical
				  procedure might follow the initial procedure.
3. The carrier/self-insured employer should
				  have an automated system for administering program requirements and documenting
				  provider compliance with the program.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2715 - Medical Treatment Schedule Authorization and Dispute Resolution

Current through Register Vol. 50, No. 6, June 20, 2024
A. Purpose. It is the purpose of this Section
				  to facilitate the management of medical care delivery, assure an orderly and
				  timely process in the resolution of care-related disputes; identify the
				  required medical documentation to be provided to the carrier/self-insured
				  employer to initiate a request for authorization as provided in
				  R.S.
				  23:1203.1(J); and provide
				  for uniform forms, timeframes, and terms for suspension of prior authorization
				  process, withdrawal of request for authorization, authorization, denial, and
				  dispute resolution in accordance with
				  R.S.
				  23:1203.1.
B. Statutory Provisions
1. Emergency Care
a. In addition to all other utilization
				  review rules and proceduR.S. res,
				  23:1142 provides that no prior consent by the
				  carrier/self-insured employer is required for any emergency medical procedure
				  or treatment deemed immediately necessary by the treating health care provider.
				  Any health care provider who authorizes or orders diagnostic testing or
				  treatment subsequently held not to have been of an emergency nature shall be
				  responsible for all of the charges incurred in such testing or treatment. Such
				  health care provider shall bear the burden of proving the emergency nature of
				  the diagnostic testing or treatment.
b. Fees for those services of the health care
				  provider held not to have been of an emergency nature shall not be an
				  enforceable obligation against the employee or the employer or the employer's
				  workers' compensation insurer unless the employee and the payor have agreed
				  upon the treatment or diagnostic testing by the health care provider.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2717 - Medical Review Guidelines

Current through Register Vol. 50, No. 6, June 20, 2024
A. Workers'
				  Compensation is designed to provide indemnity and medical care benefits for
				  workers who sustain injuries or illnesses arising out of and in the course and
				  scope of employment. The following instructions give some general guidelines
				  for medical review of workers' compensation claims.
B. Technical Considerations for Review of
				  Claims
1. Prior to a detailed medical review,
				  a cursory review of the claim should be accomplished and should include at
				  least the following.
a. Job related
				  illness/injury must be identified.
b. Each service/item billed must be
				  identifiable.
c. Billing period
				  must be identified.
d. Appropriate
				  forms must be used and filled out completely.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2718 - Utilization Review Forms

Current through Register Vol. 50, No. 6, June 20, 2024
A. LWC Form
				  1010-Request of Authorization/ Carrier or Self Insured Employer Response
Click Here
					 To View Image
B.
				  LWC Form 1010A-First Request
Click Here
					 To View Image
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1203.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2901 - Applicability

Current through Register Vol. 50, No. 6, June 20, 2024
A. This Emergency
				  Rule shall apply to any and all Workers' Compensation insurance related
				  entities licensed by the Department of Insurance, those defined as "carrier" in
				  LAC 40:1.103, or doing business in Louisiana (collectively known as "workers'
				  compensation insurers").
B. The
				  assistant secretary or the secretary reserves the right to amend, modify, alter
				  or rescind all or any portions of Emergency Rule.
C. If any section or provision of this
				  Emergency Rule is held invalid, such invalidity or determination shall not
				  affect other sections or provisions, or the application of Emergency Rule, to
				  any persons or circumstances that can be given effect without the invalid
				  sections or provisions and the application to any person or circumstance shall
				  be severable.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1203.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2902 - Effective Date

Current through Register Vol. 50, No. 6, June 20, 2024
A. This Emergency
				  Rule shall become effective at 12:01 a.m. on March 19, 2020 and shall continue
				  in full force and effect for the maximum time period allowed under the
				  Administrative Procedure Act or for the period of the Governor's Stay-at-Home
				  Order, whichever shall end first.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1203.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2903 - Prescription Drug Coverage

Current through Register Vol. 50, No. 6, June 20, 2024
A. Workers'
				  compensation insurers shall allow insured individuals to obtain refills of
				  their prescriptions even if the prescription was recently filled, consistent
				  with approval from patients' health care providers and/or pharmacists. This
				  provision does not apply to prescription drugs with a high likelihood of abuse,
				  such as opioids that are restricted to 7-day prescriptions.
B. This authorization shall be for at least
				  30-day and up to 90-day supply, consistent with approval from patients' health
				  care providers and/or pharmacists.
C. Mail order prescriptions should be mailed
				  to an alternate address if requested by the insured.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1203.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2904 - Prior Authorizations or Restrictions

Current through Register Vol. 50, No. 6, June 20, 2024
A. All workers' compensation insurers shall
				  waive time restrictions on prescription medication refills, which include
				  suspension of electronic "refill too soon" edits to pharmacies, to enable
				  insureds or subscribers to refill prescriptions in advance, if there are
				  authorized refills remaining.
B.
				  All workers' compensation insurers shall authorize payment to pharmacies for at
				  least a 30-day supply of any prescription medication, regardless of the date
				  upon which the prescription had most recently been filled by a pharmacist, at
				  any time when the state is declared to be under a state of emergency in an
				  executive order issued by the governor and;
1. the prescription is not for a Schedule II
				  medicinal drug;
2. the medication
				  is essential to the maintenance of life or to the continuation of therapy in a
				  chronic condition;
3. in the
				  pharmacist's professional judgment, the interruption of therapy might
				  reasonably produce undesirable health consequences or may cause physical or
				  mental discomfort; or
4. the
				  dispensing pharmacist notifies the prescriber of emergency dispensing within a
				  reasonable time after such dispensing.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2905 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Drugs
				  prescribed by the treating or a consulting physician for an occupational injury
				  or disease are reimbursable under workers' compensation. If a drug is
				  prescribed for other than primary treatment of the compensable condition the
				  treating physician must provide written justification. For example, a weight
				  control drug may be necessary to reduce a person's weight in order to relieve
				  pain and enable proper strengthening and treatment of a back injury; or, an
				  antidepressant may be prescribed to enhance an analgesic.
B. Durable medical equipment, prosthetics,
				  and nonreusable supplies are also reimbursable to pharmacies but must be billed
				  on the HCFA 1500 Form. National Drug Codes (NDCs) are not acceptable for the
				  billing of supplies. Separate billing instructions are provided for these
				  services. Refer to the appropriate reimbursement schedule.
C. Medication paid for by a claimant will be
				  reimbursed directly to the claimant. In order for the claimant to bill the
				  carrier/self-insured employer, the pharmacist must furnish the claimant with a
				  signed receipt and a nonnegotiable copy of each prescription including the
				  national drug code and quantity. The pharmacy billing must include only the
				  actual amount billed for the amount of drugs being dispensed on any one
				  visit.
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 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2907 - Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Payment for
				  brand-name pharmaceuticals including oral non-legend drugs will be made at the
				  lesser of:
1. the provider's usual
				  charge;
2. a provider/insurer
				  contracted charge; or
3. the
				  average wholesale price (AWP) plus 10 percent plus a dispensing fee equal to
				  the Medicaid dispensing fee set by the state of Louisiana, Department of Health
				  and Hospitals.