La. Admin. Code tit. 40 § I-5329

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

Section I-5329 - Special Instructions

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.

B. By Report (BR)

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

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

a. the pertinent history and physical findings;

b. diagnostic tests and interpretations;

c. therapeutic procedures;

d. treatment for concurrent medical conditions;

e. the final diagnosis/diagnoses;

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

g. summary of treatment plan;

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

i. description of equipment necessary to provide the service.

3. Reimbursement by the carrier of BR procedures should be based upon the carrier's review of the submitted documentation, the recommendation from the carrier's medical consultant, and the carrier's review of the prevailing charges for similar services as identified by the carrier based on data which is representative of Louisiana charges.

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

La. Admin. Code tit. 40, § I-5329

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:1167 (September 1993), amended LR 20:1298 (November 1994).

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