DMEFEE - lamedicaid.com

1 LAM5M116 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM REPORT NO: RF-0-76D RUN: 09/14/18 08:05:50 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: 1 LOUISIANA MEDICAID DMEPOS FEE SCHEDULE EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2018 AND FORWARD LEGEND ---------------------------------------- ---------------------------------------- ---------------------------------------- ------------ Listed below are some aids we hope will help you understand this fee schedule.

2 If, after reading the information below, you need further clarification of an item, please call Molina Provider Relations at 1-800-473-2783. ---------------------------------------- ---------------------------------------- ---------------------------------------- ------------ COLUMN 1. CODE: The medical billing procedure code. J CODES LISTED ON THIS FEE SCHEDULE ARE FOR THE USE OF INPATIENT HOSPITALS ONLY.

3 _____ COLUMN 2. TOS: TOS 07 is used for procedure codes in which a modifier is required. TOS 09 is used for all other procedure codes. COLUMN 3.

4 DESCRIPTION: A short description of the medical billing procedure code. COLUMN 4. FEE: The fee listed refers to the maximum, allowable payment for one unit of that item. When a fee must be manually priced, instead of a fee, the letters MP will appear. COLUMN 5.

5 ICFDD EXEMPT: "Y" in the "ICFDD EXEMPT" field indicates that the Intermediate Care Facility for the developmentally disabled is not responsible for payment of this item for those Medicaid recipients residing in its' facility on the date of delivery. COLUMN 6. NHOME RESP: "Y" in the "NH RESP" field indicates that nursing home is responsible for payment of this item for those Medicaid Recipients residing in the facility on the date of delivery.

6 COLUMN 7. MCARE EXEMPT: "1" indicates Medicare does not cover this item. "2" indicates that Medicare does not cover this item for nursing home residents. If there is nothing in this field, Medicare covers this item in all locations. COLUMN 8.

7 AGE RESTRICTION: If there is an age restriction for this procedure, the eligible age group will be given. COLUMN 9. PA REQUIRED: "R" in this field indicates that Prior Authorization by the Fiscal Intermediary is required. COLUMN 10. EFFECT DATE: The date in this column represents the date on which the fee from column 4 becomes effective.

8 THIS IS NOT AN ALL INCLUSIVE LIST. PAYMENT OF OTHER PROCEDURES CODES NOT INCLUDED IN THIS LIST MAY BE CONSIDERED BY THE DEPARTMENT OF HEALTH AND HOSPITALS ON A CASE BY CASE BASIS. IMPORTANT INFORMATION: THE 'J' CODES LISTED ON THIS FEE SCHEDULE ARE PAYABLE TO HOSPITALS ONLY!

9 ! _____ LAM5M116 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM REPORT NO: RF-0-76D RUN: 09/14/18 08:05:50 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: 2 LOUISIANA MEDICAID DMEPOS FEE SCHEDULE EFFECTIVE FOR DATES OF SERVICE JANUARY 1, 2018 AND FORWARD COLUMN.

10 1 2 34 5 6 7 8 9 10 ICFDD NHOME MCARE AGE PA EFFECT CODE TOS DESCRIPTIONFEE EXEMPT RESP EXEMPT RESTRICTION REQUIRED DATE A4206 09 SYRINGE WITH NEEDLE, STERILE 1CC MP Y R A4207 09 SYRINGE WITH NEEDLE, STERILE 2CC MP Y R A4208 09 SYRINGE WITH NEEDLE, STERILE 3CC MP Y R A4209 09 SYRINGE W/ NEEDLE, STERILE 5CC OR GR MP Y R A4210 09 NEEDLE-FREE INJECTION DEVICE Y Y R 20120901 A4212 09 HUBER-TYPE NEEDLE.