FEESCHED - Louisiana Medicaid

1 LAM5M110 Louisiana Medicaid MANAGEMENT INFORMATION SYSTEM REPORT NO: RF-0-76 RUN: 02/23/18 08:03:36 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: Louisiana Medicaid PROFESSIONAL SERVICES FEE SCHEDULE FEES EFFECTIVE FOR DOS ON AND AFTER FEBRUARY 01, 2018 LEGEND ---------------------------------------- ---------------------------------------- ---------------------------------------- ------------ Listed below are some aids we hope will help you understand this fee schedule. If, after reading the information below, you need further clarification of an item, please call Molina Provider Relations at 1-800-473-2783.

2 ---------------------------------------- ---------------------------------------- ---------------------------------------- ------------ COLUMN 1. TS (Type Service): Definition: Files on which codes are loaded and from which claims are paid. The file to which a claim goes for pricing is determined by, among other things, the type of provider who is billing and by the modifier appended to the procedure code. Listed below is an explanation of the types of service found on this schedule. 01 - Anesthesia.

3 Anesthesia claims are priced off this file. 02 - Assistant Surgeon. Assistant surgeon (MD) claims are priced off this file. Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, and Physician Assistant claims are paid at 80% of this fee. 03 - Full service. The file from which physician services are paid primarily for recipients 16 years of age and older. Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives, and Physician Assistants are paid at 80% of this fee except for physician administered injections, long-acting reversible contraceptives (LARC's), immunizations and EPSDT preventive medical, vision and hearing screenings which are reimbursed at 100%. Licensed Midwives are paid at 75% of the full service fee. See Immunization Fee Schedule and Louisiana Medicaid EPSDT Program Fee Schedule.

4 05 - Professional component. Claims with modifier -26 are priced from this file. 07 - Full service file for physician services for recipients 0 through 15 (0-15) years of age. Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives, and Physician Assistants are paid at 80% of this fee except for physician administered injections, long-acting reversible contraceptives (LARC's), immunizations, and EPSDT preventive medical, vision and hearing screenings which are reimbursed at 100%. Licensed Midwives are paid at 75% of the full service fee. See Immunization Fee Schedule and Louisiana Medicaid EPSDT Program Fee Schedule. 13 - Office of Public Health (OPH). These codes are only payable to Provider Specialty of 60 - Public Health or Welfare Agencies and Clinics and are only being listed for informational purposes.

5 COLUMNS 2, 3 and 4. CODE, DESCRIPTION and FEE: Codes with modifier TH are prenatal obstetrical visits. MP - MANUALLY PRICED; SP - SYSTEM PRICED COLUMN 5. AGE MIN and MAX: Codes with minimum or maximum age restrictions. If the recipient's age on the date of service is outside the minimum or maximum age, claims will deny. COLUMN 6. MED REV (Medical Review): Claims with some codes pend to Medical Review for review of the attachments, manual pricing, or to confirm Prior authorization by the surgeon. COLUMN 7.

6 PA (Prior Authorization): Some services must be prior authorized before they are rendered. If a PA request is approved, a PA number will be issued for inclusion on the claim. If a PA request is not approved, no payment for the service will be made. COLUMN 8. SEX (Restriction): Some procedure codes are indicated for only one sex. COLUMN 9. PSR (Provider Specialty Restriction): If a code has a provider specialty restriction, reimbursement for its performance will not be made to other specialties. COLUMN 10. SL (Service Limitation): Codes with frequency limitations. COLUMN 11. BASE UNITS: The base units for anesthesia codes.

7 COLUMN 12. X-OVERS (Only): These codes are payable for Medicare/ Medicaid recipients only. COLUMN 13. UVS>001: An 'X' in this column means more than one unit of service per day may be billed. COLUMN 14. SPEC IND: Indicate if code was related to a particular process. Code E - Medicaid Expansion Code M - Global Maternity Code - These codes are payable only when billed to Medicaid as Secondary Payer. Global Maternity Codes billed to Medicaid as Primary Payer will be denied. LAM5M110 Louisiana Medicaid MANAGEMENT INFORMATION SYSTEM REPORT NO: RF-0-76 RUN: 02/23/18 08:03:36 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: 1 Louisiana Medicaid PROFESSIONAL SERVICES FEE SCHEDULE FEES EFFECTIVE FOR DOS ON AND AFTER FEBRUARY 01, 2018 COLUMN.

8 1 2 34 5 6 7 8 9 10 11 12 13 14 AGE MED BASE X- UVS SPEC TS CODE DESCRIPTIONFEE MIN-MAX REV PA SEX PSR SL UNITS OVERS >001 IND 03 99201 NEW PATIENT OFFICE OR OTHER OUTPATIE 03 99201 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 59 F 07 99201 NEW PATIENT OFFICE OR OTHER OUTPATIE 00 15 07 99201 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 15 F 03 99202 NEW PATIENT OFFICE OR OTHER OUTPATIE 03 99202 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 59 F 07 99202 NEW PATIENT OFFICE OR OTHER OUTPATIE 00 15 07 99202 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 15 F 03 99203 NEW PATIENT OFFICE OR OTHER OUTPATIE 03 99203 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 59 F 07 99203 NEW PATIENT OFFICE OR OTHER OUTPATIE 00 15 07 99203 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 15 F

9 03 99204 NEW PATIENT OFFICE OR OTHER OUTPATIE 03 99204 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 59 F 07 99204 NEW PATIENT OFFICE OR OTHER OUTPATIE 00 15 07 99204 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 15 F 03 99205 NEW PATIENT OFFICE OR OTHER OUTPATIE 03 99205 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 59 F 07 99205 NEW PATIENT OFFICE OR OTHER OUTPATIE 00 15 07 99205 TH NEW PATIENT OFFICE OR OTHER OUTPATIE 10 15 F 03 99211 OFFICE,EST PT, MINIMAL PROBLEMS 03 99211 TH OFFICE,EST PT,MINIMAL 10 59 F 07 99211 EST PATIENT OFFICE VISIT 00 15 07 99211 TH OFFICE,EST PT.

10 MINIMAL 10 15 F 03 99212 ESTABLISHED PATIENT OFFICE OR OTHER 03 99212 TH ESTABLISHED PATIENT OFFICE OR OTHER 10 59 F 07 99212 ESTABLISHED PATIENT OFFICE OR OTHER 00 15X 07 99212 TH ESTABLISHED PATIENT OFFICE OR OTHER 10 15 F 03 99213 ESTABLISHED PATIENT OFFICE OR OTHER 03 99213 TH ESTABLISHED PATIENT OFFICE OR OTHER 10 59 F 07 99213 ESTABLISHED PATIENT OFFICE OR OTHER 00 15 07 99213 TH ESTABLISHED PATIENT OFFICE OR OTHER 10 15 F 03 99214 ESTABLISHED PATIENT OFFICE OR OTHER 03 99214 TH ESTABLISHED PATIENT OFFICE OR OTHER 10 59 F 07 99214 ESTABLISHED PATIENT OFFICE OR OTHER 00 15 07 99214 TH ESTABLISHED PATIENT OFFICE OR OTHER 10 15 F 03 99215 ESTABLISHED PATIENT OFFICE OR OTHER 03 99215 TH ESTABLISHED PATIENT OFFICE OR OTHER 10 59 F 07 99215 ESTABLISHED PATIENT OFFICE OR OTHER 00 15