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-2519 - Outlier Reimbursement and Appeals Procedures

1. AIDS: ICD-10 diagnosis code B20;

2. Acute Myocardial Infarction: ICD10 diagnosis codes: I213, I214, I220, I221, I222, I228, I229; I2101, I2102, I2109, I2111, I2119, I2121, I2129; and

3. severe burns: ICD-10 diagnosis codes: T2030XA, T20311A, T20312A, T20319A, T2032XA, T2033XA, T2034XA, T2035XA, T2036XA, T2037XA, T2039XA, T2070XA, T20711A, T20712A, T20719A, T2072XA, T2073XA, T2074XA, T2075XA, T2076XA, T2077XA, T2079XA; T2130XA, T2131XA, T2132XA, T2133XA, T2134XA, T2135XA, T2136XA, T2137XA, T2139XA, T2170XA, T2171XA, T2172XA, T2173XA, T2174XA, T2175XA, T2176XA, T2177XA, T2179XA; T2230XA, T22311A, T22312A, T22319A, T22321A, T22322A, T22329A, T22331A, T22332A, T22339A, T22341A, T22342A, T22349A, T22351A, T22352A, T22359A, T22361A, T22362A, T22369A, T22391A, T22392A, T22399A, T2270XA, T22711A, T22712A, T22719A, T22721A, T22722A, T22729A, T22731A, T22732A, T22739A, T22741A, T22742A, T22749A, T22751A, T22752A, T22759A, T22761A, T22762A, T22769A, T22791A, T22792A, T22799A; T23301A, T23302A, T23309A, T23311A, T23312A, T23319A, T23321A, T23322A, T23329A, T23331A, T23332A, T23339A, T23341A, T23342A, T23349A, T23351A, T23352A, T23359A, T23361A, T23362A, T23369A, T23371A, T23372A, T23379A, T23391A, T23392A, T23399A, T23701A, T23702A, T23709A, T23711A, T23712A, T23719A, T23721A, T23722A, T23729A, T23731A, T23732A, T23739A, T23741A, T23742A, T23749A, T23751A, T23752A, T23759A, T23761A, T23762A, T23769A, T23771A, T23772A, T23779A, T23791A, T23792A, T23799A; T24301A, T24302A, T24309A, T24311A, T24312A, T24319A, T24321A, T24322A, T24329A, T24331A, T24332A, T24339A, T24391A, T24392A, T24399A, T24701A, T24702A, T24709A, T24711A, T24712A, T24719A, T24721A, T24722A, T24729A, T24731A, T24732A, T24739A, T24791A, T24792A, T24799A; T25311A, T25312A, T25319A, T25321A, T25322A, T25329A, T25331A, T25332A, T25339A, T25391A, T25392A, T25399A, T25711A, T25712A, T25719A, T25721A, T25722A, T25729A, T25731A, T25732A, T25739A, T25791A, T25792A, T25799A; T2600XA, T2601XA, T2602XA, T2610XA, T2611XA, T2612XA, T2620XA, T2621XA, T2622XA, T2630XA, T2631XA, T2632XA, T2640XA, T2641XA, T2642XA, T2650XA, T2651XA, T2652XA, T2660XA, T2661XA, T2662XA, T2670XA, T2671XA, T2672XA, T2680XA, T2681XA, T2682XA, T2690XA, T2691XA, T2692XA; T270XXA, T271XXA, T272XXA, T273XXA, T274XXA, T275XXA, T276XXA, T277XXA; T281XXA, T282XXA, T283XXA, T2840XA, T28411A, T28412A, T28419A, T2849XA, T285XXA, T286XXA, T287XXA, T288XXA, T28911A, T28912A, T28919A, T2899XA; T300; T304; T310, T320; T3110, T3210; T3111, T3211; T3120. T3220; T3121, T3221; T3122, T3222; T3130, T3230; T3131, T3231; T3132, T3232; T3133, T3233; T3140, T3240; T3141, T3142, T3143, T3243; T3144, T3244; T3150, T3250; T3152, T3252; T3151, T3251; T3154, T3254; T3153, T3253; T3155, T3255; T3160, T3260; T3161, T3261; T3162, T3262; T3163, T3263; T3164, T3264; T3165, T3265; T3166, T3266; T3170, T3270; T3171, T3271; T3172, T3272; T3173, T3273; T3174, T3274; T3175, T3275; T3176, T3276; T3177, T3277; T3180, T3280; T3181, T3281; T3182, T3282; T3183, T3283; T3184, T3284; T3185, T3285; T3186, T3286; T3187, T3287; T3188, T3288; T3190, T3290; T3191, T3291; T3192, T3292; T3191, T3293; T3194, T3294; T3196, T3296; T3195, T3295; T3197, T3297; T3198, T3298; T3199, T3299.

1. The following general criteria will be applied to determine when a case, originally paid at the per diem rate, may be appealed:

2. When a provider determines that a case falls within the appealable criteria, a request for review may be submitted to the carrier/self-insured employer.

3. If denied, a provider may then file a formal appeal with the Office of Workers' Compensation using the Special Reimbursement Consideration Appeal Form (LDOL-WC-3000) (see §2519. B.7.a Exhibit II). Forms are available upon request from the Office of Workers' Compensation at the address shown on the sample form. Procedures for filing an appeal and documentation required are provided on the form.

4. Final determination as to acceptance of a case for special reimbursement rests solely with the state of Louisiana, Office of Workers' Compensation.

5. If approved, the provider will be reimbursed at covered billed charges less a 15 percent discount.

6. The formula for calculation of the reimbursement amount for both automatic outliers and approved appeal cases is:

(Billed Charges) - (Noncovered Charges) = Covered Charges x 0.85 = Payment Amount

7. All workers' compensation claims paid outside the per diem reimbursement method either as automatic outliers or as Special Reimbursement Consideration Appeal cases are subject to on-site bill audit. Bill audits are governed by the rules and procedures found in the Utilization Review Procedures Manual. Please refer to that manual for details.