Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 51 - Medical Reimbursement Schedule
Section I-5115 - Surgery Guidelines

1. Global Surgery. The reimbursement allowances for surgical procedures are based on a global reimbursement concept that covers performing the basic service and the normal range of care required before and after surgery. The global reimbursement includes:

2. Follow-Up Care for Diagnostic Procedures. Follow-up care for diagnostic procedures, e.g., endoscopy, arthroscopy, injections procedures for radiography; includes only care that is related to the recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other concomitant condition is not included and may be charged for in accordance with the services provided.

3. Follow-Up Care for Therapeutic Surgical Procedures. Follow-up care for therapeutic surgical procedures includes only care that is usually part of the surgical procedure. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services concurrent with the procedure(s) or during the listed period of normal follow-up care may warrant additional charges. The workers' compensation carrier is responsible only for charges related to the compensable injury or illness unless the noncompensable condition has a direct bearing on the treatment of the compensable condition.

4. Additional Surgical Procedure(s). When an additional surgical procedure(s) is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods will continue concurrently to other normal terminations.

5. Operating Microscope. Additional reimbursement for the use of an operating microscope (excluding loupes or other magnifying devices) will be allowed when the listed code does not state the use of the microscope is inherent in the procedure.

6. Unique Techniques. A surgeon is not entitled to an extra fee for a unique technique. It is inappropriate to use Modifier-22 unless the procedure is significantly more difficult than indicated by the description of the code.

7. Surgical Destruction. Surgical destruction is part of a surgical procedure, and different methods of destruction are not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition. Exceptions under special circumstances are provided for by separate code numbers.

8. Incidental Procedure(s). An additional charge for an incidental procedure (e.g., incidental appendectomy, incidental scar excisions, puncture of ovarian cysts, simple lysis of adhesions, simple repair of hiatal hernia, etc.) is not customary and does not warrant additional reimbursement.

9. Endoscopic Procedures. When multiple endoscopic procedures are performed, the major procedure is reimbursed at 100 percent. If a secondary procedure is performed through the same opening/orifice, 50 percent is allowable as a multiple procedure. However, diagnostic procedures during the same session and entry site are incidental to the major procedure, which is coded per the deepest penetration. Generally, no payment will be made for a visit on the same day in addition to the endoscopic procedure unless documented, separately identifiable service is furnished.

10. Biopsy Procedures. A biopsy of the skin and another surgical procedure performed on the same lesion on the same day must be billed as one procedure.

11. Repair of Nerves, Blood Vessels, and Tendons with Wound Repairs. The repair of nerves, blood vessels, and tendons is usually reported under the appropriate system. The repair of associated wounds is included in the primary procedure unless it qualifies as a complex wound, in which case Modifier-51 may be applied. Simple exploration of nerves, blood vessels, and tendons exposed in an open wound is also considered part of the essential treatment of the wound closure and is not a separate procedure unless appreciable dissection is required.

12. Suture Removal. Billing for suture removal by the operating surgeon is not appropriate as this is considered part of the global fee.

13. Joint Manipulation under Anesthesia. There is no charge for manipulation of a joint under anesthesia when it is preceded or followed by a surgical procedure on that same day by that surgeon or associate. However, when manipulation of a joint is the scheduled procedure and it indicates additional procedures are necessary and appropriate, 50 percent of the manipulation may be allowed.

14. Supplies and Materials. Supplies and materials provided by the physician, e.g., sterile trays/drugs, over and above those usually included with the office visit may be listed separately using CPT Code 99070. These supplies and materials over $50 will be reimbursed at invoice cost plus 20 percent. Specialized supplies and DME may require a copy of the invoice be sent to the C/SIE.

15. Plastic and Metallic Implants. Plastic and metallic implants or non-autogenous graft materials supplied by the physician are to be reimbursed at invoice cost plus 20 percent. An invoice with the cost of the material must be submitted to the C/SIE with the bill.

16. Aspirations and Injections. Puncture of a cavity of joint for aspiration followed by an injection of a therapeutic agent is one procedure and should be billed as such.

17. Assistant-at-Surgery. An assistant-at-surgery is an individual who has the necessary qualifications to participate in a particular operation and actively assist in performing the surgery.

18. Operative Reports. An operative report must be submitted to the carrier before reimbursement can be made for the surgeon's or assistant surgeon's services.

19. Needle Procedures. Needle procedures (lumbar puncture, thoracentesis, jugular or femoral taps, etc.) should be billed in addition to the medical care on the same day.

20. Therapeutic Procedures. Therapeutic procedures (injecting into cavities, nerve blocks, etc.) (20550-20610; 64400-64450) may be billed in addition to the medical care for a new patient. (Use appropriate level of service plus injection.) In follow-up cases for additional therapeutic injections and/or aspirations, an office visit is only indicated if it is necessary to re-evaluate the patient. In this case, a minimal visit may be listed in addition to the injection. Documentation supporting the office visit charge must be submitted with the bill to the carrier/SIE. Reimbursement for therapeutic injections will be made according to the multiple procedure rule. Trigger point injection is considered one procedure and reimbursed as such regardless of the number of injection sites.

21. Anesthesia by Surgeon. In certain circumstances it may be appropriate for the attending surgeon to provide regional or general anesthesia. Anesthesia by the surgeon is considered to be more than local or digital anesthesia. Identify this service by adding the Modifier-47 to the surgical code. Only base anesthesia units are allowed (See Anesthesia, §5117).

1. Multiple Procedure Reimbursement Rule. When more than one procedure is performed during the same operative session at the same operative site and also multiple procedures performed during the same operative session through multiple incisions for the same operative procedure the following reimbursement applies:

2. Bilateral Procedure Reimbursement Rule. When bilateral procedures are performed that require preparation of separate operative sites, e.g., bilateral carpal tunnel, the second (or bilateral) site will be reimbursed as follows:

3. Multiple Procedure Reimbursement. When multiple surgical procedures are performed in different areas of the body during the same operative sessions and the procedures are unrelated (i.e., abdominal hernia repair and a knee arthroscopy), the multiple procedure reimbursement rule will apply independently to each area. Modifier-51 must be added.

1. Degree of Burns

1. Diagnostic or Therapeutic

2. Anesthetic

1. Modifier codes may be used by providers to identify procedures or services that are modified due to specific circumstances.

2. Modifiers listed in the CPT must be added to the procedure code when the service or procedure has been altered from the basic procedure described by the descriptor.

3. When Modifier-22 is used to report an unusual service, a report explaining the medical necessity of the situation must be submitted with the claim to the C/SIE. It is not appropriate to use Modifier-22 for routine billing.

4. The use of modifiers does not imply or guarantee that a provider will receive reimbursement as billed. Reimbursement for modified services or procedures must be based on documentation of medical necessity and must be determined on a case by case basis.