Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions
Section I-5315 - Coding System

22

Unusual Services-Report required.

50

Bilateral or Multiple Field Procedures-Multiple procedures in separate anatomical field. The following values may be used:

100 percent first major procedure.

70 percent each additional field procedure.

51

Multiple Procedures-Multiple procedure in the same anatomical field. The following values may be used:

Single Field

100 percent for first major procedure

50 percent of listed value for second

25 percent of listed value for third

10 percent of listed value for fourth

5 percent of listed value for fifth

BR for any procedure beyond 5

52

Reduced Values-Reduced or estimated value for procedure because of common practice or at the dentists election.

53

Primary Emergency Services-Procedure is carried out by a dentist who will not be providing the follow-up care. The value may be 70 percent of the listed value.

54

Surgical Procedure Only-Used to identify the dentist performing surgery. The value may be 70 percent of the listed value.

55

Follow-Up Care Only-Identifies the dentist providing follow-up care. The value may be 30 percent of the listed value.

56

Pre-Operative Care Only-Identifies the dentist performing care up until surgery when another dentist takes over. Value may be 30 percent of the listed value.

75

Services Rendered by More than One Dentist-When the condition requires more than one dentist, each dentist may be allowed 80 percent of the value for that procedure

99

Multiple Modifiers-By Report

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.