LAC 40:I.5315
A. Resources:
B. CDT-1 Coding
4. All fees should include the price of materials supplied and the performance of the service. Under some circumstances, however, fee adjustments are necessary and values of listed codes may be modified by use of the appropriate “modifier code number.” Modifiers available.
| 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 dentist’s 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 ModifiersBy 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. |
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:1163 (September 1993), amended LR 20:1298 (November 1994), ), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 40:379 (February 2014), LR 42:288 (February 2016).