DECLARATION OF EMERGENCY
Workforce Commission
Office of Workers' Compensation Administration
Medical Treatment Guidelines
(LAC 40:I.2519, 2701, 2705, 2707,
2718, 5101, 5113, 5315, and 5399)
The Louisiana Workforce Commission has exercised the emergency provision in accordance with R.S. 49:953(B), the Administrative Procedure Act to amend certain portions of the Medical Guidelines contained in the Louisiana Administrative Code, Title 40, Labor and Employment, Part I, Workers’ Compensation Administration, Subpart 2, Medical Guidelines, Chapters 25-53. This Emergency Rule effective October 1, 2015, will remain in effect for a period of 120 days.
This amendment is required to stay in compliance with the federal Protecting Access to Medicare Act of 2014. The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Department of Health and Human Services set the compliance date for October 1, 2015. This does not affect CPT coding for outpatient procedures and physician services.
The department considers emergency action necessary to facilitate an efficient and timely transition to ICD-10 medical coding, pending enactment of a rule through regular administrative procedure. Notice is hereby given, in accordance with R.S. 49:950, et seq., that the Louisiana Workforce Commission, Office of Workers’ Compensation, pursuant to authority vested in the Director of the Office of Workers’ Compensation by R.S. 23:1291 and 23:1310.1, and in accordance with applicable provisions of the Administrative Procedure Act, proposes to amend LAC 40:I., Subpart 2, Chapters 25-53.
Title 40
LABOR AND EMPLOYMENT
Part I. Workers’ Compensation Administration
Chapter 25. Hospital Reimbursement Schedule, Billing Instruction and Maintenance Procedures
Editor's Note:Other Sections applying to this Chapter can be found in Chapter 51.
§2519. Outlier Reimbursement and Appeals Procedures
A. Automatic Outliers. Inpatient hospital acute care services falling within certain diagnosis code ranges will be reimbursed outside the normal per diem reimbursement method. These atypical admissions will be paid at covered billed charges less a 15 percent discount. Conditions requiring acute care inpatient hospital services that are work-related and are recognized as "automatic outliers" are:
1. AIDS: ICD-10 Diagnosis Code B20;
2. Acute Myocardial Infarction: ICD10 Diagnosis Codes: I2109; I220; I2101; I2102; I2119; I221; I2111; I2129; I228; I2121; I228; I213; I229; and
3. Severe Burns: ICD-10 Diagnosis Codes: T2650XA, T2651XA, T2652XA; T2600XA, T2601XA, T2602XA; T2660XA, T2661XA, T2662XA; T2660XA, T2610XA, T2611XA, T2612XA; T2620XA, T2621XA, T2622XA; T2630XA, T2631XA, T2632XA, T2640XA, T2641XA, T2642XA, T2680XA, T2681XA, T2682XA, T2690XA, T2691XA, T2692XA; T2030XA, T2070XA; T20311A, T20312A, T20319A, T20711A, T20712A, T20719A; T2032XA, T2072XA; T2033XA, T2073XA; T2034XA, T2074XA; T2035XA, T2075XA; T2036XA, T2076XA; T2037XA, T2077XA; T2039XA, T2079XA; T2670XA, T2671XA, T2672XA; T2130XA, T2170XA; T2131XA, T2171XA; T2132XA, T2172XA; T2133XA, T2134XA, T2135XA, T2173XA, T2174XA, T2175XA, T2136XA, T2176XA; T2139XA, T2179XA; T2230XA, T2270XA; T22311A, T22312A, T22319A, T22711A, T22712A, T22719A; T22321A, T22322A, T22329A, T22721A, T22722A, T22729A; T22331A, T22332A, T22339A, T22731A, T22732A, T22739A; T22341A, T22342A, T22349A, T22741A, T22742A, T22749A; T22351A, T22352A, T22359A, T22751A, T22752A, T22759A; T22361A, T22362A, T22369A, T22761A, T22762A, T22769A; T22391A, T22392A, T22399A, T22791A, T22792A, T22799A; T23301A, T23302A, T23309A, T23701A, T23702A, T23709A; T23321A, T23322A, T23329A, T23721A, T23722A, T23729A; T23311A, T23312A, T23319A, T23711A, T23712A, T23719A; T23331A, T23332A, T23339A, T23731A, T23732A, T23739A; T23341A, T23342A, T23349A, T23741A, T23742A, T23749A, T23351A, T23352A, T23359A, T32751A, T23752A, T23759A, T23361A, T23362A, T23369A, T23761A, T23762A, T23769A, T23371A, T23372A, T23379A, T23771A, T23772A, T23779A, T23391A, T23392A, T23399A, T23791A, T23792A, T23799A, T23301A, T23302A, T23309A, T23701A, T23702A, T23709A, T23321A, T23322A, T23329A, T23721A, T23722A, T23729A; T24301A, T24302A, T24309A, T24701A, T24702A, T24709A; T25331A, T25332A, T25339A, T25731A, T25731A, T25732A, T25739A; T25321A, T25322A, T25329A, T25721A, T25722A, T25729A; T25311A, T25312A, T25319A, T25711A, T25712A, T25719A; T24331A, T24332A, T24339A, T24731A, T24732A, T24739A; T24321A, T24322A, T24329A, T24721A, T24722A, T24729A; T24311A, T24312A, T24319A, T24711A, T24712A, T24719A; T24391A, T24392A, T24399A, T24791A, T24792A, T24799A, T25391A, T25392A, T25399A, T25791A, T25792A, T25799A; T300; T304; T270XXA, T271XXA, T273XXA, T274XXA, T275XXA,T276XXA, T277XXA; T281XXA, T286XXA; T282XXA, T287XXA; T283XXA, T28411A, T28412A, T28419A, T2849XA, T288XXA, T28911A, T28912A, T28919A, T2899XA; T310, T320; T3110, T3210; T3111, T3211; T3120. T3220; T3121, T3221; T3122, T3222; T3130, T3230; T3131, T3231; T3132, T3232; T3133, T3233; T3140, T3240; 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.
B. Appeal Procedures. Special reimbursement consideration will be given to cases that are atypical in nature due to case acuity causing unusually high charges when compared to the provider's usual case mix. This appeal process applies to workers' compensation cases paid under the per diem reimbursement formula limiting the payment amount to the lesser of per diem or covered billed charges.
1. - 7.a. …
* * *
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), amended by the Workforce Commission, Office of Workers’ Compensation, LR 41:981 (May 2015), ), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
Chapter 27. Utilization Review Procedures
A. - B.3. …
4. Statements of charges shall be made in accordance with standard coding methodology as established by these rules, ICD-10-CM, ICD-10-PCS, HCPCS, and CPT-4 coding manuals. Unbundling or fragmenting charges, duplicating or over-itemizing coding, or engaging in any other practice for the purpose of inflating bills or reimbursement is strictly prohibited. Services must be coded and charged in the manner guaranteeing the lowest charge applicable. Knowingly and willfully misrepresenting services provided to workers' compensation claimants is strictly prohibited.
5. - 7. …
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.
HISTORICAL NOTE: Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991), amended by the Louisiana Workforce Commission, Office of Workers' Compensation, LR 38:1030 (April 2012), amended by the Louisiana Workforce Commission, Office of Workers' Compensation, LR 38:1030 (April 2012), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
§2705. Pre-Admission Certification
Editor's Note: The telephone number for the Office of Workers' Compensation has been changed to
(225) 342-9836.
A. - B. …
C. Louisiana Office of Worker’s Compensation Administration shall support both ICD-9 and ICD-10 coding formats for a period of time after the compliance date. Claims shall be accepted with ICD-9 codes for service dates or discharge dates prior to the compliance date for pre-authorized services and/or treatment or timely filing requirements. If an authorization is requested on or before
the compliance date, and the date of service is on or after October 1, 2015, healthcare professionals must submit an ICD-10 code. If an authorization is requested after the compliance date, the ICD-10 code will be required. The pre-admission certification process follows the sequence below.
1. - 1.i. …
j. admitting diagnosis (to include ICD-10-CM codes);*
k. …
l. major procedures and related CPT/ICD-10 -PCS codes;*
m. - v. …
*The provider will provide descriptive/narrative information and the reviewer, representing the carrier/self-insured employer, will provide the ICD-10-CM, ICD-10-PCS and/or CPT-4 codes.
D. - E.2.b. …
3. Evaluation
a. …
b. Carrier/Self-Insured Employer Data Reporting. Carrier/self-insured employer will be required to collect the following data according to the Office of Workers' Compensation Administration requirements.
Information |
Positions |
Type |
/ICD-10-CM |
5/7 |
Numeric |
Provider Name |
30 |
Alpha |
Provider Street Address |
30 |
Alpha Numeric |
Parish Code for Provider of Service (Use Standard FIPS code, see Exhibit 5) |
3 |
Numeric |
Place of Treatment |
1 |
Alpha Numeric |
Type of Facility* |
6 |
Numeric |
Type of Service: Medical vs. Surgical |
1 |
Alpha Numeric |
Claimant Name |
30 |
Alpha |
Claimant Social Security Number |
9 |
Numeric |
Length of Stay |
4 |
Numeric |
*See "Type Facility Codes" in Exhibit 6. |
c. - e. …
* * *
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.
HISTORICAL NOTE: Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
§2707. Admission and Continued Stay Review
Editor's Note: The telephone number for the Office of Workers' Compensation has been changed to
(225) 342-9836.
A. - E.2.b. …
3. Evaluation
a. …
b. Carrier/Self-Insured Employer Data Reporting. Carrier/self-insured employer will be required to collect data according to the Office of Workers' Compensation Administration requirements.
Information |
Positions |
Type |
/ICD-10-CM |
5/7 |
Numeric |
Provider Name |
30 |
Alpha |
Provider Street Address |
30 |
Alpha Numeric |
Parish Code for Provider of Service |
3 |
Numeric |
Place of Treatment |
1 |
Alpha Numeric |
Type of Facility* |
6 |
Numeric |
Type of Service: |
1 |
Alpha Numeric |
Claimant Name |
30 |
Alpha |
Claimant Social Security Number |
9 |
Numeric |
Length of Stay |
4 |
Numeric |
* See "Type Facility Codes" in Exhibit 6. |
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.
HISTORICAL NOTE: Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
§2718. Utilization Review Forms
A. LWC Form 1010¾Request of Authorization/
Carrier or Self Insured Employer Response
LWC FORM 1010¾REQUEST OF AUTHORIZATION/ CARRIER OR SELF INSURED EMPLOYER RESPONSE PLEASE PRINT OR TYPE |
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SECTION 1. IDENTIFYING INFORMATION - To Be Filled Out By Health Care Provider |
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PATIENT |
Last Name: First: Middle: |
Street Address, City, State, Zip: |
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Last Four Digits of Social Security Number: |
Date of Birth: |
Phone Number: |
Date of Injury: |
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Employers Name: |
Street Address, City, State, Zip: |
Phone Number: |
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CARRIER |
Name: |
Adjuster: |
Claim Number (if known): |
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Street Address, City, State Zip: |
Email Address: |
Phone Number:
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Fax Number: |
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SECTION 2. REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider |
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PROVIDER |
Requesting Health Care Provider |
Phone Number: |
Fax Number: |
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Street Address, City, State Zip: |
Email: |
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Diagnosis: |
CPT/DRG Code: |
ICD-10-CM/ DSM-V Code: |
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Requested Treatment or Testing (Attach Supplement If Needed): |
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Reason for Treatment or Testing (Attach Supplement If Needed): |
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INFORMATION REQUIRED BY RULE TO BE INCLUDED WITH REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider |
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(Following is the required minimum information for Request of Authorization (LAC 40:2715 (C)) |
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PROVIDER |
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History provided to the level of condition and as provided by Medical Treatment Schedule |
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Physical Findings/Clinical Tests |
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Documented functional improvements from prior treatment |
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Test/imaging results |
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Treatment Plan including services being requested along with the frequency and duration |
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I hereby certify that this completed form and above required information was |
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to the Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) |
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Signature of Health Care Provider: |
Printed Name: |
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SECTION 3. RESPONSE OF CARRIER/SELF INSURED EMPLOYER FOR AUTHORIZATION (Check appropriate box below and return to requesting Health Care Provider, Claimant and Claimant Attorney as provided by rule) |
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CARRIER |
The requested Treatment or Testing is approved
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The requested Treatment or Testing is approved with modifications (Attach summary of reasons and explanation of any modifications)
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Not in accordance with Medical Treatment Schedule or R.S.23:1203.1(D) (Attach summary of reasons) |
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The request, or a portion thereof, is not related to the on-the-job injury |
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The claim is being denied as non-compensable |
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Other (Attach brief explanation) |
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I hereby certify that this response of Carrier/Self Insured Employer for Authorization was |
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to the Health Care Provider (and to the Attorney of Claimant if one exists, if denied or approved with modification) on this the _____ day of ______ , ______ (day) (month) (year) |
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Signature of Carrier/Self Insured Employer: |
Printed Name: |
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The prior denied or approved with modification request is now approved
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I hereby certify that this response of Carrier/Self Insured Employer for Authorization was |
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to the Health Care Provider and Attorney of Claimant if one exists on this the _____ day of ______ , ______ (day) (month) (year) |
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Signature of Carrier/Self Insured Employer: |
Printed Name: |
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SECTION 4. FIRST REQUEST |
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(Form 1010A is required to be filled out by Carrier/Self Insured Employer and Health Care Provider) |
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CARRIER |
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I hereby certify that this First Request and accompanying Form 1010A was |
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to the Health Care Provider on this the |
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_____ day of ______ , ______ (day) (month) (year) |
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Signature of Carrier/Self Insured Employer: |
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PROVIDER |
I hereby certify that a response to the First Request and accompanying Form 1010A was |
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to the Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) |
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Signature of Health Care Provider: |
Printed Name: |
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SECTION 5. SUSPENSION OF PRIOR AUTHORIZATION DUE TO LACK OF INFORMATION |
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CARRIER |
Suspension of Prior Authorization Process due to Lack of Information |
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The requested Treatment or Testing is delayed due to a Suspension of Prior Authorization Due to Lack of Information
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I hereby certify that this Suspension of Prior Authorization was |
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to the Health Care Provider on this the _____ day of ______ , ______ (day) (month) (year) |
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Signature of Carrier/Self Insured Employer: |
Printed Name: |
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PROVIDER |
Appeal of Suspension to Medical Services Section by Health Care Provider |
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I hereby certify that this form and all information previously submitted to Carrier/Self Insured Employer was faxed to OWCA Medical Services (Fax Number: 225-342-9836) this _______ day of ______, _________. |
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I hereby certify that this Appeal of Suspension of Prior Authorization was |
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to the Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) |
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Signature of Health Care Provider: |
Printed Name: |
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SECTION 6. DETERMINATION OF MEDICAL SERVICES SECTION |
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OWCA |
The required information of LAC40:2715(C) was not provided
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The required information of LAC40:2715(C) was provided
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I hereby certify that a written determination was |
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to the Health Care Provider & Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) |
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Signature: |
Printed Name: |
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SECTION 7. HEALTH CARE PROVIDER RESPONSE TO MEDICAL SERVICES DETERMINATION |
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PROVIDER |
I hereby certify that additional information, pursuant to the determination of Medical Services Section, was |
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to the Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) |
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Signature of Health Care Provider: |
Printed Name: |
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B. …
* * *
AUTHORITY NOTE: Promulgated in accordance with RS 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers' Compensation, LR 38:1037 (April 2012), amended LR 38:3255 (December 2012), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
Chapter 51 Medical Reimbursement Schedule
Editor's Note: The following Sections of this Chapter are applicable and shall be used for the Chapters in this Part governing reimbursement. These specific Chapters are: Chapter 25, Hospital Reimbursement; Chapter 29, Pharmacy; Chapter 31, Vision Care Services; Chapter 33, Hearing Aid Equipment and Services; Chapter 35, Nursing/Attendant Care and Home Health Services; Chapter 37, Home and Vehicle Modification; Chapter 39, Medical Transportation; Chapter 41, Durable Medical Equipment and Supplies; Chapter 43, Prosthetic and Orthopedic Equipment; Chapter 45, Respiratory Services; Chapter 47, Miscellaneous Claimant Expenses; Chapter 49, Vocational Rehabilitation Consultant; Chapter 51, Medical Reimbursement Schedule; and Chapter 53, Dental Care Services.
A. - B.3. …
4. Statements of charges shall be made in accordance with standard coding methodology as established by these rules, ICD-10-CM, ICD-10-PCS, HCPCS, CPT-4, CDT-1, NDAS coding manuals. Unbundling or fragmenting charges, duplicating or over-itemizing coding, or engaging in any other practice for the purpose of inflating bills or reimbursement is strictly prohibited. Services must be coded and charged in the manner guaranteeing the lowest charge applicable. Knowingly and willfully misrepresenting services provided to workers' compensation claimants is strictly prohibited.
5. - 8. …
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), amended by the Workforce Commission, Office of Workers’ Compensation, LR 40:375 (February 2014), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
A. Diagnosis Coding. The International Classification of Diseases, Tenth Revision (ICD-10-CM) is the basis of diagnosis coding. These are the disease codes in the international classification, tenth revision, clinical modifications published by the U.S. Department of Health and Human Resources.
B. Helpful Hints for Diagnosis Coding
1. - 2. …
3. All digits of the appropriate ICD-10-CM code(s) should be reported.
4. The date of accident should always be reported if the ICD-10-CM code is for an accident diagnosis.
5. It is important to provide a complete description of the diagnosis if an appropriate ICD-10-CM code cannot be located.
C. - C.3. …
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993),
repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
Chapter 53. Dental Care Services, Reimbursement Schedule and Billing Instructions
Editor's Note: Other Sections applying to this Chapter can be found in Chapter 51.
§5315. Coding System
A. - A.6. ...
* * *
B. CDT-1 Coding
1. - 2. …
3. Procedures denoted “BR” (by report) in the fee schedule should be justified by the submission of a report.
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 |
Mulitple Modifers- 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. |
5. Fees for surgical procedures should be global in nature and include the surgery, any local anesthesia and normal follow-up care. Fees for general anesthesia are extra as are complications or additional services and should be coded separately.
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, LR 40:379 (February 2014), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
§5399. Schedule for Maximum Allowances for Dental Services
CDT Code |
Description |
Maximum |
D0120 |
Periodic oral evaluation—established patient |
50 |
D0140 |
Limited oral evaluation—problem focused |
75 |
D0145 |
Oral evaluation—patient under 3yrs & counseling with primary caregiver |
69 |
D0150 |
Comprehensive oral evaluation—new or established patient |
88 |
D0160 |
Detailed & Extensive oral evaluation—problem focused, by report |
160 |
D0170 |
Re-evaluation—limited, problem focused (established patient; not post-operative visit |
70 |
D0180 |
Comprehensive periodontal evaluation—new or established patient |
95 |
D0210 |
Intraoral—complete series (including bitewings) |
128 |
D0220 |
Intraoral—periapical first film |
28 |
D0230 |
Intraoral—periapical each additional film |
24 |
D0240 |
Intraoral—occlusal films |
42 |
D0250 |
Intraoral—first film |
67 |
D0260 |
Extraoral—first film |
55 |
D0270 |
Bitewing—single film |
28 |
D0272 |
Bitewing—two films |
45 |
D0273 |
Bitewing—three films |
55 |
D0274 |
Bitewing—four films |
65 |
D0277 |
Vertical bitewings—7 to 8 films |
97 |
D0290 |
Posterior-anterior or lateral skull & facial bone survey film |
135 |
D0310 |
Sialography |
389 |
D0320 |
Temporomandibular joint films, including injection |
592 |
D0321 |
Other temporomandibular joint films, by report |
210 |
D0322 |
Tomographic survey |
530 |
D0330 |
Panoramic film |
110 |
D0340 |
Cephalometric film |
125 |
D0350 |
Oral/facial photographic images |
71 |
D0360 |
Cone beam CT—craniofacial data capture |
589 |
D0362 |
Cone beam CT—two-dimensional image reconstruction using existing data, includes multiple images |
359 |
D0363 |
Cone beam CT—three-dimensional image reconstruction using existing data, includes multiple images |
398 |
D0415 |
Collection of microorganisms for culture and sensitivity |
186 |
D0416 |
Viral culture |
168 |
D0417 |
Collection and preparation of saliva sample for laboratory diagnostic testing |
167 |
D0418 |
Analysis of saliva sample |
150 |
D0421 |
Genetic test for susceptibility to oral diseases |
136 |
D0425 |
Caries susceptibility tests |
95 |
D0431 |
Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures |
71 |
D0460 |
Pulp vitality tests |
55 |
D0470 |
Diagnostic casts |
109 |
D0472 |
Accession of tissue, gross examination, preparation and transmission of written report |
118 |
D0473 |
Accession of tissue, gross examination and microscopic examination, preparation and transmission of written report |
165 |
D0474 |
Accession of tissue, gross examination and microscopic examination including assessment of surgical margins for presence of disease, preparation and transmission of written report |
184 |
D0480 |
Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report |
176 |
D0486 |
Accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report |
150 |
D0475 |
Decalcification procedure |
195 |
D0476 |
Special stains for microorganisms |
289 |
D0477 |
Special stains not for microorganisms |
296 |
D0478 |
Immunohistochemical stains |
175 |
D0479 |
Tissue in-situ hybridization, including interpretation |
231 |
D0481 |
Electron microscopy—diagnostic |
188 |
D0482 |
Direct immunofluorescence |
105 |
D0483 |
Indirect immunofluorescence |
123 |
D0484 |
Consultation on slides prepared elsewhere |
168 |
D0485 |
Consultation, including preparation of slides from biopsy material supplied by referring source |
180 |
D0502 |
Other oral pathology procedures, by report |
170 |
D0999 |
Unspecified diagnostic procedure, by report |
BR |
D1110 |
Prophylaxis—adult |
90 |
D1120 |
Prophylaxis—child |
66 |
D1203 |
Topical application of fluoride—child |
37 |
D1204 |
Topical application of fluoride—adult |
37 |
D1206 |
Topical fluoride varnish; therapeutic application for moderate to high caries risk patients |
45 |
D1310 |
Nutritional counseling for control of dental disease |
70 |
D1320 |
Tobacco counseling for the control and prevention of oral disease |
82 |
D1330 |
Oral hygiene instructions |
55 |
D1351 |
Sealant—per tooth |
54 |
D1352 |
Preventative resin restoration in a moderate to high caries risk patient—permanent tooth |
BR |
D1510 |
Space maintainer—fixed—unilateral |
317 |
D1515 |
Space maintainer—fixed—bilateral |
432 |
D1520 |
Space maintainer—removable—unilateral |
390 |
D1525 |
Space maintainer—removable—bilateral |
495 |
D1550 |
Re-cementation of space maintainer |
83 |
D1555 |
Removal of fixed space maintainer |
79 |
D2140 |
Amalgam—one surface, primary or permanent |
138 |
D2150 |
Amalgam—two surfaces, primary or permanent |
176 |
D2160 |
Amalgam—three surfaces, primary or permanent |
214 |
D2161 |
Amalgam—four surfaces, primary or permanent |
251 |
D2330 |
Resin-based composite—one surface, anterior |
160 |
D2331 |
Resin-based composite—two surfaces, anterior |
200 |
D2332 |
Resin-based composite—three surfaces, anterior |
249 |
D2335 |
Resin-based composite—four or more surfaces or involving incisal angle (anterior) |
312 |
D2390 |
Resin-based composite crown—anterior |
450 |
D2391 |
Resin-based composite—one surface, posterior |
177 |
D2392 |
Resin-based composite—two surfaces, posterior |
230 |
D2393 |
Resin-based composite—three surfaces, posterior |
284 |
D2394 |
Resin-based composite—four or more surfaces posterior |
341 |
D2410 |
Gold foil—one surface |
635 |
D2420 |
Gold foil—two surfaces |
692 |
D2430 |
Gold foil—three surfaces |
806 |
D2510 |
Inlay—metallic—one surface |
833 |
D2520 |
Inlay—metallic—two surfaces |
892 |
D2530 |
Inlay—metallic—three or more surfaces |
965 |
D2542 |
Onlay—metallic—two surfaces |
990 |
D2543 |
Onlay—metallic—three surfaces |
1015 |
D2544 |
Onlay—metallic—four or more surfaces |
1050 |
D2610 |
Inlay—porcelain/ceramic—one surface |
907 |
D2620 |
Inlay—porcelain/ceramic—two surfaces |
950 |
D2630 |
Inlay—porcelain/ceramic—three or more surfaces |
995 |
D2642 |
Onlay—porcelain/ceramic—two surfaces |
1008 |
D2643 |
Onlay—porcelain/ceramic—three surfaces |
1049 |
D2644 |
Onlay—porcelain/ceramic—four or more surfaces |
1094 |
D2650 |
Inlay—resin based—one surface |
869 |
D2651 |
Inlay—resin based—two surfaces |
904 |
D2652 |
Inlay—resin based—three or more surfaces |
940 |
D2662 |
Onlay—resin based—two surfaces |
944 |
D2663 |
Onlay—resin based—three surfaces |
983 |
D2664 |
Onlay—resin based—four or more surfaces |
1025 |
D2710 |
Crown—resin-based composite (indirect) |
940 |
D2712 |
Crown—3/4 resin-based composite (indirect) |
999 |
D2720 |
Crown—resin with high noble metal |
1061 |
D2721 |
Crown—resin with predominantly base metal |
998 |
D2722 |
Crown—resin with noble metal |
1015 |
D2740 |
Crown—porcelain/ceramic substrate |
1132 |
D2750 |
Crown—porcelain fused to high noble metal |
1100 |
D2571 |
Crown—porcelain fused predominantly base metal |
1029 |
D2752 |
Crown—porcelain fused to noble metal |
1050 |
D2780 |
Crown—3/4 cast high noble metal |
1063 |
D2781 |
Crown—3/4 cast predominantly base metal |
1027 |
D2782 |
Crown—3/4 cast noble metal |
1030 |
D2783 |
Crown—3/4 porcelain /ceramic |
1100 |
D2790 |
Crown—full cast high noble metal |
1100 |
D2791 |
Crown—full cast predominantly base metal |
997 |
D2792 |
Crown—full cast noble metal |
1045 |
D2794 |
Crown—titanium |
1076 |
D2799 |
Provisional crown |
437 |
D2910 |
Recement inlay, only, or partial coverage restoration |
108 |
D2915 |
Recement cast or prefabricated post and core |
114 |
D2920 |
Recement crown |
109 |
D2930 |
Prefabricated stainless steel crown—primary tooth |
271 |
D2931 |
Prefabricated stainless steel crown—permanent tooth |
325 |
D2932 |
Prefabricated resin crown |
351 |
D2933 |
Prefabricated stainless steel crown with resin window |
363 |
D2934 |
Prefabricated esthetic coated stainless tell crown—primary tooth |
372 |
D2940 |
Protective restoration |
120 |
D2950 |
Core buildup, including any pins |
271 |
D2951 |
Pin retention—per tooth, in addition to restoration |
75 |
D2952 |
Post and core in addition to crown, indirectly fabricated |
422 |
D2953 |
Each additional indirectly fabricated post—same tooth |
312 |
D2954 |
Prefabricated post and core in addition to crown |
335 |
D2955 |
Post removal (not in conjunction with endodontic therapy) |
291 |
D2957 |
Each additional prefabricated post—same tooth |
200 |
D2960 |
Labial veneer (resin laminate)—chairside |
658 |
D2961 |
Labial veneer (resin laminate)—laboratory |
975 |
D2962 |
Labial veneer (porcelain laminate)—laboratory |
1150 |
D2970 |
Temporary crown (fractured tooth) |
375 |
D2971 |
Additional procedures to construct new crown under existing partial denture framework |
169 |
D2975 |
Coping |
597 |
D2980 |
Crown repair, by report |
293 |
D2999 |
Unspecified restorative procedure, by report |
BR |
D3110 |
Pulp cap—direct (excluding final restoration) |
83 |
D3120 |
Pulp cap—indirect (excluding final restoration) |
84 |
D3220 |
Therapeutic pulpotomy (exclucing final restoration)—removal of pulp coronal to the dentinocemental junction and application of medicament |
198 |
D3221 |
Pulpal debridement, primary and permanent teet |
234 |
D3222 |
Partial pulpotomy for apexogenesis—permament tooth with incomplete root development |
298 |
D3230 |
Pulpal therapy (resorbable filling)—anterior , primary tooth (excluding final restoration) |
275 |
D3240 |
Pulpal therapy (resorbable filling)—posterior , primary tooth (excluding final restoration) |
312 |
D3310 |
Endodontic therapy, anterior tooth (excluding final restoration) |
725 |
D3320 |
Endodontic therapy, biscuspid tooth (excluding final restoration) |
842 |
D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
1009 |
D3331 |
Treatment of root canal obstruction: non-surgical access |
611 |
D3332 |
Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth |
444 |
D3333 |
Internal root repari of perforation defects |
350 |
D3346 |
Retreatment of previous root canal therapy—anterior |
850 |
D3347 |
Retreatment of previous root canal therapy—bicuspid |
970 |
D3348 |
Retreatment of previous root canal therapy—molar |
1132 |
D3351 |
Apexification/recalcification/pulpal regeneration—initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc) |
362 |
D3352 |
Apexification/recalcification/pulpal regeneration—interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc) |
258 |
D3353 |
Apexification/recalcification/pulpal regeneration—final visit (includes completed root canal therapy—apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc) |
542 |
D3354 |
Pupal regeneration—(completion of regenerative treatment in an immature permanent tooth with a necrotic pulp); does not include final restoration |
BR |
D3410 |
Apicoectomy/periradicular surgery—anterior |
700 |
D3421 |
Apicoectomy/periradicular surgery—bicuspid (first root) |
780 |
D3425 |
Apicoectomy/periradicular surgery—molar (first root) |
895 |
D3426 |
Apicoectomy/periradicular surgery—(each additional root) |
400 |
D3430 |
Retrograde filling—per root |
280 |
D3450 |
Root amputation—per root |
483 |
D3460 |
Endodontic endosseous implant |
1524 |
D3470 |
Intentional reimplantation (including necessary splinting) |
796 |
D3910 |
Surgical procedure for isolation of tooth with rubber dam |
235 |
D3920 |
Hemisection (including any root removal), not including root canal therapy |
474 |
D3950 |
Canal preparation and fitting of preformed dowel or post |
258 |
D3999 |
Unspecified endodontic procedure, by report |
BR |
D4210 |
Gingivectomy or gingivoplasty—four or more contiguous teeth or tooth bounded spaces per quadrant |
626 |
D4211 |
Gingivectomy or gingivoplasty—one to three contiguous teeth or tooth bounded spaces per quadrant |
290 |
D4230 |
Anatomical crown exposure—four or more contiguous teeth per quadrant |
698 |
D4231 |
Anatomical crown exposure—one to three contiguous teeth per quadrant |
596 |
D4240 |
Gingival flap procedure, including root planing—one to three contiguous teeth or toth bounded spaces per quadrant |
738 |
D4241 |
Gingival flap procedure, including root planing—four or more contiguous teeth or tooth bounded spaces per quadrant |
635 |
D4245 |
Apically positioned flap |
819 |
D4249 |
Clinical crown lengthening—hard tissue |
751 |
D4260 |
Osseous surgery (including flap entry and closure)—four or more contiguous teeth or tooth bounded spaces per quadrant |
1074 |
D4261 |
Osseous surgery (including flap entry and closure)—one to three contiguous teeth or tooth bounded spaces per quadrant |
890 |
D4263 |
Bone replacment graft—eah additional site in quadrant |
727 |
D4264 |
Bone replacment graft—first site in quadrant |
555 |
D4265 |
Biologic materials to aid in soft and osseous tissue regeneration |
550 |
D4266 |
Guided tissue regeneration—resorbable barrier, per site |
831 |
D4267 |
Guided tissue regeneration—nonresorbable barrier, per site (includes membrane removal) |
984 |
D4268 |
Surgical revision procedure, per tooth |
810 |
D4270 |
Pedical soft tissue graft procedure |
826 |
D4271 |
Free soft tissue graft procedure (including donor site surgery) |
895 |
D4273 |
Subepithelial connective tissue graft procedures, per tooth |
1088 |
D4274 |
Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) |
670 |
D4275 |
Soft tissue allograft |
969 |
D4276 |
Combined connective tissue and double pedicle graft, per tooth |
1085 |
D4320 |
Provisional splinting—intracoronal |
508 |
D4321 |
Provisional splinting—extracoronal |
466 |
D4341 |
Periodontal scaling and root planing—four or more teeth per quadrant |
251 |
D4342 |
Periodontal scaling and root planing—one to three teeth per quadrant |
185 |
D4355 |
Full mouth debridement to enable comprehensive evaluation and diagnosis |
183 |
D4381 |
Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report |
140 |
D4910 |
Periodontal maintenance |
139 |
D4920 |
Unscheduled dressing change (by someone other than treating dentist) |
100 |
D4999 |
Unspecified periodontal procedure, by report |
BR |
D5110 |
Complete denture—maxillary |
1689 |
D5120 |
Complete denture—mandibular |
1700 |
D5130 |
Immediate denture—maxillary |
1831 |
D5140 |
Immediate denture—mandibular |
1849 |
D5211 |
Maxillary partial denture—resin base (including any conventional clasps, rests and teeth) |
1350 |
D5212 |
Mandibular partial denture—resin base (including any conventional clasps, rests and teeth) |
1350 |
D5213 |
Maxillary partial denture—cast base framework with resin denture bases (including any conventional clasps, rests and teeth) |
1781 |
D5214 |
Mandibular partial denture—cast base framework with resin denture bases (including any conventional clasps, rests and teeth) |
1780 |
D5225 |
Maxillary partial denture—flexible base (including any clasps, rests and teeth) |
1566 |
D5226 |
Mandibular partial denture—flexible base (including any clasps, rests and teeth) |
1552 |
D5281 |
Removable unilateral partial denture—one piece cast metal (including clasps and teeth) |
995 |
D5410 |
Adjust complete denture—maxillary |
89 |
D5411 |
Adjust complete denture—mandibular |
88 |
D5421 |
Adjust partial denture—maxillary |
88 |
D5422 |
Adjust partial denture—mandibular |
88 |
D5510 |
Repair broken complete denture base |
208 |
D5520 |
Replace missing or broken teeth—complete denture (each tooth) |
186 |
D5610 |
Repair resin denture base |
202 |
D5620 |
Repair cast framework |
291 |
D5630 |
Repair or replace broken clasp |
262 |
D5640 |
Replace broken teeth—per tooth |
184 |
D5650 |
Add tooth to existing partial denture |
224 |
D5660 |
Add clasp to existing partial denture |
268 |
D5670 |
Replace all teeth and acrylic on cast metal framework (maxillary) |
735 |
D5671 |
Replace all teeth and acrylic on cast metal framework (mandibular) |
750 |
D5710 |
Rebase complete maxillary denture |
591 |
D5711 |
Rebase complete mandibular denture |
585 |
D5720 |
Rebase maxillary partial denture |
563 |
D5721 |
Rebase mandibular partial denture |
562 |
D5730 |
Reline complete maxillary denture (chairside) |
372 |
D5731 |
Reline complete mandibular denture (chairside) |
369 |
D5740 |
Reline maxillary partial denture (chairside) |
364 |
D5741 |
Reline mandibular partial denture (chairside) |
368 |
D5750 |
Reline complete maxillary denture (laboratory ) |
475 |
D5751 |
Reline complete mandibular denture (laboratory) |
475 |
D5760 |
Reline maxillary partial denture (laboratory) |
469 |
D5761 |
Reline mandibular partial denture (laboratory) |
472 |
D5810 |
Interim complete denture (maxillary) |
848 |
D5811 |
Interim complete denture (mandibular) |
853 |
D5820 |
Interim partial denture (maxillary) |
690 |
D5821 |
Interim partial denture (mandibular) |
690 |
D5850 |
Tissue conditioning, maxillary |
204 |
D5851 |
Tissue conditioning, mandibular |
205 |
D5860 |
Overdenture—complete, by report |
2121 |
D5861 |
Overdenture—partial, by report |
2048 |
D5862 |
Precision attachment, by report |
700 |
D5867 |
Replacement of replaceable part of semi-precision or precision attachment (male or female component) |
385 |
D5875 |
Modification of removable prosthesis following implant surgery |
393 |
D5899 |
Unspecified removable prosthodontic procedure, by report |
BR |
D5911 |
Facial moulage (sectional) |
BR |
D5912 |
Facial moulage (complete) |
BR |
D5913 |
Nasal prosthesis |
BR |
D5914 |
Auricular prosthesis |
BR |
D5915 |
Orbital prosthesis |
BR |
D5916 |
Ocular prosthesis |
BR |
D5919 |
Facial prosthesis |
BR |
D5923 |
Ocular prosthesis, interim |
BR |
D5924 |
Cranial prosthesis |
BR |
D5925 |
Facial augmentation implant prosthesis |
BR |
D5926 |
Nasal prosthesis, replacement |
BR |
D5957 |
Auricular prosthesis, replacement |
BR |
D5958 |
Orbital prosthesis, replacement |
BR |
D5929 |
Facial prosthesis, replacement |
BR |
D5931 |
Obturator prosthesis, surgical |
BR |
D5932 |
Obturator prosthesis, definitive |
BR |
D5933 |
Obturator prosthesis, modification |
BR |
D5934 |
Mandibular resection prosthesis with guide flange |
BR |
D5935 |
Mandibular resection prosthesis without guide flange |
BR |
D5936 |
Obturator prosthesis interim |
BR |
D5937 |
Trismus appliance (not for TMD treatment) |
746 |
D5951 |
Feeding aid |
844 |
D5952 |
Speech aid prosthesis, pediatric |
BR |
D5953 |
Speech aid prosthesis, adult |
BR |
D5954 |
Palatal augmentation prosthesis |
BR |
D5955 |
Palatal lift prosthesis, definitive |
BR |
D5958 |
Palatal lift prosthesis, interim |
BR |
D5959 |
Palatal lift prosthesis, modification |
BR |
D5960 |
Speech aid prosthesis modification |
BR |
D5982 |
Surgical stent |
450 |
D5983 |
Radiation carrier |
BR |
D5984 |
Radiation shield |
BR |
D5985 |
Radiation cone locater |
BR |
D5986 |
Fluoride gel carrier |
210 |
D5987 |
Commissure splint |
BR |
D5988 |
Surgical splint |
770 |
D5991 |
Topical medicament carrier |
226 |
D5992 |
Adjust maxillofacial prosthetic appliance, by report |
BR |
D5993 |
Maintenance and cleaning of maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report |
BR |
D5999 |
Unspecified maxillofacial prosthesis, by report |
BR |
D6190 |
Radiographic/surgical implant index, by report |
375 |
D6010 |
Surgical placement of implant body: endosteal implant |
2001 |
D6012 |
Surgical placement of interim implant body for transitional prosthesis: endosteal implant |
1577 |
D6040 |
Surgical placement: eposteal implant |
8380 |
D6050 |
Surgical placement: transosteal implant |
5807 |
D6100 |
Implant removal, by report |
760 |
D6055 |
Connecting bar—implant supported abutment support |
2900 |
D6506 |
Prefabricated abutment—includes placement |
789 |
D6057 |
Custom abutment—includes placement |
952 |
D6053 |
Implant/abutment supported removable denture for completely edentulous arch |
2790 |
D6054 |
Implant/abutment supported removable denture for partially edentulous arch |
2751 |
D6078 |
Implant/abutment supported fixed denture for completely edentulous arch |
5335 |
D6079 |
Implant/abutment supported fixed denture for partially edentulous arch |
3800 |
D6058 |
Abutment supported porcelain/ceramic crown |
1479 |
D6059 |
Abutment supported procelain/ceramic crown (high noble metal |
1479 |
D6060 |
Abutment supported procelain fused to metal crown (predominatly base metal) |
1361 |
D6061 |
Abutment supported procelain fused to metal crown (noble metal) |
1382 |
D6062 |
Abutment supported cast metal crown (high noble metal) |
1432 |
D6063 |
Abutment supported cast metal crown (predominantly base metal) |
1317 |
D6064 |
Abutment supported cast metal crown (noble metal) |
1366 |
D6094 |
Abutment supported crown—(titanium) |
1376 |
D6065 |
Implant supported porcelain/ceramic crown |
1543 |
D6066 |
Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) |
1545 |
D6067 |
Implant supported metal crown (titanium, titanium alloy, high noble metal) |
1575 |
D6068 |
Abutment supported retainer for porcelain/ceramic FPD |
1469 |
D6069 |
Abutment supported retainer for porcelain fused to metal FPD (high noble metal) |
1474 |
D6070 |
Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) |
1384 |
D6071 |
Abutment supported retainer for porcelain fused to metal FPD (noble metal) |
1384 |
D6072 |
Abutment supported retainer for cast metal FPD (high noble metal) |
1451 |
D6073 |
Abutment supported retainer for porcelain cast metal FPD (predominantly base metal) |
1384 |
D6074 |
Abutment supported retainer for cast metal FPD (noble metal) |
1384 |
D6194 |
Abutment supported retainer crown for FPD (titanium) |
1392 |
D6075 |
Implant supported retainer for ceramic FPD |
1529 |
D6076 |
Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy or high noble metal |
1538 |
D6077 |
Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal) |
1587 |
D6080 |
Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis |
297 |
D6090 |
Repair implant supported prosthesis, by report |
742 |
D6095 |
Repair implnat abutment, by report |
731 |
D6091 |
Replacement of semi-precious or precision attachment (male or female componenet) of implant/abutment supported prosthesis, per attachment |
631 |
D6092 |
Recement implant/abutment supported crown |
160 |
D6093 |
Recement implant/abutment supported fixed partial denture |
182 |
D6199 |
Unspecified implant procedure, by report |
BR |
D6205 |
Pontic—indirect resin based composite |
988 |
D6210 |
Pontic—cast high noble metal |
1089 |
D6211 |
Pontic—cast predominately base metal |
998 |
D6212 |
Pontic—cast noble metal |
1041 |
D6214 |
Pontic—titanium |
1100 |
D6240 |
Pontic—porcelain fused to high noble metal |
1100 |
D6241 |
Pontic—porcelain fused to predominantly base metal |
1024 |
D6242 |
Pontic—porcelain fused to noble metal |
1051 |
D6245 |
Pontic—porcelain/ceramic |
1140 |
D6250 |
Pontic—resin with high noble metal |
1058 |
D6251 |
Pontic—resin with predominantly base metal |
1049 |
D6252 |
Pontic—resin with noble metal |
1040 |
D6253 |
Provisional pontic |
769 |
D6254 |
Interim pontic |
BR |
D6545 |
Retainer—cast metal for resin bonded fixed prosthesis |
852 |
D6548 |
Retainer—procelain/ceramic for resin bonded fixed prosthesis |
950 |
D6600 |
Inlay—porcelain/ceramic, two surfaces |
1000 |
D6601 |
Inlay—porcelain/ceramic, three or more surfaces |
1052 |
D6602 |
Inlay—cast high noble metal, two surfaces |
1015 |
D6603 |
Inlay—cast high noble metal, three or more surfaces |
1050 |
D6604 |
Inlay—predominantly base metal, two surfaces |
994 |
D6605 |
Inlay—predominantly base metal, three or more surfaces |
1046 |
D6606 |
Inlay—cast noble metal, two surfaces |
998 |
D6607 |
Inlay—cast noble metal, three or more surfaces |
1050 |
D6624 |
Inlay—titanium |
1080 |
D6608 |
Onlay—porcelain/ceramic, two surfaces |
1061 |
D6609 |
Onlay—porcelain/ceramic, three or more surfaces |
1127 |
D6610 |
Onlay—cast high noble metal, two surfaces |
1074 |
D6611 |
Onlay—cast high noble metal, three or more surfaces |
1111 |
D6612 |
Onlay—predominantly base metal, two surfaces |
1038 |
D6613 |
Onlay—predominantly base metal, three or more surfaces |
1095 |
D6614 |
Onlay—cast noble metal, two surfaces |
1050 |
D6615 |
Onlay—cast noble metal, three or more surfaces |
1102 |
D6634 |
Onlay—titanium |
1125 |
D6710 |
Crown—indirect resin based composite |
1025 |
D6720 |
Crown—resin with high noble metal |
1056 |
D6721 |
Crown—resin with predominantly base metal |
1032 |
D6722 |
Crown—resin with noble metal |
1050 |
D6740 |
Crown—porcelain/ceramic |
1146 |
D6750 |
Crown—porcelain fused to high noble metal |
1107 |
D6751 |
Crown—porcelain fused to predominantly base metal |
1010 |
D6752 |
Crown—porcelain fused to noble metal |
1050 |
D6780 |
Crown—3/4 cast high noble metal |
1075 |
D6781 |
Crown—3/4 cast predominantly base metal |
1038 |
D6782 |
Crown—3/4 cast noble metal |
1050 |
D6783 |
Crown—3/4 porcelain/ceramic |
1100 |
D6790 |
Crown—full cast high noble metal |
1085 |
D6791 |
Crown—full cast predominantly base metal |
997 |
D6792 |
Crown—full cast noble metal |
1040 |
D6794 |
Crown—titanium |
1059 |
D6793 |
Provisional retainer crown |
523 |
D6795 |
Interim retainer crown |
BR |
D6920 |
Connector bar |
995 |
D6930 |
Recement fixed partial denture |
171 |
D6940 |
Stress breaker |
435 |
D6950 |
Precision attachment |
650 |
D6970 |
Post and core in addition to fixed partial denture retainer, indirectly fabricated |
433 |
D6972 |
Prefabricated post and core in addition to fixed partial denture retainer |
344 |
D6973 |
Core build up for retainer, including any pins |
275 |
D6975 |
Coping—metal |
700 |
D6976 |
Each additional indirectly fabricated post—same tooth |
290 |
D6977 |
Each additional prefabricated post—same tooth |
204 |
D6980 |
Fixed partial denture repair, by report |
387 |
D6985 |
Pediatric partial denture, fixed |
915 |
D6999 |
Unspecified fixed prosthodontic procedure, by report |
BR |
D7111 |
Extraction, coronal remnants—deciduous tooth |
135 |
D7140 |
Extraction, erupted tooth or exposed root (elevation and/or forceps removal) |
174 |
D7210 |
Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated |
275 |
D7220 |
Removal of impacted tooth—soft tissue |
315 |
D7230 |
Removal of impacted tooth—partially bony |
395 |
D7240 |
Removal of impacted tooth—completely bony |
484 |
D7241 |
Removal of impacted tooth—completely bony, with unusual surgical complications |
576 |
D7250 |
Surgical removal of residual tooth roots (cutting procedure) |
304 |
D7251 |
Coronectomy—intentional partial tooth removal |
BR |
D7260 |
Oroantral fistula closure |
1026 |
D7261 |
Primary closure of a sinus perforation |
757 |
D7270 |
Tooth reimplantation and/or stablization of accidentally evulsed or displaced tooth |
561 |
D7272 |
Tooth tranplantation (includes reimplantation from one site to another and splinting and/or stablization) |
746 |
D7280 |
Surgical access of an unerupted tooth |
482 |
D7282 |
Mobilization of erupted or malpositioned tooth to aid eruption |
526 |
D7283 |
Placement of device to facilitate eruption of impacted tooth |
523 |
D7285 |
Biopsy of oral tissue—hard (bone, tooth) |
437 |
D7286 |
Biopsy of oral tissue—soft |
320 |
D7287 |
Exfoliative cytological sample collection |
184 |
D7288 |
Brush biopsy—transepithelial sample collection |
195 |
D7290 |
Surgical repositioning of teeth |
528 |
D7291 |
Transseptal fiberotomy/surpa crestal fibertotomy, by report |
315 |
D7292 |
Surgical placement: temporary anchorage device [screw retained plate] requiring surgical flap |
3300 |
D7293 |
Surgical placement: temporary anchorage device requiring surgical flap |
2528 |
D7294 |
Surgical placement: temporary anchorage device without surgical flap |
1619 |
D7295 |
Harvest of bone for use in autogenous grafting procedure |
BR |
D7310 |
Alveolplasty in conjuction with extractions—four or more teeth or tooth spaces, per quadrant |
295 |
D7311 |
Alveolplasty in conjuction with extractions—one to three teeth or tooth spaces, per quadrant |
309 |
D7320 |
Alveolplasty not in conjuction with extractions—four or more teeth or tooth spaces, per quadrant |
443 |
D7321 |
Alveolplasty not in conjuction with extractions—one to three teeth or tooth spaces, per quadrant |
437 |
D7340 |
Vestibuloplasty—ridge extension (secondary epithelialization) |
1164 |
D7350 |
Vestibuloplasty—ridge extension (including soft tissue graft, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) |
2467 |
D7410 |
Excision of benign lesion up to 1.25 cm |
415 |
D7411 |
Excision of benign lesion greater than 1.25 cm |
630 |
D7412 |
Excision of benign lesion, complicated |
850 |
D7413 |
Excision of malignant lesion greater than 1.25 cm |
751 |
D7414 |
Excision of malignant lesion up to 1.25 cm |
1132 |
D7415 |
Excision of malignant lesion, complicated |
1253 |
D7465 |
Destruction of lesion(s) by phyiscal or chemical method, by report |
459 |
D7440 |
Excision of malignant tumor—lesion diameter up to 1.25cm |
720 |
D7441 |
Excision of malignant tumor—lesion greater than 1.25cm |
1224 |
D7450 |
Removal of benign odontogenic cyst or tumor—lesion diameter up to 1.25cm |
588 |
D7451 |
Removal of benign odontogenic cyst or tumor—lesion diameter greater than 1.25cm |
782 |
D7460 |
Removal of benign nonodontogenic cyst or tumor—lesion diameter greater than 1.25cm |
573 |
D7461 |
Removal of benign nonodontogenic cyst or tumor—lesion diameter up to 1.25cm |
874 |
D7470 |
Removal of lateral exostosis (maxilla or mandible) |
653 |
D7472 |
Removal of torus palatinus |
859 |
D7473 |
Removal of torus mandibularis |
761 |
D7485 |
Surgical reduction of osseous tuberosity |
755 |
D7490 |
Radial resection of maxilla or mandible |
8006 |
D7510 |
Incision and drainage of abscess—intraoral soft tissue |
236 |
D7511 |
Incision and drainage of abscess—intraoral soft tissue—complicated (includes drainage of multiple fascial spaces) |
367 |
D7520 |
Incision and drainage of abscess—extraoral tissue |
169 |
D7521 |
Incision and drainage of abscess—extraoral tissue—complicated (includes drainage of multiple fascial spaces) |
630 |
D7530 |
Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue |
364 |
D7540 |
Removal of reaction producing foreign bodies, musculoskeletal system |
708 |
D7550 |
Partial ostectomy/sequestrectomy for removal of non-vital bone |
600 |
D7560 |
Maxillary sinusotomy for removal of tooth fragment or foreign body |
1308 |
D7610 |
Maxilla—open reduction (teeth immobilized, if present) |
4464 |
D7620 |
Maxilla—closed reduction (teeth immobilized, if present) |
3450 |
D7630 |
Mandible—open reduction (teeth immobilized, if present) |
4576 |
D7640 |
Mandible—closed reduction (teeth immobilized, if present) |
3483 |
D7650 |
Malar and/or zygomatic arch—open reduction |
3924 |
D7660 |
Malar and/or zygomatic arch—closed reduction |
3277 |
D7670 |
Alveolus closed reduction may include stabilization of teeth |
1746 |
D7671 |
Alveolus open reduction may include stabilization of teeth |
1298 |
D7680 |
Facial bones—complicated reduction with fixation and multiple surgical approaches |
6555 |
D7710 |
Maxilla open reduction |
4568 |
D7720 |
Maxillia—closed reduction |
3462 |
D7730 |
Mandible—open reduction |
4826 |
D7740 |
Mandible—closed reduction |
3636 |
D7750 |
Malar and/or zygomatic arch—open reduction |
4230 |
D7760 |
Malar and/or zygomatic arch—closed reduction |
6044 |
D7770 |
Alveolus open reduction stabilization of teeth |
2794 |
D7771 |
Alveolus closed reduction stabilization of teeth |
1958 |
D7780 |
Facial bones—complicated reduction with fixation and multiple surgical approaches |
8587 |
D7810 |
Open reduction of dislocation |
4271 |
D7820 |
Closed reduction of dislocation |
644 |
D7830 |
Manipulation under anesthesia |
990 |
D7840 |
Condylectomy |
5466 |
D7850 |
Surgical discectomy, with/without implant |
5356 |
D7852 |
Disc repair |
5541 |
D7854 |
Synovectomy |
5278 |
D7856 |
Myotomy |
3505 |
D7858 |
Joint reconstruction |
BR |
D7860 |
Arthrotomy |
BR |
D7865 |
Arthroplasty |
BR |
D7870 |
Arthrocentesis |
562 |
D7871 |
Non-arthroscopic lysis and lavage |
BR |
D7872 |
Arthroscopy—diagnosis, with or without biopsy |
BR |
D7873 |
Arthroscopy—surgical: lavage and lysis of adhesions |
BR |
D7874 |
Arthroscopy—surgical: disc repositioning and stabilization |
BR |
D7875 |
Arthroscopy—surgical: synovectomy |
BR |
D7876 |
Arthroscopy—surgical: discectomy |
BR |
D7877 |
Arthroscopy—surgical: debridement |
BR |
D7880 |
Occlusal orthotic device, by report |
990 |
D7899 |
Unspecified TMD therapy, by report |
BR |
D7910 |
Suture of recent small wounds up to 5 cm |
300 |
D7911 |
Complicated suture—up to 5 cm |
486 |
D7912 |
Complicated suture—greater than 5 cm |
792 |
D7920 |
Skin graft (identify defect coverd, location and type of graft |
2677 |
D7940 |
Osteoplasty—for orthognathic deformaties |
4123 |
D7941 |
Osteotomy—mandibular rami |
9139 |
D7943 |
Osteotomy—mandibular rami with bone graft; includes obtaining the graft |
8623 |
D9744 |
Osteotomy—segmented or subapical |
7006 |
D7945 |
Osteotomy—body of mandible |
6983 |
D7946 |
LeFort I (maxillia—total) |
8251 |
D7947 |
LeFort I (maxillia—segmentedl) |
8393 |
D7948 |
LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion)-without bone graft |
9586 |
D7949 |
LeFort II of LeFort III—with bone graft |
11832 |
D7950 |
Osseous, osteoperiosteal or cartilage graft of the mandible or maxillia—autogenous or nonautogenous, by report |
3116 |
D7951 |
Sinus augmentation with bone or bone substitutes |
3200 |
D7953 |
Bone replacement graft for ridge preservation—per site |
800 |
D7955 |
Repair of maxillofacial soft and/or hard tissue defect |
3807 |
D7960 |
Frenulectomy—also known as frenectomy or frenotomy—separate procedure not incidental to another procedure |
450 |
D7936 |
Frenuloplasty |
499 |
D7970 |
Excision of hyperplastic tissue—per arch |
517 |
D7971 |
Excision of pericoronal gingiva |
258 |
D7972 |
Surgical reduction of fibrous tuberosity |
796 |
D7980 |
Sialolithotomy |
843 |
D7981 |
Excision of salivary gland, by report |
BR |
D7982 |
Sialodochoplasty |
1749 |
D7983 |
Closure of salivary fistula |
1528 |
D7990 |
Emergency tracheotomy |
1482 |
D7991 |
Coronoidectomy |
4056 |
D7995 |
Synthetic graft—mandible or facial bones, by report |
BR |
D7996 |
Implant-mandible for augmentation purposes (excluding alveolar ridge), by report |
BR |
D7997 |
Appliance removal (not by dentist who place appliance), includes removal of archbar |
350 |
D7998 |
Intraoral placement of a fixation device not in conjunction with a fracture |
2572 |
D7999 |
Unspecified oral surgery procedure, by report |
BR |
D8010 |
Limited orthodontic treatment of the primary dentition |
2149 |
D8020 |
Limited orthodontic treatment of the transitional dentition |
2459 |
D8030 |
Limited orthodontic treatment of the adolescent dentition |
2901 |
D8040 |
Limited orthodontic treatment of the adult dentition |
3237 |
D8050 |
Interceptive orthodontic treatment of the primary dentition |
2590 |
D8060 |
Interceptive orthodontic treatment of the transitional dentition |
2796 |
D8070 |
Comprehensive orthodontic treatment of the transitional dentition |
5200 |
D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
5250 |
D8090 |
Comprehensive orthodontic treatment of the adult dentition |
5308 |
D8210 |
Removable appliance therapy |
861 |
D8220 |
Fixed appliance therapy |
968 |
D8660 |
Pre-orthodontic treatment visit |
384 |
D8670 |
Periodlic orthodontic treatment bisit (as part of contract) |
263 |
D8680 |
Orthodontic retention (removal of appliances, construction and placement of retainers(s)) |
532 |
D8690 |
Orthodontic treatment (alternative billing to a contract fee) |
283 |
D8691 |
Repair of orthodontic appliance |
210 |
D8692 |
Replacement of lost or broken retainer |
330 |
D8693 |
Rebonding or recementing; and/or repair as require, of fixed retainers |
356 |
D8999 |
Unspecified orthodontic procedure, by report |
BR |
D9110 |
Palliative (emergency) treatment of dental pain—minor procedure |
126 |
D9120 |
Fixed partial denture sectioning |
250 |
D9210 |
Local anesthesia not in conjunction with operative or surgical procedures |
74 |
D9211 |
Regional block anesthesia |
96 |
D9212 |
Trigeminal division block anesthesia |
272 |
D9215 |
Local anesthesia in conjunction with operative or surgical procedures |
65 |
D9220 |
Deep sedation/general anesthesia—first 30 minutes |
392 |
D9221 |
Deep sedation/general anesthesia—each additional 15 minutes |
174 |
D9230 |
Inhalation of nitrous oxide / anxiolysis analgesia |
79 |
D9241 |
Intravenous conscious sedation/analgesia—first 30 minutes |
416 |
D9242 |
Intravenous conscious sedation/analgesia—each additional 15 minutes |
169 |
D9248 |
Non-intravenous concious sedation |
325 |
D9310 |
Consultation—diagnostic services provided by dentis or physician other than requesting dentist or physician |
129 |
D9410 |
House/extended care facility call |
246 |
D9420 |
Hospital or ambulatory surgery center call |
299 |
D9430 |
Office visit for observation (during regularly scheduled hours)—no other services performed |
76 |
D9440 |
Office visit after regularly scheduled hours |
179 |
D9450 |
Case presentation, detailed and extensive treatment planning |
145 |
D9610 |
Therapeutic parental drug, single administration |
111 |
D9612 |
Therapeutic parental drug, two or more administrations, different medications |
193 |
D9630 |
Other drugs and/or medicaments, by report |
49 |
D9910 |
Application of disensitizing medicament |
63 |
D9911 |
Application of disensitizing resin for cervical and/or root surface, per tooth |
79 |
D9920 |
Behavior management, by report |
160 |
D9930 |
Treatment of complications (post-surgical)—unusual circumstances, by report |
132 |
D9940 |
Occlusal guard, by report |
600 |
D9941 |
Fabrication of athletic mouthguard |
254 |
D9942 |
Repair and/or reline of occlusal guard |
250 |
D9950 |
Occulusion analysis—mounted case |
344 |
D9951 |
Occulusal adjustment—limited |
182 |
D9952 |
Occulusal adjustment—complete |
687 |
D9970 |
Enamel microabrasion |
202 |
D9971 |
Odontoplasty 1-2 teeth; includes removal of enamel projections |
176 |
D9972 |
External bleaching—per arch |
328 |
D9973 |
External bleaching—per tooth |
231 |
D9974 |
Internal bleaching—per tooth |
291 |
D9999 |
Unspecified adjunctive procedure, by report |
BR |
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:1167 (September 1993), amended LR 20:1298 (November 1994), amended by the Workforce Commission, Office of Workers’ Compensation, LR 39:2043 (July 2013), LR 40:379 (February 2014), amended by the Workforce Commission, Office of Workers’ Compensation Administration, LR 41:
Public Comments
Inquiries concerning the Emergency Rule may be sent to Patrick Robinson, OWC-Administration, 1001 North Twenty-Third Street, Baton Rouge, LA 70802.
Curt Eysink
Executive Director
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