Louisiana Medicaid Professional Services Fee Schedule

1. What Is the Professional Services Fee Schedule?

The PSFS is a standardized list of fee amounts that the Louisiana Department of Health (LDH) will pay for each billable service rendered under Medicaid. It is based on the Medicare Physician Fee Schedule (MPFS) with statespecific adjustments, including the Medicaid conversion factor, geographic practice cost indices, and any supplemental state modifiers.

Key components of the schedule include:

• Current Procedural Terminology (CPT) codes the national coding system used to describe medical, surgical, and diagnostic services.
• Relative Value Units (RVUs) a weighted measure of the resources required to provide a service (work, practice expense, and malpractice).
• Conversion factor a dollar amount applied to the total RVU to calculate the base fee.
• Geographic adjustments modifications based on the providers practice location, reflecting cost differences across the state.

2. How Fees Are Calculated

For each CPT code, the fee is calculated using the following formula:

Fee = (Work RVU + Practice Expense RVU + Malpractice RVU)  Conversion Factor  Geographic Modifier

Example (simplified):

• CPT 99213 (Office Visit, established patient) Total RVU = 1.31
• Conversion Factor (2024) = $20.00
• Geographic Modifier (New Orleans) = 1.10
• Fee = 1.31 $20.00 1.10 $28.82

The LDH publishes the official conversion factor quarterly and provides an Excelbased feeschedule tool that incorporates all current modifiers.

3. Key Service Categories

The PSFS groups services into several broad categories. Below is a snapshot of typical reimbursement ranges (2024 rates) for each category. Exact amounts depend on the CPT code, RVU values, and location.

Note: All amounts listed are maximum fees. Payers may negotiate lower rates for contracted providers.

4. Who Is Covered?

The PSFS applies to a wide range of Medicaideligible providers, including:

• Physicians (MD, DO)
• Advanced Practice Clinicians (NPs, PAs, CRNAs)
• Dentists and dental hygienists
• Physical, occupational, and speech therapists
• Behavioral health specialists

Providers must be enrolled in the Louisiana Medicaid program and have a valid National Provider Identifier (NPI) to bill under the schedule.

5. Updating the Schedule

The LDH updates the fee schedule annually, with interim adjustments published as needed. Key dates:

• January 1 New conversion factor becomes effective.
• April 15 Final rule incorporating any CMS updates to RVUs.
• July 1 Geographic modifiers reviewed and adjusted.

Providers receive an electronic notice through the My LA Health portal and can download the latest schedule PDF or Excel file.

6. Common Billing Issues & How to Avoid Them

1. Using outdated CPT codes Verify that the code version matches the current years schedule.
2. Missing geographic modifier The modifier (e.g., LA001) must be appended to each claim; otherwise, the system applies the default state rate, which may be lower.
3. Incorrect place of service code Telehealth, office, and mobile services each have distinct POS codes (02, 11, 20). Mismatches cause claim rejections.
4. Bundled services Some procedures are considered inclusive of evaluation and management (E&M) work. Submitting both can result in a duplicate service denial.
5. Failure to attach supporting documentation For services such as wound care or behavioral health, documentation is required for audit purposes.

Regularly review the LDH Provider Bulletin for alerts on billing changes.

7. Appeals and Claim Adjustments

If a claim is denied or underpaid, providers have a 30day window to file an appeal. Steps:

1. Obtain the Explanation of Benefits (EOB) detailing the denial reason.
2. Gather supporting records (progress notes, order forms, signed consent).
3. Submit a written appeal through the My LA Health portal, referencing the claim number and citing the specific CPT code and fee schedule provision.
4. If the appeal is denied, a secondlevel appeal can be filed with the Office of Inspector General (OIG) within 60 days.

8. Resources for Providers

• Louisiana Medicaid Provider Handbook Comprehensive guide to policies, codes, and billing processes.
• Fee Schedule Excel Tool Allows providers to calculate expected reimbursement for any CPT code.
• Webinars & Training LDH conducts quarterly virtual sessions covering updates and best practices.
• Provider Help Desk Phone: 1800555MEDI (18005556334) | Email: medicaid.help@ldh.la.gov

9. Future Trends

The state is exploring valuebased payment models that integrate the PSFS with quality metrics. Possible developments include:

• Performancebased bonuses for preventive care adherence.
• Bundled payments for chronic disease management (e.g., diabetes, COPD).
• Expanded telehealth reimbursement parity with inperson services.

Staying informed about these initiatives can position practices to benefit from upcoming incentive programs.

10. Quick Reference Checklist

1. Verify enrollment and active NPI status.
2. Use the current years CPT codes and RVU values.
3. Apply the correct conversion factor and geographic modifier.
4. Include the appropriate placeofservice code.
5. Attach required documentation for highrisk or specialty services.
6. Monitor the LDH portal for schedule updates and bulletin alerts.
7. Promptly address denials with a documented appeal.