effective 05/01/2021tbd ......2021/06/24 · tc fee pc fee (mod 26) pre/intra op (mod 54) post op...
TRANSCRIPT
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 1 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
10060 $78.70 $70.83 $7.87 NCS $65.58 $59.02 $6.56 NCS Y 10 1/day n/a
10061 $136.56 $122.90 $13.66 NCS $113.80 $102.42 $11.38 NCS Y 10 1/day n/a
11200 $57.81 NCS $48.16 NCS Y 10 1/day n/a
11310 $59.48 $9.52 $49.57 $7.93 Y 0 1/day n/a
11311 $75.95 $12.15 $63.29 $10.13 Y 0 1/day n/a
11312 $87.69 $14.03 $73.08 $11.69 Y 0 1/day n/a
11313 $110.30 $17.65 $91.91 $14.71 Y 0 1/day n/a
11440 $89.75 $80.78 $8.98 NCS $74.79 $67.31 $7.48 NCS Y 10 1/day n/a
11441 $114.76 $103.28 $11.48 NCS $95.63 $86.07 $9.56 NCS Y 10 1/day n/a
11442 $129.58 $116.62 $12.96 NCS $107.98 $97.18 $10.80 NCS Y 10 1/day n/a
11443 $156.57 $140.91 $15.66 NCS $130.47 $117.42 $13.05 NCS Y 10 1/day n/a
11444 $198.52 $178.67 $19.85 NCS $165.44 $148.90 $16.54 NCS Y 10 1/day n/a
11446 $271.92 $244.73 $27.19 NCS $226.60 $203.94 $22.66 NCS Y 10 1/day n/a
11640 See Post Op See Post Op $13.35 NCS See Post Op See Post Op $11.12 NCS Y 10 1/day n/a
11641 See Post Op See Post Op $16.48 NCS See Post Op See Post Op $13.74 NCS Y 10 1/day n/a
11642 See Post Op See Post Op $19.05 NCS See Post Op See Post Op $15.88 NCS Y 10 1/day n/a
11643 See Post Op See Post Op $22.55 NCS See Post Op See Post Op $18.79 NCS Y 10 1/day n/a
11644 See Post Op See Post Op $27.92 NCS See Post Op See Post Op $23.26 NCS Y 10 1/day n/a
11646 See Post Op See Post Op $37.08 NCS See Post Op See Post Op $30.90 NCS Y 10 1/day n/a
11900 $39.86 NCS $33.21 NCS Y 0 1/day n/a
12011 $112.29 NCS $93.57 NCS Y 0 1/day n/a
12013 $124.08 NCS $103.39 NCS Y 0 1/day n/a
12014 $146.87 NCS $122.38 NCS Y 0 1/day n/a
12015 $184.81 NCS $154.00 NCS Y 0 1/day n/a
12016 $221.41 NCS $184.51 NCS Y 0 1/day n/a
12017 $202.60 $32.42 $168.83 $27.01 Y 0 1/day n/a
12018 $250.48 $40.08 $208.73 $33.40 Y 0 1/day n/a
12020 See Post Op See Post Op $19.06 $30.49 See Post Op See Post Op $15.88 $25.41 Y 10 1/day n/a
12051 See Post Op See Post Op $18.86 NCS See Post Op See Post Op $15.72 NCS Y 10 1/day n/a
12052 See Post Op See Post Op $21.32 NCS See Post Op See Post Op $17.77 NCS Y 10 1/day n/a
12053 See Post Op See Post Op $23.49 NCS See Post Op See Post Op $19.58 NCS Y 10 1/day n/a
12054 See Post Op See Post Op $24.96 NCS See Post Op See Post Op $20.80 NCS Y 10 1/day n/a
12055 See Post Op See Post Op $30.24 NCS See Post Op See Post Op $25.20 NCS Y 10 1/day n/a
12056 See Post Op See Post Op $35.76 $57.21 See Post Op See Post Op $29.80 $47.68 Y 10 1/day n/a
12057 See Post Op See Post Op $39.90 $63.84 See Post Op See Post Op $33.25 $53.20 Y 10 1/day n/a
14040 See Post Op See Post Op $104.41 NCS See Post Op See Post Op $87.01 NCS Y 90 1/day n/a
14041 See Post Op See Post Op $129.92 NCS See Post Op See Post Op $108.27 NCS Y 90 1/day n/a
14060 See Post Op See Post Op $56.10 NCS See Post Op See Post Op $46.75 NCS Y 90 1/day n/a
14061 See Post Op See Post Op $73.20 NCS See Post Op See Post Op $61.00 NCS Y 90 1/day n/a
15115 See Post Op See Post Op $119.23 NCS See Post Op See Post Op $99.36 NCS Y 90 1/day Y
15135 See Post Op See Post Op $119.55 NCS See Post Op See Post Op $99.62 NCS Y 90 1/day Y
15155 See Post Op See Post Op $102.60 NCS See Post Op See Post Op $85.50 NCS Y 90 1/day Y
15630 See Post Op See Post Op $61.49 NCS See Post Op See Post Op $51.24 NCS Y 90 1/day Y
15730 See Post Op See Post Op $252.54 NCS See Post Op See Post Op $210.45 NCS Y 90 1/day n/a
15750 See Post Op See Post Op $128.80 $112.98 See Post Op See Post Op $107.33 $112.98 Y 90 1/day n/a
15770 See Post Op See Post Op $92.07 NCS See Post Op See Post Op $76.73 NCS Y 90 1/day n/a
15820 See Post Op See Post Op $98.37 NCS See Post Op See Post Op $40.24 NCS Y 90 Y 1/lifetime Y
15821 See Post Op See Post Op $111.40 NCS See Post Op See Post Op $44.26 NCS Y 90 Y 1/lifetime Y
15822 See Post Op See Post Op $120.72 NCS See Post Op See Post Op $120.72 NCS Y 90 Y 1/lifetime Y
15823 See Post Op See Post Op $132.79 NCS See Post Op See Post Op $132.79 NCS Y 90 Y 1/lifetime Y
15841 See Post Op See Post Op $240.18 $210.69 See Post Op See Post Op $200.15 $210.69 Y 90 1/day n/a
15845 See Post Op See Post Op $133.32 $116.94 See Post Op See Post Op $111.10 $116.94 Y 90 1/day n/a
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 2 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
17000 $55.24 $49.72 $5.52 NCS $46.04 $41.44 $4.60 NCS Y 10 1/day n/a
17003 $5.45 NCS $4.54 NCS n/a n/a 1/day n/a
21256 See Post Op See Post Op $184.27 $146.25 See Post Op See Post Op $153.56 $146.25 Y 90 1/year Y
21260 See Post Op See Post Op $205.25 $162.90 See Post Op See Post Op $171.04 $162.90 Y 90 1/year Y
21261 See Post Op See Post Op $356.46 $282.91 See Post Op See Post Op $297.05 $282.91 Y 90 1/year Y
21263 See Post Op See Post Op $320.07 $254.02 See Post Op See Post Op $266.73 $254.02 Y 90 1/year Y
21267 See Post Op See Post Op $240.56 $190.92 See Post Op See Post Op $200.47 $190.92 Y 90 1/year Y
21268 See Post Op See Post Op $302.61 $240.16 See Post Op See Post Op $252.17 $240.16 Y 90 1/year Y
21275 See Post Op See Post Op $127.06 $100.84 See Post Op See Post Op $105.89 $100.84 Y 90 1/year Y
21282 See Post Op See Post Op $69.31 NCS See Post Op See Post Op $57.76 NCS Y 90 1/year Y
21365 See Post Op See Post Op $173.84 $137.97 See Post Op See Post Op $144.87 $137.97 Y 90 1/year Y
21385 See Post Op See Post Op $110.92 $88.03 See Post Op See Post Op $92.44 $88.03 Y 90 1/year Y
21386 See Post Op See Post Op $104.06 $82.59 See Post Op See Post Op $86.72 $82.59 Y 90 1/year Y
21387 See Post Op See Post Op $115.94 $92.02 See Post Op See Post Op $96.62 $92.02 Y 90 1/year Y
21390 See Post Op See Post Op $120.04 $95.27 See Post Op See Post Op $100.03 $95.27 Y 90 1/year Y
21395 See Post Op See Post Op $152.45 $120.99 See Post Op See Post Op $127.04 $120.99 Y 90 1/year Y
21400 See Post Op See Post Op $26.17 NCS See Post Op See Post Op $21.81 NCS Y 90 1/year Y
21401 See Post Op See Post Op $69.55 NCS See Post Op See Post Op $57.96 NCS Y 90 1/year Y
21406 See Post Op See Post Op $83.95 $66.63 See Post Op See Post Op $69.96 $66.63 Y 90 1/year Y
21407 See Post Op See Post Op $99.72 $79.15 See Post Op See Post Op $83.10 $79.15 Y 90 1/year Y
21408 See Post Op See Post Op $137.73 $109.31 See Post Op See Post Op $114.78 $109.31 Y 90 1/year Y
64612 See Post Op See Post Op $22.88 NCS See Post Op See Post Op $19.07 NCS Y 10 1/3-6 months Y
65091 See Post Op See Post Op $85.62 NCS See Post Op See Post Op $71.35 NCS Y 90 1/lifetime Y
65093 See Post Op See Post Op $85.36 NCS See Post Op See Post Op $71.13 NCS Y 90 1/lifetime Y
65101 See Post Op See Post Op $98.56 NCS See Post Op See Post Op $82.13 NCS Y 90 1/lifetime Y
65103 See Post Op See Post Op $103.06 NCS See Post Op See Post Op $85.88 NCS Y 90 1/lifetime Y
65105 See Post Op See Post Op $113.84 $94.87 See Post Op See Post Op $94.87 $94.87 Y 90 1/lifetime Y
65110 See Post Op See Post Op $167.22 $139.35 See Post Op See Post Op $139.35 $139.35 Y 90 1/lifetime Y
65112 See Post Op See Post Op $197.59 $164.65 See Post Op See Post Op $164.65 $164.65 Y 90 1/lifetime Y
65114 See Post Op See Post Op $205.08 $170.90 See Post Op See Post Op $170.90 $170.90 Y 90 1/lifetime Y
65125 See Post Op See Post Op $60.04 NCS See Post Op See Post Op $50.04 NCS Y 90 1/lifetime Y
65130 See Post Op See Post Op $97.67 NCS See Post Op See Post Op $81.39 NCS Y 90 1/lifetime Y
65135 See Post Op See Post Op $99.50 NCS See Post Op See Post Op $82.92 NCS Y 90 1/lifetime Y
65140 See Post Op See Post Op $108.47 NCS See Post Op See Post Op $90.39 NCS Y 90 1/lifetime Y
65150 See Post Op See Post Op $78.40 NCS See Post Op See Post Op $65.34 NCS Y 90 1/lifetime Y
65155 See Post Op See Post Op $114.69 NCS See Post Op See Post Op $95.57 NCS Y 90 1/lifetime Y
65175 See Post Op See Post Op $87.86 NCS See Post Op See Post Op $73.22 NCS Y 90 1/lifetime Y
65205 $38.96 NCS $32.47 NCS Y 0 1/day Y
65210 $47.63 NCS $39.69 NCS Y 0 1/day Y
65220 $40.06 NCS $33.37 NCS Y 0 1/day Y
65222 $52.33 NCS $43.61 NCS Y 0 1/day Y
65235 See Post Op See Post Op $94.50 NCS See Post Op See Post Op $78.75 NCS Y 90 1/day Y
65260 See Post Op See Post Op $129.88 $108.23 See Post Op See Post Op $108.23 $108.23 Y 90 1/day Y
65265 See Post Op See Post Op $146.33 $121.94 See Post Op See Post Op $121.94 $121.94 Y 90 1/day Y
65270 See Post Op See Post Op $17.60 NCS See Post Op See Post Op $14.67 NCS Y 10 1/day Y
65272 $328.34 $262.67 $65.67 NCS $273.62 $218.90 $54.72 NCS Y 90 1/day Y
65273 See Post Op See Post Op $51.69 NCS See Post Op See Post Op $43.07 NCS Y 90 1/day Y
65275 $372.52 $298.02 $74.50 NCS $310.42 $248.34 $62.08 NCS Y 90 1/day Y
65280 See Post Op See Post Op $90.70 NCS See Post Op See Post Op $75.58 NCS Y 90 1/day Y
65285 See Post Op See Post Op $141.97 NCS See Post Op See Post Op $118.31 NCS Y 90 1/day Y
65286 $465.00 $372.00 $93.00 NCS $387.50 $310.00 $77.50 NCS Y 90 1/day Y
65290 See Post Op See Post Op $66.54 NCS See Post Op See Post Op $55.45 NCS Y 90 1/day Y
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 3 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
65400 See Post Op $357.48 $89.37 NCS See Post Op $297.90 $74.48 NCS Y 90 1/day Y
65410 $96.90 NCS $80.75 NCS Y 0 1/day Y
65420 See Post Op See Post Op $67.93 NCS See Post Op See Post Op $56.61 NCS Y 90 1/year Y
65426 See Post Op See Post Op $86.06 NCS See Post Op See Post Op $71.72 NCS Y 90 1/year Y
65430 $79.46 NCS $66.22 NCS Y 0 1/day Y
65435 $54.46 NCS $45.39 NCS Y 0 1/day Y
65436 $259.99 $207.99 $52.00 NCS $216.66 $173.33 $43.33 NCS Y 90 1/day Y
65450 See Post Op See Post Op $42.62 NCS See Post Op See Post Op $35.52 NCS Y 90 1/day Y
65600 $258.07 $206.46 $51.61 NCS $215.05 $172.04 $43.01 NCS Y 90 1/day Y
65710 See Post Op See Post Op $149.40 $124.50 See Post Op See Post Op $124.50 $124.50 Y 90 Y 1/lifetime Y
65730 See Post Op See Post Op $166.44 $138.70 See Post Op See Post Op $138.70 $138.70 Y 90 Y 1/lifetime Y
65750 See Post Op See Post Op $169.08 $140.90 See Post Op See Post Op $140.90 $140.90 Y 90 Y 1/lifetime Y
65755 See Post Op See Post Op $168.07 NCS See Post Op See Post Op $140.06 NCS Y 90 Y 1/lifetime Y
65756 See Post Op See Post Op $162.44 NCS See Post Op See Post Op $135.36 NCS Y 90 Y 1/lifetime Y
65757 NCS NCS 20% NCS NCS NCS 20% NCS Y 90 1/lifetime Y
65770 See Post Op See Post Op $193.63 $161.36 See Post Op See Post Op $161.36 $161.36 Y 90 Y 1/lifetime Y
65772 See Post Op See Post Op $59.87 NCS See Post Op See Post Op $49.89 NCS Y 90 1/lifetime Y
65775 See Post Op See Post Op $74.02 NCS See Post Op See Post Op $61.69 NCS Y 90 1/lifetime Y
65778 $762.79 $686.51 $76.28 NCS $635.65 See Post Op $63.57 NCS Y 0 1/lifetime Y
65779 $690.76 $621.68 $69.08 NCS $575.64 $518.08 $57.56 NCS Y 0 1/lifetime Y
65780 See Post Op See Post Op $118.92 NCS See Post Op See Post Op $99.10 NCS Y 90 1/lifetime Y
65781 See Post Op See Post Op $181.55 $151.30 See Post Op See Post Op $151.30 $151.30 Y 90 1/lifetime Y
65782 See Post Op See Post Op 20% manual pric NCS See Post Op See Post Op 20% manual pric NCS Y 90 1/lifetime Y
65785 See Post Op See Post Op $347.69 NCS See Post Op See Post Op $289.74 NCS Y 90 1/lifetime Y
65800 $103.76 NCS $86.47 NCS Y 0 1/day Y
65810 See Post Op See Post Op $62.75 NCS See Post Op See Post Op $52.29 NCS Y 90 1/year Y
65815 See Post Op See Post Op $84.25 NCS See Post Op See Post Op $70.21 NCS Y 90 1/year Y
65820 See Post Op See Post Op $100.78 NCS See Post Op See Post Op $83.98 NCS Y 90 1/lifetime Y
65850 See Post Op See Post Op $115.62 NCS See Post Op See Post Op $96.35 NCS Y 90 1/lifetime Y
65855 $229.35 $206.42 $22.94 NCS $191.13 $172.02 $19.11 NCS Y 10 2/year Y
65860 See Post Op See Post Op $42.34 NCS See Post Op See Post Op $35.29 NCS Y 90 1/lifetime Y
65865 See Post Op See Post Op $64.22 NCS See Post Op See Post Op $53.52 NCS Y 90 1/lifetime Y
65870 See Post Op See Post Op $79.40 NCS See Post Op See Post Op $66.17 NCS Y 90 1/lifetime Y
65875 See Post Op See Post Op $84.29 NCS See Post Op See Post Op $70.24 NCS Y 90 1/lifetime Y
65880 See Post Op See Post Op $88.96 NCS See Post Op See Post Op $74.13 NCS Y 90 1/lifetime Y
65900 See Post Op See Post Op $130.78 $108.99 See Post Op See Post Op $108.99 $108.99 Y 90 1/lifetime Y
65920 See Post Op See Post Op $105.64 NCS See Post Op See Post Op $88.03 NCS Y 90 1/lifetime Y
65930 See Post Op See Post Op $87.17 NCS See Post Op See Post Op $72.64 NCS Y 90 1/lifetime Y
66020 See Post Op See Post Op $12.36 NCS See Post Op See Post Op $10.30 NCS Y 10 1/lifetime Y
66030 See Post Op See Post Op $10.87 NCS See Post Op See Post Op $9.06 NCS Y 10 1/lifetime Y
66130 See Post Op See Post Op $47.46 NCS See Post Op See Post Op $39.55 NCS Y 90 1/lifetime Y
66150 See Post Op See Post Op $115.85 NCS See Post Op See Post Op $96.54 NCS Y 90 1/lifetime Y
66155 See Post Op See Post Op $115.40 NCS See Post Op See Post Op $96.17 NCS Y 90 1/lifetime Y
66160 See Post Op See Post Op $131.70 NCS See Post Op See Post Op $109.75 NCS Y 90 1/lifetime Y
66170 See Post Op See Post Op $159.47 $132.89 See Post Op See Post Op $132.89 $132.89 Y 90 1/lifetime Y
66172 See Post Op See Post Op $200.32 $166.94 See Post Op See Post Op $166.94 $166.94 Y 90 1/lifetime Y
66174 See Post Op See Post Op $119.75 $99.80 See Post Op See Post Op $99.80 $99.80 Y 90 1/year Y
66175 See Post Op See Post Op $134.41 $112.01 See Post Op See Post Op $112.01 $112.01 Y 90 1/year Y
66179 See Post Op See Post Op $186.27 $155.22 See Post Op See Post Op $155.22 $155.22 Y 90 1/lifetime Y
66180 See Post Op See Post Op $159.87 $133.22 See Post Op See Post Op $133.22 $133.22 Y 90 1/lifetime Y
66183 See Post Op See Post Op $88.16 NCS See Post Op See Post Op $73.47 NCS Y 90 1/year Y
66184 See Post Op See Post Op $135.07 $112.56 See Post Op See Post Op $112.56 $112.56 Y 90 1/lifetime Y
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 4 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
66185 See Post Op See Post Op $100.33 $83.61 See Post Op See Post Op $83.61 $83.61 Y 90 1/lifetime Y
66225 See Post Op See Post Op $126.62 $105.52 See Post Op See Post Op $105.52 $105.52 Y 90 1/lifetime Y
66250 See Post Op See Post Op $99.03 NCS See Post Op See Post Op $82.52 NCS Y 90 1/lifetime Y
66500 See Post Op See Post Op $47.12 NCS See Post Op See Post Op $39.27 NCS Y 90 1/lifetime Y
66505 See Post Op See Post Op $51.61 NCS See Post Op See Post Op $43.01 NCS Y 90 1/lifetime Y
66600 See Post Op See Post Op $110.06 NCS See Post Op See Post Op $91.72 NCS Y 90 1/lifetime Y
66605 See Post Op See Post Op $144.22 NCS See Post Op See Post Op $120.18 NCS Y 90 1/lifetime Y
66625 See Post Op See Post Op $57.92 NCS See Post Op See Post Op $48.27 NCS Y 90 1/lifetime Y
66630 See Post Op See Post Op $76.32 NCS See Post Op See Post Op $63.60 NCS Y 90 1/lifetime Y
66635 See Post Op See Post Op $77.10 NCS See Post Op See Post Op $64.25 NCS Y 90 1/lifetime Y
66680 See Post Op See Post Op $68.85 NCS See Post Op See Post Op $57.38 NCS Y 90 1/lifetime Y
66682 See Post Op See Post Op $83.40 NCS See Post Op See Post Op $69.50 NCS Y 90 1/lifetime Y
66761 $300.08 $270.07 $30.01 NCS $250.06 $225.05 $25.01 NCS Y 10 1/year Y
66762 $315.16 $252.13 $63.03 NCS $262.63 $210.10 $52.53 NCS Y 90 1/lifetime Y
66770 $350.64 $280.51 $70.13 NCS $292.20 $233.76 $58.44 NCS Y 90 1/lifetime Y
66820 See Post Op See Post Op $52.71 NCS See Post Op See Post Op $43.92 NCS Y 90 1/lifetime Y
66821 $214.04 $171.23 $42.81 NCS $178.37 $142.70 $35.67 NCS Y 90 1/lifetime Y
66825 See Post Op See Post Op $102.16 NCS See Post Op See Post Op $85.14 NCS Y 90 1/lifetime Y
66830 See Post Op See Post Op $96.29 NCS See Post Op See Post Op $80.24 NCS Y 90 1/lifetime Y
66840 See Post Op See Post Op $93.89 NCS See Post Op See Post Op $78.24 NCS Y 90 1/lifetime Y
66850 See Post Op See Post Op $107.23 NCS See Post Op See Post Op $89.36 NCS Y 90 1/lifetime Y
66852 See Post Op See Post Op $114.86 NCS See Post Op See Post Op $95.72 NCS Y 90 1/lifetime Y
66920 See Post Op See Post Op $102.47 NCS See Post Op See Post Op $85.39 NCS Y 90 1/lifetime Y
66930 See Post Op See Post Op $116.48 NCS See Post Op See Post Op $97.07 NCS Y 90 1/lifetime Y
66940 See Post Op See Post Op $105.62 NCS See Post Op See Post Op $88.01 NCS Y 90 1/lifetime Y
66982 See Post Op See Post Op $146.04 NCS See Post Op See Post Op $121.70 NCS Y 90 1/lifetime Y
66983 See Post Op See Post Op $100.13 NCS See Post Op See Post Op $83.45 NCS Y 90 1/lifetime Y
66984 See Post Op See Post Op $104.42 NCS See Post Op See Post Op $87.02 NCS Y 90 1/lifetime Y
66985 See Post Op See Post Op $102.90 NCS See Post Op See Post Op $85.75 NCS Y 90 1/lifetime Y
66986 See Post Op See Post Op $126.48 NCS See Post Op See Post Op $105.40 NCS Y 90 1/lifetime Y
66987 See Post Op See Post Op $146.04 NCS See Post Op See Post Op $121.70 NCS Y 90 1/lifetime Y
66988 See Post Op See Post Op $104.42 NCS See Post Op See Post Op $87.02 NCS Y 90 1/lifetime Y
66999 manual price manual price Y Y
no PA
1/year Y
67005 See Post Op See Post Op $63.43 NCS See Post Op See Post Op $52.86 NCS Y 90 1/lifetime Y
67010 See Post Op See Post Op $73.64 NCS See Post Op See Post Op $61.37 NCS Y 90 1/lifetime Y
67015 See Post Op See Post Op $78.27 NCS See Post Op See Post Op $65.22 NCS Y 90 1/lifetime Y
67025 See Post Op See Post Op $96.62 NCS See Post Op See Post Op $80.51 NCS Y 90 1/day Y
67027 See Post Op See Post Op $116.47 $97.06 See Post Op See Post Op $97.06 $97.06 Y 90 1/day Y
67030 See Post Op See Post Op $69.58 NCS See Post Op See Post Op $57.99 NCS Y 90 1/lifetime Y
67031 See Post Op See Post Op $51.44 NCS See Post Op See Post Op $42.86 NCS Y 90 1/lifetime Y
67036 See Post Op See Post Op $131.63 NCS See Post Op See Post Op $109.70 NCS Y 90 1/lifetime Y
67039 See Post Op See Post Op $168.27 $140.22 See Post Op See Post Op $140.22 $140.22 Y 90 1/lifetime Y
67040 See Post Op See Post Op $194.42 $162.01 See Post Op See Post Op $162.01 $162.01 Y 90 1/lifetime Y
67041 See Post Op See Post Op $182.63 $152.19 See Post Op See Post Op $152.19 $152.19 Y 90 1/lifetime Y
67042 See Post Op See Post Op $209.49 $174.58 See Post Op See Post Op $174.58 $174.58 Y 90 1/lifetime Y
67043 See Post Op See Post Op $219.59 $183.00 See Post Op See Post Op $183.00 $183.00 Y 90 1/lifetime Y
67101 See Post Op See Post Op $103.58 NCS See Post Op See Post Op $86.31 NCS Y 10 1/day Y
67105 See Post Op See Post Op $96.19 NCS See Post Op See Post Op $80.16 NCS Y 10 1/day Y
67107 See Post Op See Post Op $165.46 $137.88 See Post Op See Post Op $137.88 $137.88 Y 90 1/day Y
67108 See Post Op See Post Op $220.89 $184.07 See Post Op See Post Op $184.07 $184.07 Y 90 1/day Y
67110 See Post Op See Post Op $116.32 NCS See Post Op See Post Op $96.94 NCS Y 90 1/day Y
67113 See Post Op See Post Op $240.35 $200.29 See Post Op See Post Op $200.29 $200.29 Y 90 1/day Y
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 5 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
67115 See Post Op See Post Op $66.06 NCS See Post Op See Post Op $55.05 NCS Y 90 1/day Y
67120 See Post Op See Post Op $87.09 NCS See Post Op See Post Op $72.57 NCS Y 90 1/day Y
67121 See Post Op See Post Op $123.17 $102.64 See Post Op See Post Op $102.64 $102.64 Y 90 1/day Y
67141 See Post Op See Post Op $69.49 NCS See Post Op See Post Op $57.91 NCS Y 90 1/day Y
67145 See Post Op See Post Op $70.17 NCS See Post Op See Post Op $58.47 NCS Y 90 1/day Y
67208 See Post Op See Post Op $80.77 NCS See Post Op See Post Op $67.31 NCS Y 90 1/day Y
67210 See Post Op See Post Op $94.88 NCS See Post Op See Post Op $79.07 NCS Y 90 1/day Y
67218 See Post Op See Post Op $193.43 NCS See Post Op See Post Op $161.19 NCS Y 90 1/day Y
67220 See Post Op See Post Op $145.50 NCS See Post Op See Post Op $121.25 NCS Y 90 1/day Y
67227 See Post Op See Post Op $82.04 NCS See Post Op See Post Op $68.37 NCS Y 10 1/day Y
67228 See Post Op See Post Op $161.13 NCS See Post Op See Post Op $134.28 NCS Y 10 1/day Y
67229 See Post Op See Post Op $157.78 NCS See Post Op See Post Op $131.48 NCS Y 90 1/day Y
67250 See Post Op See Post Op $106.36 NCS See Post Op See Post Op $88.63 NCS Y 90 1/year Y
67255 See Post Op See Post Op $113.50 $94.59 See Post Op See Post Op $94.59 $94.59 Y 90 1/year Y
67311 See Post Op See Post Op $80.90 NCS See Post Op See Post Op $67.42 NCS Y 90 1/year Y
67312 See Post Op See Post Op $97.00 NCS See Post Op See Post Op $80.83 NCS Y 90 1/year Y
67314 See Post Op See Post Op $90.71 NCS See Post Op See Post Op $75.59 NCS Y 90 1/year Y
67316 See Post Op See Post Op $108.96 NCS See Post Op See Post Op $90.80 NCS Y 90 1/year Y
67318 See Post Op See Post Op $94.88 NCS See Post Op See Post Op $79.07 NCS Y 90 1/year Y
67343 See Post Op See Post Op $88.08 NCS See Post Op See Post Op $73.40 NCS Y 90 1/year Y
67345 See Post Op See Post Op $16.07 NCS See Post Op See Post Op $13.39 NCS Y 10 1/day n/a
67400 See Post Op See Post Op $126.32 $105.27 See Post Op See Post Op $105.27 $105.27 Y 90 1/year Y
67405 See Post Op See Post Op $107.21 NCS See Post Op See Post Op $89.34 NCS Y 90 1/year Y
67412 See Post Op See Post Op $116.88 NCS See Post Op See Post Op $97.40 NCS Y 90 1/year Y
67413 See Post Op See Post Op $116.93 $97.44 See Post Op See Post Op $97.44 $97.44 Y 90 1/year Y
67414 See Post Op See Post Op $180.44 $150.36 See Post Op See Post Op $150.36 $150.36 Y 90 1/year Y
67420 See Post Op See Post Op $225.20 $187.67 See Post Op See Post Op $187.67 $187.67 Y 90 1/year Y
67430 See Post Op See Post Op $170.17 $141.80 See Post Op See Post Op $141.80 $141.80 Y 90 1/year Y
67440 See Post Op See Post Op $163.88 $136.57 See Post Op See Post Op $136.57 $136.57 Y 90 1/year Y
67445 See Post Op See Post Op $193.94 $161.62 See Post Op See Post Op $161.62 $161.62 Y 90 1/year Y
67450 See Post Op See Post Op $169.97 $141.64 See Post Op See Post Op $141.64 $141.64 Y 90 1/year Y
67550 See Post Op See Post Op $131.98 NCS See Post Op See Post Op $109.99 NCS Y 90 1/lifetime Y
67560 See Post Op See Post Op $134.25 NCS See Post Op See Post Op $111.87 NCS Y 90 1/lifetime Y
67570 See Post Op See Post Op $157.84 $131.53 See Post Op See Post Op $131.53 $131.53 Y 90 1/lifetime Y
67700 $173.66 $156.29 $17.37 NCS $144.72 $130.25 $14.47 NCS Y 10 1/day Y
67710 See Post Op See Post Op $14.60 NCS See Post Op See Post Op $12.16 NCS Y 10 1/day Y
67715 See Post Op See Post Op $15.44 NCS See Post Op See Post Op $12.86 NCS Y 10 1/day Y
67800 $85.43 $76.89 $8.54 NCS $71.19 $64.07 $7.12 NCS Y 10 1/day Y
67801 $109.95 $98.96 $11.00 NCS $91.62 $82.46 $9.16 NCS Y 10 1/day Y
67805 $135.81 $122.23 $13.58 NCS $113.18 $101.86 $11.32 NCS Y 10 1/day Y
67808 See Post Op See Post Op $49.14 NCS See Post Op See Post Op $40.95 NCS Y 90 1/day Y
67810 $150.35 NCS $125.30 NCS Y 0 1/day Y
67820 $36.50 NCS $30.42 NCS Y 0 1/day Y
67825 $86.55 $77.90 $8.66 NCS $72.13 $64.92 $7.21 NCS Y 10 1/day Y
67830 See Post Op See Post Op $17.53 NCS See Post Op See Post Op $14.61 NCS Y 10 1/year Y
67835 See Post Op See Post Op $59.98 NCS See Post Op See Post Op $49.99 NCS Y 90 1/year Y
67840 $184.46 $166.01 $18.45 NCS $153.72 $138.35 $15.37 NCS Y 10 1/day Y
67850 $148.51 $133.66 $14.85 NCS $123.76 $111.38 $12.38 NCS Y 10 1/day Y
67880 See Post Op See Post Op $60.48 NCS See Post Op See Post Op $50.39 NCS Y 90 1/year Y
67882 See Post Op See Post Op $74.90 NCS See Post Op See Post Op $62.42 NCS Y 90 1/year Y
67900 See Post Op See Post Op $86.70 NCS See Post Op See Post Op $72.25 NCS Y 90 Y 1/lifetime Y
67901 See Post Op See Post Op $94.07 NCS See Post Op See Post Op $78.39 NCS Y 90 Y 1/lifetime Y
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 6 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
67902 See Post Op See Post Op $98.20 NCS See Post Op See Post Op $81.83 NCS Y 90 Y 1/lifetime Y
67903 See Post Op See Post Op $83.13 NCS See Post Op See Post Op $69.27 NCS Y 90 Y 1/lifetime Y
67904 See Post Op See Post Op $98.20 NCS See Post Op See Post Op $81.83 NCS Y 90 Y 1/lifetime Y
67906 See Post Op See Post Op $70.96 NCS See Post Op See Post Op $59.13 NCS Y 90 Y 1/lifetime Y
67908 See Post Op See Post Op $66.10 NCS See Post Op See Post Op $55.08 NCS Y 90 Y 1/lifetime Y
67909 See Post Op See Post Op $72.41 NCS See Post Op See Post Op $60.34 NCS Y 90 1/lifetime Y
67911 See Post Op See Post Op $75.61 NCS See Post Op See Post Op $63.01 NCS Y 90 1/lifetime Y
67912 See Post Op See Post Op $119.82 NCS See Post Op See Post Op $99.85 NCS Y 90 1/lifetime Y
67914 See Post Op See Post Op $52.42 NCS See Post Op See Post Op $43.69 NCS Y 90 1/lifetime Y
67915 See Post Op See Post Op $46.87 NCS See Post Op See Post Op $39.06 NCS Y 90 1/lifetime Y
67916 See Post Op See Post Op $72.39 NCS See Post Op See Post Op $60.33 NCS Y 90 1/lifetime Y
67917 See Post Op See Post Op $79.37 NCS See Post Op See Post Op $66.14 NCS Y 90 1/lifetime Y
67921 See Post Op See Post Op $49.81 NCS See Post Op See Post Op $41.51 NCS Y 90 1/lifetime Y
67922 See Post Op See Post Op $45.36 NCS See Post Op See Post Op $37.80 NCS Y 90 1/lifetime Y
67923 See Post Op See Post Op $76.53 NCS See Post Op See Post Op $63.78 NCS Y 90 Y 1/lifetime Y
67924 See Post Op See Post Op $78.97 NCS See Post Op See Post Op $65.81 NCS Y 90 1/lifetime Y
67930 See Post Op See Post Op $24.79 NCS See Post Op See Post Op $20.66 NCS Y 10 1/lifetime Y
67935 See Post Op See Post Op $80.93 NCS See Post Op See Post Op $67.45 NCS Y 90 1/lifetime Y
67938 $158.86 $142.97 $15.89 NCS $132.38 $119.14 $13.24 NCS Y 10 1/lifetime Y
67950 See Post Op See Post Op $78.02 NCS See Post Op See Post Op $65.02 NCS Y 90 Y
no PA
1/lifetime Y
67961 See Post Op See Post Op $77.76 NCS See Post Op See Post Op $64.80 NCS Y 90 1/lifetime Y
67966 See Post Op See Post Op $103.21 NCS See Post Op See Post Op $86.01 NCS Y 90 1/lifetime Y
67971 See Post Op See Post Op $100.68 NCS See Post Op See Post Op $83.90 NCS Y 90 1/lifetime Y
67973 See Post Op See Post Op $130.68 $108.90 See Post Op See Post Op $108.90 $108.90 Y 90 1/lifetime Y
67974 See Post Op See Post Op $130.17 $108.47 See Post Op See Post Op $108.47 $108.47 Y 90 1/lifetime Y
67975 See Post Op See Post Op $95.00 NCS See Post Op See Post Op $79.17 NCS Y 90 1/lifetime Y
68020 $80.53 $72.48 $8.05 NCS $67.09 $60.38 $6.71 NCS Y 10 1/day Y
68040 $45.21 NCS $37.68 NCS Y 0 1/day Y
68100 $114.70 NCS $95.58 NCS Y 0 1/year Y
68110 $149.37 $134.43 $14.94 NCS $124.47 $112.02 $12.45 NCS Y 10 1/year Y
68115 $206.94 $186.25 $20.69 NCS $172.45 $155.21 $17.25 NCS Y 10 1/year Y
68130 See Post Op See Post Op $71.88 NCS See Post Op See Post Op $59.90 NCS Y 90 1/year Y
68135 $106.02 $95.42 $10.60 NCS $88.36 $79.52 $8.84 NCS Y 10 1/year Y
68200 $28.85 $23.08 $5.77 NCS $24.05 $19.24 $4.81 NCS Y 0 1/year Y
68320 See Post Op See Post Op $94.95 NCS See Post Op See Post Op $79.13 NCS Y 90 1/lifetime Y
68325 See Post Op See Post Op $89.44 NCS See Post Op See Post Op $74.54 NCS Y 90 1/lifetime Y
68326 See Post Op See Post Op $86.93 NCS See Post Op See Post Op $72.44 NCS Y 90 1/lifetime Y
68328 See Post Op See Post Op $97.43 NCS See Post Op See Post Op $81.19 NCS Y 90 1/lifetime Y
68330 See Post Op See Post Op $79.95 NCS See Post Op See Post Op $66.62 NCS Y 90 1/lifetime Y
68335 See Post Op See Post Op $87.23 NCS See Post Op See Post Op $72.70 NCS Y 90 1/lifetime Y
68340 $359.11 $287.29 $71.82 NCS $299.26 $239.41 $59.85 NCS Y 90 1/lifetime Y
68360 See Post Op See Post Op $70.29 NCS See Post Op See Post Op $58.57 NCS Y 90 1/lifetime Y
68362 See Post Op See Post Op $88.44 NCS See Post Op See Post Op $73.70 NCS Y 90 1/lifetime Y
68371 See Post Op See Post Op $28.48 NCS See Post Op See Post Op $23.73 NCS Y 10 1/year Y
68400 See Post Op See Post Op $18.45 NCS See Post Op See Post Op $15.37 NCS Y 10 1/day Y
68420 See Post Op See Post Op $21.19 NCS See Post Op See Post Op $17.66 NCS Y 10 1/day Y
68440 See Post Op See Post Op $7.13 NCS See Post Op See Post Op $5.94 NCS Y 10 1/day Y
68500 See Post Op See Post Op $131.78 NCS See Post Op See Post Op $109.81 NCS Y 90 1/day Y
68505 See Post Op See Post Op $132.48 NCS See Post Op See Post Op $110.40 NCS Y 90 1/day Y
68520 See Post Op See Post Op $93.09 NCS See Post Op See Post Op $77.58 NCS Y 90 1/day Y
68530 $290.62 $261.56 $29.06 NCS $242.18 $217.96 $24.22 NCS Y 10 1/day Y
68540 See Post Op See Post Op $126.01 NCS See Post Op See Post Op $105.01 NCS Y 90 1/day Y
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 7 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
68550 See Post Op See Post Op $155.34 $129.45 See Post Op See Post Op $129.45 $129.45 Y 90 1/day Y
68700 See Post Op See Post Op $81.28 NCS See Post Op See Post Op $67.73 NCS Y 90 1/day Y
68705 $158.65 $142.79 $15.87 NCS $132.20 $118.98 $13.22 NCS Y 10 1/day Y
68720 See Post Op See Post Op $103.28 $86.06 See Post Op See Post Op $86.06 $86.06 Y 90 1/day Y
68745 See Post Op See Post Op $103.77 $86.47 See Post Op See Post Op $86.47 $86.47 Y 90 1/day Y
68750 See Post Op See Post Op $106.40 $88.66 See Post Op See Post Op $88.66 $88.66 Y 90 1/day Y
68760 $134.49 $121.04 $13.45 NCS $112.09 $100.88 $11.21 NCS Y 10 1/day Y
68761
$98.20
$88.38
$9.82
NCS
$81.83
$73.65
$8.18
NCS
Y
10
2/cycle/E1
2/cycle/E2
2/cycle/E3
2/cycle/E4
Y
68770 See Post Op See Post Op $80.78 NCS See Post Op See Post Op $67.32 NCS Y 90 1/year Y
68801 $80.79 $72.71 $8.08 NCS $67.33 $60.60 $6.73 NCS Y 10 2/cycle Y
68810 $157.32 $141.59 $15.73 NCS $131.11 $118.00 $13.11 NCS Y 10 1/cycle Y
68811 See Post Op See Post Op $13.91 NCS See Post Op See Post Op $11.59 NCS Y 10 1/year Y
68815 $293.62 $264.26 $29.36 NCS $244.69 $220.22 $24.47 NCS Y 10 1/year Y
68816 See Post Op See Post Op $44.26 NCS See Post Op See Post Op $36.88 NCS Y 10 1/year Y
68840 $83.34 $75.01 $8.33 NCS $69.45 $62.51 $6.95 NCS Y 10 1/year Y
76510 $102.82 $61.69 $41.13 NCS $102.82 $61.69 $41.13 NCS Y n/a 1/day Y
76511 $75.43 $45.26 $30.17 NCS $75.43 $45.26 $30.17 NCS Y n/a 1/day Y
76512 $71.41 $42.85 $28.56 NCS $71.41 $42.85 $28.56 NCS Y n/a 1/day Y
76513 $59.36 $35.62 $23.74 NCS $59.36 $35.62 $23.74 NCS Y n/a 2/year Y
76514 $8.11 $4.87 $3.24 NCS $8.11 $4.87 $3.24 NCS Y n/a 1/lifetime Y
76516 $47.29 $28.37 $18.92 NCS $47.29 $28.37 $18.92 NCS Y n/a 1/day Y
76519 $49.58 $29.75 $19.83 NCS $49.58 $29.75 $19.83 NCS Y n/a 1/day Y
76529 $47.83 $28.70 $19.13 NCS $47.83 $28.70 $19.13 NCS n/a n/a 1/day Y
83516 $11.48 n/a $11.48 n/a n/a 2/year Y
83861 $17.04 n/a $17.04 n/a n/a 4/year Y
92002 $54.03 NCS $45.04 NCS n/a n/a 1/day n/a
92004 $102.30 NCS $85.26 NCS n/a n/a 1/day n/a
92012 $56.92 NCS $47.42 NCS n/a n/a 1/day n/a
92014 $83.35 NCS $69.45 NCS n/a n/a 1/day n/a
92015 NCS NCS n/a 1/day n/a
92018 $105.98 NCS $88.32 NCS n/a n/a 1/day n/a
92019 $52.95 NCS $44.11 NCS n/a n/a 1/day n/a
92020 $19.39 NCS $16.17 NCS n/a n/a 1/year N
92025 $24.77 $16.51 $8.26 NCS $20.65 $12.39 $8.26 NCS Y n/a 1/day N
92060 $43.23 $28.82 $14.41 NCS $36.03 $21.62 $14.41 NCS Y n/a 1/day N
92065 $33.30 $22.10 $11.10
NCS $27.75
(ages 16-21) $16.65 $11.10
NCS n/a n/a
1/day N
92071 NCS NCS NCS NCS n/a n/a 1/cycle Y
92072 NCS NCS NCS NCS n/a n/a 1/cycle N
92081 $37.62 $25.08 $12.54 NCS $31.35 $18.81 $12.54 NCS Y n/a 2/year N
92082 $49.65 $33.10 $16.55 NCS $41.37 $24.82 $16.55 NCS Y n/a 2/year N
92083 $56.68 $37.78 $18.90 NCS $47.24 $28.34 $18.90 NCS Y n/a 2/year N
92100 $64.27 NCS $53.56 NCS n/a n/a 1/year N
92132 $22.15 $14.77 $7.38 NCS $18.45 $11.07 $7.38 NCS Y n/a 1/year N
92133 $27.19 $18.13 $9.06 NCS $22.65 $13.59 $9.06 NCS Y n/a 2/year N
92134 $27.19 $18.13 $9.06 NCS $22.65 $13.59 $9.06 NCS Y n/a 1/month N
92136 $59.32 $39.55 $19.77 NCS $49.43 $29.66 $19.77 NCS Y n/a 2/year Y
92145 $13.38 $8.92 $4.46 NCS $11.15 $6.69 $4.46 NCS Y n/a 1/year N
92201 $21.84 NCS $18.20 NCS n/a n/a 1/day N
92202 $13.83 NCS $11.53 NCS n/a n/a 1/day N
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 8 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
92225 OBSOLETE as of 12/31/2019 n/a n/a 1/day Y
92226 OBSOLETE as of 12/31/2019 n/a n/a 1/day Y
92227 NCS NCS NCS NCS n/a n/a 2/year N
92228 NCS NCS NCS NCS Y n/a 2/year N
92229 NCS NCS NCS NCS Y n/a 2/cycle N
92230 $43.71 NCS $36.42 NCS n/a n/a 1/year N
92235 $91.41 $60.94 $30.47 NCS $76.17 $45.70 $30.47 NCS Y n/a 1/day Y
92240 $167.80 $111.87 $55.93 NCS $139.83 $83.90 $55.93 NCS Y n/a 1/day Y
92242 $187.13 $124.75 $62.38 NCS $155.94 $93.56 $62.38 NCS Y n/a 1/day N
92250 $51.00 $34.00 $17.00 NCS $42.51 $25.51 $17.00 NCS Y n/a 1/day N
92260 $13.03 NCS $10.85 NCS n/a n/a 1/day N
92265 $56.79 $37.86 $18.93 NCS $47.33 $28.40 $18.93 NCS Y n/a 1/year N
92273 $111.48 $74.32 $37.16 $17.84 $92.90 $55.74 $37.16 $14.86 Y n/a 2/year N
92274 $76.09 $50.73 $25.36 $12.17 $63.41 $38.05 $25.36 $10.15 Y n/a 2/year N
92283 $31.99 $21.33 $10.66 NCS $26.66 $16.00 $10.66 NCS Y n/a 1/year N
92284 $42.90 $28.60 $14.30 NCS $35.74 $21.44 $14.30 NCS Y n/a 1/year N
92285 $29.66 $19.77 $9.89 NCS $24.72 $14.83 $9.89 NCS Y n/a 1/day N
92286 $84.82 $56.54 $28.28 NCS $70.70 $42.42 $28.28 NCS Y n/a 1/day N
92287 $81.03 NCS $67.53 NCS n/a n/a 1/day N
92310 NCS NCS n/a n/a 1/cycle N
92311 NCS NCS n/a n/a 1/cycle N
92312 NCS NCS n/a n/a 1/cycle N
92313 NCS NCS n/a n/a 1/cycle N
92314 NCS NCS n/a n/a 1/cycle N
92315 NCS NCS 1/cycle N
92316 NCS NCS 1/cycle N
92317 NCS NCS n/a n/a 1/cycle N
92325 NCS NCS n/a n/a 1/cycle N
92326 NCS NCS n/a n/a 1/cycle N
92340 NCS NCS n/a 0 1/cycle N
92341 NCS NCS n/a 0 1/cycle N
92342 NCS NCS n/a 0 1/cycle N
92352 NCS NCS n/a 1/cycle N
92353 NCS NCS n/a 1/cycle N
92355 NCS NCS n/a
92358 NCS NCS n/a
92370 $4.76 $4.76
(ages 16-20)
n/a
1/cycle
2/cycle
N
92371 NCS NCS n/a 1/cycle N
92531 $11.33 $11.33 1/cycle N
92532 $11.33 $11.33 1/cycle N
92533 $7.03 $7.03 1/cycle N
92534 $11.33 $11.33 1/cycle N
92541 $44.59 $29.73 $14.86 $37.16 $22.30 $14.86 n/a n/a 1/year n/a
92542 $45.97 $30.65 $15.32 $38.30 $22.98 $15.32 n/a n/a 1/year n/a
92544 $36.98 $24.66 $12.32 $30.81 $18.49 $12.32 n/a n/a 1/year n/a
92545 $34.68 $23.12 $11.56 $28.90 $17.34 $11.56 n/a n/a 1/year n/a
95060 $17.45 $17.45 $14.54 n/a n/a 1/cycle N
95930 $78.74 $52.49 $26.25 $65.63 $39.38 $26.25 n/a n/a 1/year n/a
96112 $122.71
$19.63 $102.26
(ages 16-20)
$16.36 n/a n/a
1/day n/a
96113 $54.96
$8.79 $45.80
(ages 16-20)
$7.33 n/a n/a
1/day n/a
effective 05/01/2021TBD
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 9 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
96116 $79.35 $66.12 n/a n/a Y 1/day N
97110 $22.97 $19.15 Y n/a 4/day n/a
97112 $23.51 $19.59 Y n/a 4/day n/a
97530 $24.03 $20.02 Y n/a Y 6/day n/a
97533 $21.29 $17.75 Y n/a 4/day n/a
99050 $13.38 $13.38 1/day n/a
99070 NCS NCS 1/day n/a
99173 $1.91 $1.59 1/year n/a
99174 NCS NCS 1/year n/a
99177 NCS NCS 1/year n/a
99201 OBSOLETE as of 12/31/2020 n/a n/a 1/day n/a
99202 $51.33 $42.77 n/a n/a 1/day n/a
99203 $74.62 $62.18 n/a n/a 1/day n/a
99204 $115.88 $96.56 n/a n/a Y 1/day n/a
99205 $146.62 $122.19 n/a n/a Y 1/day n/a
99211 $14.82 $12.36 n/a n/a 1/day n/a
99212 $29.79 $24.83 n/a n/a 1/day n/a
99213 $49.84 $41.53 n/a n/a 1/day n/a
99214 $75.18 $62.65 n/a n/a Y 1/day n/a
99215 $101.92 $84.93 n/a n/a Y 1/day n/a
99221 $75.01 $62.52 n/a n/a 1/day n/a
99222 $102.41 $85.35 n/a n/a 1/day n/a
99223 $150.65 $125.54 n/a n/a 1/day n/a
99231 $30.97 $25.81 n/a n/a 1/day n/a
99232 $55.71 $46.42 n/a n/a 1/day n/a
99233 $79.83 $66.52 n/a n/a 1/day n/a
99241 NCS NCS n/a n/a Y 1/day n/a
99242 NCS NCS n/a n/a Y 1/day n/a
99243 NCS NCS n/a n/a Y 1/day n/a
99244 NCS NCS n/a n/a Y 1/day n/a
99245 NCS NCS n/a n/a Y 1/day n/a
99251 NCS NCS n/a n/a Y 1/day n/a
99252 NCS NCS n/a n/a Y 1/day n/a
99253 NCS NCS n/a n/a Y 1/day n/a
99254 NCS NCS n/a n/a Y 1/day n/a
99255 NCS NCS n/a n/a Y 1/day n/a
99281 $16.98 $14.15 n/a n/a 1/day n/a
99282 $33.06 $27.55 n/a n/a 1/day n/a
99283 $51.44 $42.88 n/a n/a 1/day n/a
99284 $96.16 $80.13 n/a n/a 1/day n/a
99285 $143.13 $119.29 n/a n/a 1/day n/a
99304 $66.63 $55.53 n/a n/a 1/day n/a
99305 $93.24 $77.70 n/a n/a 1/day n/a
99306 $119.88 $99.90 n/a n/a 1/day n/a
0333T NCS NCS
0464T NCS NCS
2019F $0.00 $0.00 n/a
2022F $0.00 $0.00 n/a
2023F $0.00 $0.00 n/a
2024F $0.00 $0.00 n/a
2025F $0.00 $0.00 n/a
2026F $0.00 $0.00 n/a
effective 05/01/2021
revised 04/14/2021 Louisiana Medicaid Optometrist Fee Schedule
Page 10 of 13
Pediatric (ages 0-15) Adult (ages 16 & over) or (ages 16-20) or (ages 16-21)
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26)
Pre/Intra Op
(mod 54)
Post Op
(mod 55)
Assist @ SX
(mod 80)
MPPR
Impact
Global
Days
Prior
Auth
Post
Review Freq per Eye?
2027F $0.00 $0.00 n/a
2033F $0.00 $0.00 n/a
3051F $0.00 $0.00 n/a
3052F $0.00 $0.00 n/a
3072F $0.00 $0.00 n/a
3073F $0.00 $0.00 n/a
3284F $0.00 $0.00 n/a
3285F $0.00 $0.00 n/a
4004F $0.00 $0.00 n/a
4040F $0.00 $0.00 n/a
4174F $0.00 $0.00 n/a
4175F $0.00 $0.00 n/a
4176F $0.00 $0.00 n/a
4177F $0.00 $0.00 n/a
A4262 NCS NCS n/a
A4263 NCS NCS n/a
A6410 Invoice Cost Invoice Cost n/a
A6411 NCS NCS n/a
A6412 NCS NCS n/a
G0117 $0.00 $0.00 n/a
G0436 OBSOLETE as of 12/31/2019 n/a
G0467 $0.00 $0.00 n/a
G2102 $0.00 $0.00 n/a
G2103 $0.00 $0.00 n/a
G2104 $0.00 $0.00 n/a
G8397 $0.00 $0.00 n/a
G8398 $0.00 $0.00 n/a
G8427 $0.00 $0.00 n/a
G8428 $0.00 $0.00 n/a
G8430 $0.00 $0.00 n/a
G8598 $0.00 $0.00 n/a
G8599 $0.00 $0.00 n/a
G8783 $0.00 $0.00 n/a
G9744 $0.00 $0.00 n/a
G9902 $0.00 $0.00 n/a
G9903 $0.00 $0.00 n/a
G9904 $0.00 $0.00 n/a
G9905 $0.00 $0.00 n/a
G9906 $0.00 $0.00 n/a
G9907 $0.00 $0.00 n/a
G9908 $0.00 $0.00 n/a
G9909 $0.00 $0.00 n/a
G9970 $0.00 $0.00 n/a
S0620 NCS NCS n/a 1/cycle n/a
S0621 NCS NCS n/a 1/cycle n/a
Louisiana Medicaid Optical/Material Fee Schedule effective 01/01/2021
revised 01/28/2021
Page 11 of 13
AGES 0-20
AGES 21 & OVER
Eyeglasses or CLs covered once every calendar year, up to $100
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26) Freq per Eye?
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26) Freq per Eye?
MPPR
Impact
Prior
Auth
Post
Review
92499 NCS 1/cycle N $100.00 1/cycle N n/a
S0580 $34.43 2/cycle Y NCS 1/cycle Y n/a Y
S0590 NCS NCS n/a
V2020 $14.96 2/cycle n/a $14.96 1/cycle n/a n/a
V2025 $72.23 NCS n/a Y
V2100 $9.65 2/cycle Y $9.65 1/cycle Y n/a
V2101 $11.07 2/cycle Y $11.07 1/cycle Y n/a
V2102 $13.40 2/cycle Y $13.40 1/cycle Y n/a
V2103 $9.65 2/cycle Y $9.65 1/cycle Y n/a
V2104 $9.65 2/cycle Y $9.65 1/cycle Y n/a
V2105 $9.65 2/cycle Y $9.65 1/cycle Y n/a
V2106 $33.85 2/cycle Y $33.85 1/cycle Y n/a Y
V2107 $11.07 2/cycle Y $11.07 1/cycle Y n/a
V2108 $11.07 2/cycle Y $11.07 1/cycle Y n/a
V2109 $11.07 2/cycle Y $11.07 1/cycle Y n/a
V2110 $35.68 2/cycle Y $35.68 1/cycle Y n/a Y
V2111 $13.40 2/cycle Y $13.40 1/cycle Y n/a
V2112 $13.40 2/cycle Y $13.40 1/cycle Y n/a
V2113 $13.40 2/cycle Y $13.40 1/cycle Y n/a
V2114 $40.25 2/cycle Y $40.25 1/cycle Y n/a Y
V2115 $43.34 2/cycle Y $43.34 1/cycle Y n/a Y
V2118 $47.52 2/cycle Y $47.52 1/cycle Y n/a Y
V2121 $44.94 2/cycle Y $44.94 1/cycle Y n/a Y
V2199 Invoice Cost Invoice Cost n/a Y
V2200 $31.83 2/cycle Y $31.83 1/cycle Y n/a Y
V2201 $34.28 2/cycle Y $34.28 1/cycle Y n/a Y
V2202 $37.56 2/cycle Y $37.56 1/cycle Y n/a Y
V2203 $34.09 2/cycle Y $34.09 1/cycle Y n/a Y
V2204 $35.10 2/cycle Y $35.10 1/cycle Y n/a Y
V2205 $36.11 2/cycle Y $36.11 1/cycle Y n/a Y
V2206 $37.46 2/cycle Y $37.46 1/cycle Y n/a Y
V2207 $35.97 2/cycle Y $35.97 1/cycle Y n/a Y
V2208 $36.50 2/cycle Y $36.50 1/cycle Y n/a Y
V2209 $37.36 2/cycle Y $37.36 1/cycle Y n/a Y
V2210 $39.29 2/cycle Y $39.29 1/cycle Y n/a Y
Louisiana Medicaid Optical/Material Fee Schedule effective 01/01/2021
revised 01/28/2021
Page 12 of 13
AGES 0-20
AGES 21 & OVER
Eyeglasses or CLs covered once every calendar year, up to $100
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26) Freq per Eye?
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26) Freq per Eye?
MPPR
Impact
Prior
Auth
Post
Review
V2211 $36.02 2/cycle Y $36.02 1/cycle Y n/a Y
V2212 $39.24 2/cycle Y $39.24 1/cycle Y n/a Y
V2213 $40.35 2/cycle Y $40.35 1/cycle Y n/a Y
V2214 $42.18 2/cycle Y $42.18 1/cycle Y n/a Y
V2215 $45.84 2/cycle Y $45.84 1/cycle Y n/a Y
V2218 $50.03 2/cycle Y $50.03 1/cycle Y n/a Y
V2219 $19.26 2/cycle Y $19.26 1/cycle Y n/a Y
V2220 $18.30 2/cycle Y $18.30 1/cycle Y n/a Y
V2221 $47.45 2/cycle Y $47.45 1/cycle Y n/a Y
V2299 Invoice Cost Invoice Cost n/a Y
V2300 $35.92 2/cycle Y $35.92 1/cycle Y n/a Y
V2301 $38.91 2/cycle Y $38.91 1/cycle Y n/a Y
V2302 $40.45 2/cycle Y $40.45 1/cycle Y n/a Y
V2303 $37.03 2/cycle Y $37.03 1/cycle Y n/a Y
V2304 $37.89 2/cycle Y $37.89 1/cycle Y n/a Y
V2305 $39.15 2/cycle Y $39.15 1/cycle Y n/a Y
V2306 $40.21 2/cycle Y $40.21 1/cycle Y n/a Y
V2307 $38.57 2/cycle Y $38.57 1/cycle Y n/a Y
V2308 $39.43 2/cycle Y $39.43 1/cycle Y n/a Y
V2309 $40.93 2/cycle Y $40.93 1/cycle Y n/a Y
V2310 $43.09 2/cycle Y $43.09 1/cycle Y n/a Y
V2311 $41.12 2/cycle Y $41.12 1/cycle Y n/a Y
V2312 $41.55 2/cycle Y $41.55 1/cycle Y n/a Y
V2313 $42.85 2/cycle Y $42.85 1/cycle Y n/a Y
V2314 $44.11 2/cycle Y $44.11 1/cycle Y n/a Y
V2315 $47.76 2/cycle Y $47.76 1/cycle Y n/a Y
V2318 $51.95 2/cycle Y $51.95 1/cycle Y n/a Y
V2319 $28.89 2/cycle Y $28.89 1/cycle Y n/a Y
V2320 $27.93 2/cycle Y $27.93 1/cycle Y n/a Y
V2321 $49.37 2/cycle Y $49.37 1/cycle Y n/a Y
V2399 Invoice Cost Invoice Cost n/a Y
V2410 $48.82 $48.82 n/a Y
V2430 $53.64 $53.64 n/a Y
V2499 Invoice Cost Invoice Cost n/a Y
V2500 $120.38 1/cycle Y NCS 1/cycle Y n/a Y
Louisiana Medicaid Optical/Material Fee Schedule effective 01/01/2021
revised 01/28/2021
Page 13 of 13
AGES 0-20
AGES 21 & OVER
Eyeglasses or CLs covered once every calendar year, up to $100
CPT / CPTII /
HCPCS
Pediatric Fee
(POS 11) TC Fee
PC Fee
(mod 26) Freq per Eye?
Adult Fee
(POS 11) TC Fee
PC Fee
(mod 26) Freq per Eye?
MPPR
Impact
Prior
Auth
Post
Review
V2501 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2502 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2503 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2510 $120.38 1/cycle Y NCS 1/cycle Y n/a Y
V2511 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2512 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2513 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2520 $120.38 1/cycle Y NCS 1/cycle Y n/a Y
V2521 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2522 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2523 $144.45 1/cycle Y NCS 1/cycle Y n/a Y
V2530 $168.53 1/cycle Y NCS 1/cycle Y n/a Y
V2531 $168.53 1/cycle Y NCS 1/cycle Y n/a Y
V2599 Invoice Cost 1/cycle Y NCS 1/cycle Y n/a Y
V2600 NCS NCS n/a
V2700 NCS NCS n/a Y
V2710 $33.71 1/cycle Y $33.71 1/cycle Y n/a n/a
V2715 $5.78 1/cycle Y $5.78 1/cycle Y n/a n/a
V2730 $11.56 1/cycle Y $11.56 1/cycle Y n/a Y
V2744 $6.74 2/cycle Y $6.74 1/cycle Y n/a n/a
V2745 $4.82 2/cycle Y $4.82 1/cycle Y n/a n/a
V2750 NCS NCS n/a Y
V2755 NCS NCS n/a Y
V2756 NCS NCS n/a
V2760 $8.67 1/cycle Y $8.67 1/cycle Y n/a n/a
V2762 NCS NCS n/a Y
V2770 NCS 5/cycle N NCS 5/cycle N n/a
V2781 $67.41 2/cycle Y $67.41 1/cycle Y n/a n/a
V2782 NCS 2/cycle Y NCS 2/cycle Y n/a Y
V2783 NCS 2/cycle Y NCS 2/cycle Y n/a Y
V2784 NCS 2/cycle N NCS 2/cycle N n/a Y
V7280 NCS NCS n/a