LA Medicaid EPSDT Health and IDEA -Related Services - Fees Effective for DOS on and after January 01, 2017

Sep 21, 2026

Fee schedule for Louisiana Medicaid EPSDT health and IDEA-related services, effective for dates of service on and after January 01, 2017. The report details how service types and claim pricing files are determined, explains the schedule columns including code, description, fee amounts, and units-billable indication, and lists numerous service entries with provider-type modifiers and CPT codes. It also notes copyright restrictions for CPT codes and provides a contact line for clarification.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages5

Reading Time13 min

AccessFree to download

LA Medicaid EPSDT Health and IDEA -Related Services

Fees effective for dates of service on and after January 01, 2017

Legend and column definitions

Service and CPT code fee listings

LAM5M136 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM REPORT NO: RF-0-76EP RUN: 05/27/25 08:22:38 LOUISIANA DEPARTMENT OF HEALTH -BUREAU OF HEALTH SERVICES -FINANCING PAGE: LA MEDICAID EPSDT HEALTH AND IDEA -RELATED SERVICES FEES EFFECTIVE FOR DOS ON AND AFTER JANUARY 01, 2017 LEGEND Listed below are some aids we hope will help you understand this fee schedule . If, after reading the information below, you need further clarification of an item, please call DXC Technologies Provider Relations at 1-800-473-2783 . COLUMN 1. TS (Type Service): Definition: Files on which codes are loaded and from which claims are paid . The file to which a claim goes for pricing is determined by, among other things, the type of provider who is billing and by the modifier appended to the procedure code . Listed below is an explanation of the types of service found on this schedule . 12 - School Boards and Early Intervention Centers COLUMNS 2, 3 and 4. CODE, DESCRIPTION, and FEE . COLUMN 5 UVS>001: An 'X' in this column means more than one unit of service per day may be billed . LAM5M136 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM REPORT NO: RF-0-76EP RUN: 05/27/25 08:22:38 LOUISIANA DEPARTMENT OF HEALTH -BUREAU OF HEALTH SERVICES -FINANCING PAGE: 1 LA MEDICAID EPSDT HEALTH AND IDEA -RELATED SERVICES FEES EFFECTIVE FOR DOS ON AND AFTER JANUARY 01, 2017 COLUMN: 1 2 3 4 5 TS CODE DESCRIPTION FEE UVS >001 12 H0031 MH ASSMT-NON-PHYS 10.00 12 H0032 MH SVC PLAN DEV -NON-PHYS 10.00 12 S5125 ATTD CARE SVC; 15 MINS 1.50 X 12 T1001 NURS ASSMT/EVAL 10.00 X 12 T1002 IMPLEMENTATION OF PHYSICIANS ORDERS 10.00 X 12 T1003 LPN SERVICE 10.00 X 12 T1023 PHYS SVC 10.00 12 T1502 MEDICATION ADMINISTRATION 10.00 X 12 T1502 TD MEDICATION ADMINISTRATION-RN 10.00 X 12 T1502 TE MEDICATION ADMINISTRATION-LPN 10.00 X 12 V2799 VISION ITEM/SERVICE,MISCELLANEOUS 10.00 12 0362T BX ID SPDG ASS, 1 TECH, W/PT 10.00 X 12 0373T ADAPT BX TREAT, 1 TECH, 15 MINS 10.00 X 12 90785 AH INTERACTIVE CPLX ADD-ON, PSYD .69 X 12 90785 AJ INTERACTIVE CPLX ADD-ON, LCSW 2.41 X 12 90785 HO INTERACTIVE CPLX ADD-ON,LPC/LMFT 2.41 X 12 90791 AH PSY DIAG EVAL-PSYD 21.68 12 90791 AJ PSY DIAG EVAL-LCSW 10.00 12 90791 HO PSY DIAG EVAL-LPC/LMFT 10.00 12 90832 AH PSYT, 30 MIN W/PT -PSYD 9.53 X 12 90832 AJ PSYT, 30 MIN W/PT-LCSW 10.00 X 12 90832 HF PSYT, 30 MIN W/PT-LAC 8.34 X 12 90832 HO PSYT, 30 MIN W/PT-LPC/LMFT 10.00 X 12 90834 AH PSYT, 45 MIN W/PT-PSYD 13.42 X 12 90834 AJ PSYT, 45 MIN W/PT -LCSW 10.00 X 12 90834 HF PSYT, 45 MIN W/PT -LAC 11.74 X 12 90834 HO PSYT, 45 MIN W/PT -LPC/LMFT 10.00 X 12 90837 AH PSYT, 60 MIN W/PT -PSYD 19.76 X 12 90837 AJ PSYT, 60 MIN W/PT -LCSW 10.00 X 12 90837 HO PSYT,60 MIN W/PT -LPC/LMFT 10.00 X 12 90839 AH PSYT CRISIS - 60 MIN -PSYD 10.00 12 90839 AJ PSYT CRISIS - 60 MIN, LCSW 10.00 12 90839 HO PSYT CRISIS - 60 MIN LPC/LMFT 10.00 12 90840 AH EACH ADDTL 30 MIN 90839, PSYD 10.00 X 12 90840 AJ EACH ADDTL 30 MIN 90839, LCSW 10.00 X 12 90840 HO EACH ADDTL 30 MIN 90839,LPC/LMFT 10.00 X 12 90846 FAMILY PSYCHOTHERAPY W/P PT PRESENT 22.50 12 90846 AF FAM PSYT W/P PT - 50 MIN, PSYCH 22.50 12 90846 AH FAM PSYT W/P PT - 50 MIN, PSYD 10.00 12 90846 AJ FAM PSYT W/O PT-50 MIN, LCSW 10.00 12 90846 HF FAM PSYT W/O PT-50 MIN, LAC 10.00 NOTE: ALL CPT CODES AND DESCRIPTIONS ARE COPYRIGHTED BY THE AMERICAN MEDICAL ASSOCIATION . LAM5M136 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM REPORT NO: RF-0-76EP RUN: 05/27/25 08:22:38 LOUISIANA DEPARTMENT OF HEALTH -BUREAU OF HEALTH SERVICES -FINANCING PAGE: 2 LA MEDICAID EPSDT HEALTH AND IDEA -RELATED SERVICES FEES EFFECTIVE FOR DOS ON AND AFTER JANUARY 01, 2017 COLUMN: 1 2 3 4 5 TS CODE DESCRIPTION FEE UVS >001 12 90846 HO FAM PSYT W/O PT-50 MIN,LPC/LMFT 10.00 12 90847 FAM PSYCHOTHERAPY W/ PATIENT PRESENT 22.50 12 90847 AF FAM PSYT W/PT 50 MIN, PSYCH 22.50 12 90847 AH FAM PSYT W/PT 50 MIN, PSYD 10.00

FAQs

What is the effective date range for the fees in this report?

The fees are effective for dates of service on and after January 01, 2017.

What do the report’s columns represent?

The schedule includes service type (TS), code, description, fee amount, and a unit-billing indicator (UVS) showing when more than one unit per day may be billed.

How are claims priced to the correct file in this fee schedule?

The file used for pricing is determined by factors including the type of provider billing and the modifier appended to the procedure code.

Sep 21, 2026

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