Table Of Content5
368.41 PROVIDER BULLETIN
W20PB
2009 WIN
1 Winter 2009
New New
Year, Fee Schedule
As most ofyou are aware, the passing of Montana Facility Fee Schedule
HB 738 during the 2007 legislative session After a short delay, the Montana Facility Fee Schedule (MFFS) was
changed the methodologv for reimbursement of adopted and it now applies to services rendered, and discharge
medical services provided to injured workers under dates, on or after December 1, 2008. It is loosely based on CMS
iVlontana's workers' compensation law. The result methodology, but governed by Montana Administrative Rules and
was the Montana Facility Fee Schedule (MFFS), affectsall facilities that provide medical servicesto injured workers
which took effect December 1, 2008, and the Montana in Montana. The rule also changed the terminologyof"hospital"
Non-Facility Fee Schedule (MNFS), which was to "facility" to clarify that thisfee schedule appliesto hospital and
implemented on January 1, 2008. ambulatory services.
Calculating Reimbursements The fee schedule uses Medicare's MS-DRG (inpatient hospital) and
The Resource Based Relative Value Scale (RBRVS) ARC (outpatient and ambulatorysurgerycenter) methodology
publication is used to calculate reimbursement for as a basisfor reimbursement ofservices.The MFFS does not
professional services rendered by licensed health care incorporate Medicare's rate of reimbursement or allowed
providers under MNFS. For coding purposes, see the CRT proceduresand medications. The DU's website containsthe
manual that is in effect at the time ofthe service. Keep following fee schedule elements:
in mind that the previousyear's RBRVS edition is used • Montana Hospital Inpatient Services MS-DRG
for calculation of payment. Reimbursement Fee Schedule
For 2008 service dates, use the 2007 edition of the • Montana Hospital Outpatient and ASC Fee Schedule
RBRVS with the 2008 CRT manual. For 2009 service Organized byARC
dates, the 2008 edition ofthe RBRVS will be used with • Montana Hospital Outpatient and ASC Fee Schedule
the 2009 CRT codes. The RBRVS has the relative value
Organized by CPT/HCPCS
units(RVUs) foreach code.The conversion factorsfor 2008
• Montana Ambulance Fee Schedule
and 2009 are-
r • Montana CCI Code Edits Listing
Fee Schedule Type 2008 2009
• Montana RCCand other Montana RCC-based
Standard $63.45 $65.28
Calculations
Anesthesia $57.20 $61.98
• Base Ratesand Conversion Formulasestablished by
the DLI
There are two levelsofpractice expense RVUs that are dependent upon
theplaceoftheservicecodein Box248on theCMS 1500form: • Montana MS-DRG GeometricTable
Non-Facility Level:forservicesperformed ina physician'soffice,patient's
home,orothernon-facilitysetting.
Facility Level: forservices provided in a hospital, ambulatorysurgery
center (ASC), skilled nursing facility (SNF) or other licensed medical
facility setting. For more information regarding the MNFS,
reference the Department of Labor and Industry's (DLI) website at
http://mtwcfeeschedule.ingenix.com/overview.aspx.
Documentation mustbesubmittedwith theCMS 1500 form in order
to substantiate charges and to establish relationship to injury.
Allprofessionalservicesmustbebilledon a CMS 1500 form. MONTANA
STATEFUND
www.montanastatefund.com
MS-DRG Methodology: Medicare Severity Diagnosis Related Group Durable Medical Equipment Prosthetics, Orthotics
A grouper will need to be used to weight inpatient services; and Supplies: will be paid at 75% of UftC charges.
www.hospitalbenchmarks.com is one grouper available at no Status Indicators: The DLI has adopted the following status
charge. Reimbursement is calculated by using the base rate indicators: A, B D, F, G, H, K, L, N, P, S, T and X. Some of the
multiplied bythe Montana MS-DRG weight. See the DLI website indicators will affect payment. Note: SI "A" includes only
for more information regarding calculation of reimbursement ambulance services. DLI did not adopt Medicare's complete
foroutliers. Services must be billed on a UB04 billing form. definition that includesotherservices. Ifthere is noAPCweight
Base Rate: $7,735.00 in the Facility Fee Schedule, reimbursement will beat 75%ofthe
UEtCcharges. See the DLI website forthe complete descriptions.
Outlier Threshold: three times the Montana MS-DRG payment
amount. See the DLI website example for calculating payment Critical Access Hospitals: will continue to be reimbursed at 100%of
the UftCcharges.
when an outlier applies to a bill.
Implant Outlier Threshold: $10,000.00. Note: When a hospital Inpatient Rehabilitation: including services provided at a long-term
requests additional payment pursuant to thisthreshold, the inpatient rehabilitation hospital orfacility will be paid at 75%of UEtC.
The servicesare excluded from the MS-DRG paymentsystem.
implantable charge is excluded from the calculation for an
outlier payment. Reimbursement is set at the actual amount Payment ofFacility Bills: Facility bills will be paid within 30 daysof
paid plus 15%, and an invoice must be provided tosubstantiate receipt where there is no dispute over liability SeeAdministrative Rules
the charge. Itshould include the handling and freight. The ofMontana (ARM) rule 24.29.1406 (4) forcomplete rule.
information provided to MSF regarding invoice costs will be Documentation Requirements for Facility Bills: When medical bills
confidential and used only for the purpose of reimbursement.
are submitted electronically, you will no longer need to attach
Implantable: is defined as an object or device that is made supporting documentation in the majority ofcases. Documentation
to replace and act as a missing biological structure that is will still be required for implantsthat hit the outlier threshold and for
surgically implanted, embedded, inserted, or otherwise applied. outpatientservicessuch as physical and occupational therapies,
The term also includes any related equipment necessary to laboratoryand radiologyservices.
operate, program and recharge the implantable.
For more information regarding the MFFS, reference
Services that Fall Outside ofthe MS-DRG: and are not the Department of Labor's website at
otherwise listed on a Montana fee schedule, will be reimbursed http://erd.dli.mt.gov/wcstudyproject/mffsoverview.asp.
at 750/0 of U&tC. Ifyou encounter incorrect paymentsduring the transition forthe new
APC Methodology:Ambulatory Payment Classification. Outpatient paymentsystem, pleasecontacta memberofthe medical team with the
hospital and ambulatory surgerycenter services will be calculated bill numbersand wewill research and requesta correction, ifneeded.
according to Medicare'sAPC weights but at Montana's base rate set Professional Services: Medical providers who furnish professional
by the DLI.The payment is calculated by multiplying the base rate services in a hospital, ASC or other facility setting must bill insurers
times the APCweight. Ifthe APC weight is not listed or ifthe APC separately and will be reimbursed using the MNFS. Providers must
weight is listed as null, reimbursement must be paid at 75%of UftC. billon a CMS 1500 form.
Services must be billed on a CMS 1500 form or UB04 form.
NOTE: DO NOT use the Montana State Fund AttendingPhysician's
Outpatient Hospital Base Rate: $105.00
FirstReportandInitialTreatmentBillor the Chiropractor'sFirstReport
ASC Base Rate: $79.00 for billing or documentation purposes.These forms are no longer
used for workers' compensation purposes.
Implant Outlier Threshold: $500. Reimbursement is setat the
actual amount paid plus 15%, and an invoice must be provided Ambulance Fee Schedule: The Montana Ambulance Fee Schedule
to substantiate the charge. It should include the handling and is based on data in CMS but it contains ONLY workers' compensation
freight.The information provided to MSF regarding invoice costs reimbursement rates and calculation for Montana. It includes both
will beconfidential and used onlyforthe purposeofreimbursement. ground and air ambulance services. See the DLI website for the
complete fee schedule.
MontanaSlateLibrary
miiiiiii
Billing Reminders for the New Year 3 0Ill8lll64 1005 8624
Resolve to get it right the first time.
Durable Medical Equipment PT, 01, Chiro Reminder: No more than a total offive codes may be
• When submitting corrected billing: please attach a copy of billed per visit without prior written authorization. Each 15 minutes
the EOR with any documentation you are submitting. For ofa timed code is equivalent to the billing ofone code.Timed codes
submission ofa corrected bill, pleaseclearly write "Corrected must have the time clearly documented in the medical record for
Billing" on the billing form. each code. Each therapy code billed must have part ofbody treated
or clearly identified in the documentation or on the flow sheet. Ifthe
• When submitting additional information: attach a copy of
notes do not support the procedures billed but refertoa flow sheet,
the EOR with the additional information.
please be sure the flow sheet is attached.
• Corrected billingsand/or additional information should be
Pre-authorization Required: If providing any durable medical
sent to:
equipment with a purchase price ofgreater than $200.00, it must
Montana State Fund be preauthorized by a claims examiner at Montana State Fund.
PO Box 4759
• All bills submitted must be on a CMS 1500 or UB04 form with
Helena, MT 59604
HCPCS code to indicate procedures/suppliesand ICD-9 code
Orfaxto: 406-444-5963
to indicate the diagnosis.
When submitting refunds for payments received directlyfrom CorVel, • MSF has a Preferred Provider Network for DME suppliesand
please send refunds to Montana State Fund. If payment was received services. This network must be used when prescribing DME,
from Montana Health Systems, please send the refund to MHS.
02 equipment and supplies, bone growth stimulators, TENS
Please attach any supporting documentation with your refund.
equipmentandsupplies,orthoticsand prosthetics,and home
Exception: If returning a CorVel check that has not been cashed, healthservices.Alistofcontracted providerscan befoundon
the check should be returned to: our website at www.montanastatefund.com
CorVel Corporation Radiology Services in a Clinic Setting:
121 N. Last Chance Gulch
Billing Technical Component (TC): When billing only the
Helena, MT 59601
technical component (TC) ofa radiologyservice provided in
MT001 : Please remember this code isa timed code.The time spent a clinic setting, the service must be billed on a separate
must be documented in the notes or by the signature. Submitting CMS 1500 with the clinic listed in Box 31.
time only on the CMS 1500 is not sufficient for reimbursement. Points of Contact:
This is a Montana unique code, which replaced CPTcode 97799 for
purposes ofworkers' compensation services. It hasan RVU of.5 per For questions regarding information in this bulletin, call
15-minute unit. Itshould only be used for the following services: 800-332-6102 and ask for a member ofthe medical team.
• Face-to-face conferences with payor representative(s) to For questions regarding payment status or an EOR, call CorVel
updatethestatusofa patient upon the requestofthe payor. at 406-442-6977 or 866-868-3828.
• A reportassociated with non-physician conferences required For questions regarding Advanced Nurse Review, contact any
ofthe following:
by the payor.
• Completion ofa job description orjob analysis. (Signature Lori Holgate, RN CPC: 406-745-0015
must be dated.) Kym Vonada, LPN, CPC, CPC-H, CPC-P: 800-332-6102 ext. 6134
Note: Do not use 99080 for the above services to avoid denial Debbie Williams, RN, CPC-A: 800-332-6102 ext. 6567
ofyour bill.
Independent Medical Examinations (IME) and Impairment
Ratings (IR): For detailed instructions on billing these services and
correctcoding, see the Provider Bulletin for Summer 2008, on the
Montana State Fund website. Requestsforthese services originate
from a claimsexaminer or Montana Health Systems, and specify
what service is being requested. If uncertain which type ofservice
is being requested, please contact the requestor.
PRSRT STD
U.S. Postage
PAID
^MONTANA Missoula, MT
STATEFUND Permit No. 536
5SOUTH LASTCHANCEGULCH
P.O.BOX4759
HELENA,MT59604-4759
CHANGE SERVICE REQUESTED
PROVIDER BULLETIN
Winter 2009
