Provider Bulletin

Physical/Occupational and Chiro Therapy (Aug 2017)

Utilization & Treatment Guidelines (U&T)
DLI adopted the U&T Guidelines in 2009 and they have been in effect since July 1, 2011. These Guidelines give recommendations for treatment types and limits based on injury type.  They also indicate treatment types that are not generally recommended such as SEMG, Thermography, VaxD etc or treatment types that are only recommended for certain types of injuries such as low level laser.  Prior approval should be sought before using treatment types that are not recommended in the Guidelines to prevent denials or refund requests or if a treatment plan goes over the maximum threshold.  If you are unsure, it is a good idea to get authorization from the Claim Examiner assigned to the claim.  The U&T Guidelines can be found at http://www.mtguidelines.com/.  For questions regarding these Guidelines, please contact Maralyn Lytle at DLI at 406-444-6604.

Timed codes
Many of the Medicine codes in the Physical Medicine and Rehabilitation have a time element. The actual time spent for each of the timed codes need to be recorded in the submitted documentation.  DLI adopted Rule of 8 for the purposes of calculating the total number of modalities/therapeutic procedures that can be billed.  The total number of minutes is divided by 15 (one unit of service = 15 minutes) for the total number of units of services that may be billed.

Services of less than 8 minutes when that is the only service performed during a visit is not billable.  Time intervals are incremented in 15 minute units (base is 8 minutes):

8-22 minutes =  1 unit
23-37 minutes =2 units
38-52 minutes = 3 unit
53-67 minutes = 4 units etc

See the Instruction Set on the DLI website in the Montana Professional Fee Schedule or Montana Facility Fee Schedule sections.

Passive/Active Modalities/Therapeutic Procedures Limits
DLI adopted limits to the number of passive and active services that may be billed in a single visit:

  • A total of 8 units of active and passive therapy may be billed per visit. If active therapy is being applied, only one unit of a passive modality may be included in the 8 units.
  • Passive therapies will be limited to 4 units per visit, if only passive therapy is being applied. Note: Only 2 units may be billed if active therapy is being applied after 7/1/2016.

Passive Modalities

CPT Code Description
97010 Hot or cold packs – one or more regions
97012 Traction – mechanical
97014 Electrical stimulation (unattended)
97016 Vasopneumatic devices
97018 Paraffin bath
97022 Whirlpool
97024 Diathermy (e.g. microwave)
97026 Infrared
97028 Ultraviolet
97032 Electrical stimulation (manual) one or more areas, ea 15 minutes
97033 Iontophoresis, ea 15 minutes
97034 Contrast Baths, ea 15 minutes
97035 Ultrasound, ea 15 minutes
97036 Hubbard tank, ea 15 minutes
97039 Unlisted modality, specify type and time if constant attendance

 

Active/Passive Therapeutic Procedures:

CPT Code Description Passive or Active
97110 Therapeutic Procedure, 1 or more areas, each 15 minutes. Therapeutic exercises to develop strength, endurance, range of motion and flexibility. Active
97112 Neuromuscular re-education Active
97113 Aquatic therapy with therapeutic exercises Active
97116 Gait training (includes stair climbing) Active
97124 Massage Passive
97139 Unlisted therapeutic procedure. ** Passive or Active will depend upon the procedure. Passive or Active**
97140 Manual therapy, ea 15 minutes Passive
97150 Therapeutic procedure(s), group (2 or more individuals) Active
97530 Therapeutic activities, direct (one-on-one) pt contact, ea 15 minutes. Active
97532 Development of cognitive skills to improve attention, memory, problem solving, direct (one-on-one) pt contact, ea 15 minutes. Active
97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) pat contact, ea 15 minutes. Active
97535 Self-care/home management training, direct (one-on-one) pt contact, ea 15 minutes. Active
97537 Community/Work reintegration training, direct (one-on-one) pt contact, ea 15 minutes. Active
97542 Wheelchair management ea 15 minutes Active
97545 Work hardening/conditioning, initial 2 hours Active
97546 Work hardening/conditioning, ea addl hour Active
97799 97799 Unlisted physical medicine/rehabilitation service or procedure. **Passive or Active will depend upon the procedure. Passive or Active**
98940 Chiropractic manipulative treatment, spinal 1-2 regions Passive
98941 Chiropractic manipulative treatment, spinal 3-4 regions Passive
98942 Chiropractic manipulative treatment, spinal 5 regions Passive
98943 Extraspinal, 1 or more regions Passive

All timed codes must have the time documented (in minutes) in the office notes submitted for each code billed for reimbursement.

Therapy codes billed must have part of body documented or it must be clearly identified in a flow sheet or other attached documentation. If the procedures are clearly documented in the notes, a flow sheet is unnecessary. If the notes do not support the procedures billed but refers to a flow sheet then the flow sheet must be attached.

Massage Therapy
Massage Therapy services also fall under the Physical/Occupational therapy rules. For MSF codes 97124 (massage) and 97010 (hot and cold packs) can be used to bill massage therapy services.  As these are both passive services, only a total of 4 units of service may be billed per visit.  U&T Guidelines include recommendations for the use of massage but it is a good idea to contact the Claim Examiner assigned to the claim to verify the number of visits approved as the injured worker’s treating physician may prescribe a specific number of visits.

Bill Status – 1-877-591-8028

Main Phone Number 406-495-5000 or 800-332-6102

Main Fax  406-495-5020

Medical Team – 406-495-5011

Submit your Claims and/or Correspondence To
Montana State Fund
PO Box 4759
Helena, MT  59604

ACS (Bill Status)
Phone  888-208-2116
Email  MSFBillReviewInquiries@Conduent.com

For questions regarding
: Information in this bulletin, call 800-332-6102 and ask for a member of the Medical Team. Advanced Nurse Review, Kym Vonada at 406-495-5389.


Medical Team

Michele Fairclough
Medical Team Leader
406-495-5362

Judy Morgan
Nurse Manager
406-495-5277

Justin Kennedy
Medical Management Specialist
406-495-5417

Shannon Hadley
Provider Relations Specialist
406-495-5245

Kym Vonada
Medical Auditor
406-495-5389

Annalyn Stewart
Medical Payment Auditor
406-495-5367

Susan Bomar
Medical Payment Auditor
406-495-5271

Cindy Gallus
Medical Customer Service Liaison
406-495-5189

Sherri Sprenger
Medical Customer Service Liaison
406-495-5420

Shannon Mergenthaler
Medical Customer Service Liaison
406-495-5185

Maggie Pentecost
Medical Customer Service Liaison
406-495-5322

Jamie Statton
Medical Customer Service Liaison
406-495-5386

Website Information

Montana State Fund montanastatefund.com

Department of LaborDepartment of Labor and Industry (DLI) website.
The website includes the Facility and Non-Facility Fee Schedule information as well as the Administrative Rules of Montana (ARM) and the instruction set for the Non-Facility Fee Schedule. Historical fee schedule information can also be found on this website.

If you have questions regarding the fee schedules call 406-444-6530 and someone will direct you to a DLI representative. For NPI information click here National Plan and Provider Enumeration System (NPPES)