Provider Connection

Coding 101

stethoscopeEvaluation and Management (E/M)

Medical necessity is the driver for choosing a level of service. A visit should include a chief complaint or reason for the visit. The chief complaint is a statement that describes the symptom, problem, condition, diagnosis or reason a patient seeks medical services. It should be in the patient’s own words. For workers’ compensation patients (or injured employees), medical necessity and care rendered must be directly related to the injury of record. If a patient is seeking treatment for conditions not directly related, that treatment should be billed separate from the workers’ compensation services or a separate appointment made to address those conditions.

New Patient: A patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Established Patient: A patient who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

There are seven components of E/M services.

  • History
  • Exam
  • Medical Decision Making
  • Counseling
  • Coordination of Care
  • Nature of Presenting Problem
  • Time

The “key” components for selecting the level of service are history, exam and medical decision making.

History

There are four types of history:

Problem Focused – Chief complaint; brief history of present illness or problem.

Expanded Problem Focused – Chief complaint; brief history of present illness; problem pertinent system review.

Detailed – Chief complaint; extended history of present illness; problem pertinent system review extended to include a review
of a limited number of additional systems; pertinent past, family and/or social history directly related to the presenting problem.

Comprehensive – Chief complaint; extended history of present illness; review of systems that are directly related to the problem(s) identified in the history of the presenting illness plus a review of all additional body systems; complete past, family and social history.

Exam

There are four types of exam:

Problem Focused – A limited examination of the affected body area or organ system.

Expanded Problem Focused – A limited examination of the affected body area or organ system and other symptomatic or related organ system.

Detailed – An extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Comprehensive – A general multisystem examination or a complete examination of a single organ system.

Per Current Procedural Terminology (CPT) guidelines, body areas are:

  • Head – including the face
  • Neck
  • Chest – including breasts and axilla
  • Abdomen
  • Genitalia – groin, buttocks
  • Back
  • Each extremity

Per CPT guidelines, the organ systems are:

  • Eyes
  • Ears, nose, mouth, throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric
  • Hematologic/lymphatic/immunologic
back to Provider Connection

Bill Status – 1-866-274-7464

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

RMS (Bill Status)
Phone  866-274-7464
Email customer.care@risingms.com

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


Medical Team

Michele Fairclough
Medical Team Leader
406-495-5362

Justin Kennedy
Nurse Manager
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

Sheryl Semans
Pharmacy Liaison
406-495-5010

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)