In May 2013 DLI proposed and subsequently adopted new rule changes to the Montana Professional Fee Schedule (MPFS) and the Montana Facility Fee Schedule (MFFS) with an effective date of 7/1/13. Some of the rule changes impact reimbursement and billing requirements, and a new code has been introduced for implants. The fee schedules and codes (CPT/HCPCS additions and revisions) will be now be updated in March of each year. See the DLI website for complete information or contact Maralyn Lytle at 406-444-6604.

Highlights of the changes are:
Montana Non-Facility name changed to Montana Professional Fee Schedule (MPFS) to distinguish professional services from facility services.

New RVU/Conversion Factors for MPFS:

Type	7/1/10 – 6/30/13	7/1/13 forward
Standard	$65.28	$60.52
Anesthesia	$60.97	$61.40
MT001 RVU per 15 minute unit	.5	.54

New Base Rates for Montana Facility Fee Schedule (MFFS)

Type	7/1/10 – 6/30/13	7/1/13 forward
Inpatient Hospital	$7,735.00	$7,944.00
Outpatient Hospital	$105.00	$107.00
ASC	$79.00	$80.00

Billing for Professional Services
Professionals who furnish services, including all outpatient therapies in a hospital, Critical Access Hospitals (CAH), Ambulatory Surgery Center (ASC), or other facility must bill using the CMS 1500 form under New Rule I FACILITY SERVICE RULES AND RATES FOR SERVICES PROVIDED ON OR AFTER JULY 1, 2013 (9) which states “Medical provider services furnished in a hospital, CAH, ASC, or other facility setting, whether those professional services are furnished as an employee of the facility or as an independent professional, must be billed separately using the CMS 1500 and must be reimbursed using the professional fee schedule”. This change includes provider-based clinics and CAHs. Provider-based clinics will be reimbursed under the non-facility column of the MPFS, and a facility fee is no longer reimbursable.

Montana Professional Fee Schedule Instruction Set

All facility providers must bill services on a UB04. This new rule includes ASCs. Please reference the “Clean Claim Defined” article in Montana State Fund’s Winter 2012 edition

Montana Facility Fee Schedule Instruction Set

Multiple Procedures
Changes were made to the percentages allowed when multiple procedures are performed at the same encounter:

First subsequent procedure 50%

Second and all additional subsequent procedures 25%

Diagnostic Imaging multiple procedures:

Professional Component

First subsequent procedure 75%

Second subsequent procedure 50%

Third and all additional subsequent procedures 25%

Technical Component

First subsequent procedure 50%

Second and all addtional subsequent procedures 25%

99455/99456/99499 – Impairment Rating/IME
Codes 99455 and 99456 will be paid at usual and customary as the RVU’s have been deleted from these codes. Non-treating providers must use 99456 when billing impairments in lieu of the consultation codes. Review of records is included in 99456 therefore 99358 and 99359 are not reimbursable.

DLI recommends 99456 be used to bill for an IME however MSF requires 99499 continue to be used for non-contracted IME services.

Physical Medicine Changes
One of the major changes in Physical Medicine services is with the timed modalities. Services of less than 8 minutes when it is the only service performed during a visit will not be reimbursable. 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 units, etc.

Providers must document time spent for each timed modality (if more than one unit of timed service is provided) to substantiate the level of service on a given day. 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 passive therapy may be included in the 8 units. If only passive therapy is being provided, only 4 units of service may be billed per visit.

Anesthesia
Anesthesia – Qualifying Circumstance codes now have a unit value applied so these services will now be fee scheduled.

CPT	Unit Value
99100	1
99116	5
99135	5
99140	2

MT001 – Written Questions
Providers have used 99080 in the past for billing for additional questions from MSF that are not answered in a regular E/M visit. Additional questions have now been assigned to Montana code MT001:

(a) face-to-face conferences with payor representative(s) to update the status of a patient upon request of the payor; or

(b) a report associated with nonphysician conferences required by the payor; or

(c) completion of a job description or job analysis form requested by the payor; or

(d) written questions that require a written response from the provider, excluding the Medical Status Form.

Code 99080 or codes other than MT001 will be denied if billed for responses to written questions.

Medical Status Form
Per 24.29.1513 DOCUMENTATION REQUIREMENTS, (1) when a treating physician, emergency room or similar urgent care facility sees the claimant for the first time (related to the claim), the provider must furnish to the insurer the initial report, the Medical Status Form (MSF), and the treatment bill (CMS 1500) within seven business days of the visit. The Medical Status Form is available on the DLI website .

Functional Improvement Status
Per 24.29.1515 Functional improvement status must identify objective medical findings of the claimant’s medical status, and note the effects of the provided treatment (positive, neutral or negative) with respect to the goals of the treatment plan. The functional improvement status can be sufficiently documented on the Medical Status Form. The Montana Utilization and Treatment Guidelines outline the standards for functional improvement.

New Implant Code MT003
Providers requesting outlier reimbursement for implants must now use MT003 to indicate implants over cost threshold. L8699 will no longer be accepted for implants. Vendor or manufacturer generated purchase orders may now be used to support implant costs in lieu of manufacturer’s invoice but carriers should be able to validate the costs on the purchase orders by the vendor or manufacturer. Outlier cost thresholds have not changed:

Inpatient Hospital $10,000.00

Outpatient Hospital/ ASCs $ 500.00

In addition to the purchase orders/invoices, providers must also submit the operative report to support the implant costs. It is also helpful to submit the implant record if your facility uses that method of documenting implants.

Tips for submitting bills for implants and supporting documentation:

• Do not use a highlighter to showcase or mark items as it obliterates the information when scanned.
• Do not use red ink as it is dropped from the scanning process.
• Underlining, circling or using an asterisk or arrow for showcasing items is helpful for processing implant reimbursement.

New Codes Not Listed on Fee Schedules
New codes that do not have a fee schedule listed in either the Montana Facility Fee Schedule (MFFS) or the Montana Professional Fee Schedule (MPFS) will be paid at 75% of a provider’s usual and customary (U&C) charges.

Durable Medical Euipement (DME)
Facilities and provider clinics billing DME will now be reimbursed the same under New Rule III (based on 24.29.1522) MEDICAL EQUIPMENT AND SUPPLIES FOR DATES OF SERVICE ON OR AFTER JULY 1, 2013. DME will be reimbursed using the same rule as MPFS. “If a Relative Value Unit (RVU) is not listed or if the RVU is listed as null, reimbursement is limited to a total amount that is determined by adding the cost of the item plus the lesser of either $30.00 or 30% of the cost of the item plus the freight cost.”

Drug Screens
Providers performing drug screens must use the following codes when billing:

G0431 – Drug screens performed by a CLIA certified lab that is in an instrumented laboratory setting and is high complexity method per patient encounter must bill using G0431. Laboratories billing G0431 must not append QW to the claim lines.

G0434 – Drug screens performed by a provider that is a CLIA waived test or ofmoderate complexity per patient encounter must bill using G0434 for one unit. This includes tests such as dip sticks, cups, cassettes and cards that are interpreted visually, with the assistance of a scanner, or are read utilizing a moderately complex reader device outside the instrumented laboratory setting.

Other Fee Schedule Information
Please see the DLI/ERD website for new and updated information within the applicable fee schedule for the following:

• CCI/MUE Edits
• Status Indicators
• Cost to Charge Ratios
• Modifiers