Provider Connection

Impairment ratings 101 an impairment rating refresher

There still seems to be confusion with regard to billing for impairment ratings. The codes for impairment ratings are 99455 (treating physician) and 99456 (non-treating).

99455 RVU 2.5 the $158.62 includes:

  • Completion of medical history commensurate with the patient’s condition.
  • Examination commensurate with the patient’s condition
  • Formulation of diagnosis assessment of capabilities and stability and calculation of impairment
  • Development of future medical treatment plan
  • Completion of necessary documentation/certificates and report.

Note: Please document the edition of the AMA guides to permanent impairment used to calculate the impairment. The 6th edition is required for all ratings as of January 1, 2008.

99456 RVU 2.8 the $177.66 includes:

  • Completion of a medical history commensurate with the patient’s condition.
  • Examination commensurate with the patient’s condition
  • Formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment
  • Development of future medical treatment plan
  • Completion of necessary documentation/certificates and report.

Note: please document the edition of the AMA guides to permanent impairment used for calculating the impairment. The 6th Edition is required for all ratings as of January 1, 2008.

A consult code (CPT codes 99241-99245) may be billed instead of 99456 for the non-treating or consulting physician along with any prolonged time codes as appropriate. Time needs to be documented if billing prolonged time codes in order to substantiate payment. Make sure that the documentation submitted supports the level of service being billed. Documentation should reference the referral sources as well as the edition of the AMA guide to impairment used for calculating the impairment.

An Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) may also evaluate an injured worker for determining an imprainment rating, however, a medical doctor must co-sign the documentation as APRNs and PAS are not authorized to provided impairment ratings under MCA 39-71-711.

Is it an independent medical evaluation (IME) or impairment rating (IR)?

On behalf of MSF  a claims examiner or  Montana Health Systems originates these requests. Requests for these services are usually in written form and should be clear on what service is being requested if it is not clear please contact the requestor prior to preforming the service and perform only the requested service. This will avoid denial or delay in the payment of your bills.

Note: For IME PPO Panel providers, reference your contract for billing and documentation requirements.

Brand vs. Generic medications

Effective July 1, 2008 MSF will no longer pay for brand-name drugs when a generic therapeutic equivalent of the brand- name drug is available. If a worker requests the brand-name drug they will be responsible for the difference in cost over the generic price. This is consistent with Montana law 39-71-727(1) and (2) this change only impacts those name brands where a federally approved generic therapeutic equivalent is available in that instance, we will pay for the generic medication.

Preferred provider listing

MSF has numerous contracts with DME, O2, TENs, orthotic and prosthetic  bone growth stimulators  and home health providers  services provided by a non-contracted entity are not payable . Before you order supplies or services for an injured worker please visit our website  www.montanastatefund.com to become familiar with our contracted providers .

Submitting additional documentation or corrected billing information

When you are submitting additional documentation for reconsideration of payment, please attach a copy of the EOR with the documentation you are submitting. This will prevent the bill from being denied as a duplicate. If you are submitting a corrected bill, please mark the bill with “corrected Billign” and attach acopy of the EOR. Please send all information to MSF at:

Montana state fund

PO Box 4759

Helena, MT 59604

Or fax to: 406-444-5963

Refunds

Just a reminder, when submitting refunds for overpayments, please send to MSF a the address listed above.

Mt001

This is a Montana unique code, which replaces CPT code 97799 for purposes of workers’ compensation services.Iit has an RVU of .5 per 15-minute unit. It should be used for the following services:

  • Face-to-face conferences with payor representative(s)to update the status of a patient upon the request of the payor.
  • Report associated with non-physician conferences required by the payor.
  • Completion of a job description or job analysis (signature must be dated.)

Time spent performing this service must be listed in the documentation. Do not use 99080 for the above services to avoid denial of your bill.

Radiology boxes 31, 32, 33 GO!

Please follow the guidelines below when billing radiology services:

  • Box 31 must represent the physician who is reading and dictating the report (is/her .0) number should be entered in Box 24J.
  • Box 32 must be the name and address of the location where services were provided.
  • Box 33 must be the physician or supplier billing entity name address and telephone number.
  • The report requires signature of a physician and must include the dictating and signing physician.

Utilization of these guidelines should help prevent denials for inadequate completion of the CMS 1500 form. If you have questions, call a medical team member listed at the end of this bulletin.

Supplies and materials supplied in a provider’s office

Just are minder as of January 1, 2008 MSF began utilizing ARM rule 24.29.1522 (2) The rule reads:

Except for prescription medicines as provided by ARM 24.29.1529, reimbursement for medical equipment and supplies dispensed through a medical provider is calculated by using the RVU listed in the RBRVS times the conversion factor established in ARM 24.29.1538 in effect on the date of service. If an 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 freight cost plus the lesser of either $30.00 or 30 percent of the cost of the item. An invoice documenting the cost of the equipment or supply must be sent to the insurer upon the insurer’s request.

MSF will be requesting an invoice for those items that do not have an RVU listed in the RBVS publication.

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)