New Year, New Fee Schedule
As most of you are aware, the passing of HB 738 during the 2007 legislative session changed the methodology for reimbursement of medical services provided to injured workers under Montana’s workers’ compensation law. The result was the Montana Facility Fee Schedule (MFFS), which took effect December 1, 2008, and the Montana Non-Facility Fee Schedule (MNFS), which was implemented on January 1, 2008.
The Resource Based Relative Value Scale (RBRVS) publication is used to calculate reimbursement for professional services rendered by licensed health care providers under MNFS. For coding purposes, see the CPT manual that is in effect at the time of the service. Keep in mind that the previous year’s RBRVS edition is used for calculation of payment.
For 2008 service dates, use the 2007 edition of the RBRVS with the 2008 CPT manual. For 2009 service dates, the 2008 edition of the RBRVS will be used with the 2009 CPT codes. The RBRVS has the relative value units (RVUs) for each code. The conversion factors for 2008 and 2009 are:
|Fee Schedule Type||2008||2009|
There are two levels of practice expense RVUs that are dependent upon the place of the service code in Box 24B on the CMS 1500 form:
Non-Facility Level: for services performed in a physician’s office, patient’s home, or other non-facility setting.
Facility Level: for services provided in a hospital, ambulatory surgery 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 must be submitted with the CMS 1500 form in order to substantiate charges and to establish relationship to injury. All professional services must be billed on a CMS 1500 form.
Montana Facility Fee Schedule
After a short delay, the Montana Facility Fee Schedule (MFFS) was adopted and it now applies to services rendered, and discharge dates, on or after December 1, 2008. It is loosely based on CMS methodology, but governed by Montana Administrative Rules and affects all facilities that provide medical services to injured workers in Montana. The rule also changed the terminology of “hospital” to “facility” to clarify that this fee schedule applies to hospital and ambulatory services.
The fee schedule uses Medicare’s MS-DRG (inpatient hospital) and APC (outpatient and ambulatory surgery center) methodology as a basis for reimbursement of services. The MFFS does not incorporate Medicare’s rate of reimbursement or allowed procedures and medications. The DLI’s website contains the following fee schedule elements:
- Montana Hospital Inpatient Services MS-DRG Reimbursement Fee Schedule
- Montana Hospital Outpatient and ASC Fee Schedule Organized by APC
- Montana Hospital Outpatient and ASC Fee Schedule Organized by CPT/HCPCS
- Montana Ambulance Fee Schedule
- Montana CCI Code Edits Listing
- Montana RCC and other Montana RCC-based Calculations
- Base Rates and Conversion Formulas established by the DLI
- Montana MS-DRG Geometric Table
MS-DRG Methodology: Medicare Severity Diagnosis Related Group
A grouper will need to be used to weight inpatient services; www.hospitalbenchmarks.com is one grouper available at no charge. Reimbursement is calculated by using the base rate multiplied by the Montana MS-DRG weight. See the DLI website for more information regarding calculation of reimbursement for outliers. Services myust be billied on a UB04 billing form.
Outlier Threshold: three times the Montana MS-DRG payment amount. See the DLI website example for calculating payment when an outlier applies to a bill.
Implant Outlier Threshold: $10 000.00. .Note: When a hospital requests additional payment pursuant to this threshold, the implantable charge is excluded from the calculation for an outlier payment. Reimbursement is set at the actual amount paid plus 15%, and an invoice must be provided to substantiate the charge. It should include the handling and freight. The information provided to MSF regarding invoice costs will be confidential and used only for the purpose of reimbursement.
Implantable: is defined as an object or device that is made to replace and act as a missing biological structure that is surgically implanted, embedded, inserted, or otherwise applied. The term also includes any related equipment necessary to operate, program and recharge the implantable.
Services that Fall Outside of the MS-DRG: and are not otherwise listed on a Montana fee schedule, will be reimbursed at 75% of U&C.
APC Methodology: Ambulatory Payment Classification. Outpatient hospital and ambulatory surgery center services will be calculated according to Medicare’s APC weights but at Montana’s base rate set by the DLI. The payment is calculated by multiplying the base rate times the APC weight. If the APC weight is not listed or if the APC weight is listed as null, reimbursement must be paid at 75% of U&C. Services must be billed on a CMS 1500 form or a UB04Form.
Outpatient Hospital Base Rate: $105.00
ASC Base Rate: $79.00
Implant Outlier Threshold: $500. Reimbursement is set at the actual amount paid plus 15%, and an invoice must be provided to substantiate the charge. It should include the handling and freight. The information provided to MSF regarding invoice costs will be confidential and used only for the purpose of reimbursement.
Durable Medical Equipment Prosthetics, Orthotics and Supplies: will be paid at 75% of U&C charges.
Status Indicators: The DLI has adopted the following status INDICATORS: A, B, D, F, G, H, K, L, N, P, S, T, and X. Some of the indicators will affect payment. Note: SI “A”includes only ambulance services. DLI did not adopt Medicare’s complete definition that includes other services. If there is no APC weight in the Facility Fee Schedule, reimbursement will be at 75% of the U&C charges. See the DLI website for the complete descriptions.
Critical Access Hospitals: will continue to be reimbursed at 100% of the U&C charges.
Inpatient Rehabilitation: including services provided at a long-term inpatient rehabilitation hospital or facility will be paid at 75% of U&C. The services are excluded from the MS-DRG payment system.
Payment of Facility Bills: Facility Bills will be paid within 30 days of receipt where there is no dispute over liability. See Administrative Rules of Montana (ARM) rule 24.29.1406 (4) for complete rule.
Documentation Requirements for Facility Bills: When medical bills are submitted electronically, you will no longer need to attach supporting documentation in the majority of cases. Documentation will still be required for implants that hit the outlier threshold and for outpatient services such as physical and occupational therapies, laboratory and radiology services.
For more information regarding the MFFS, reference the Department of Labor’s website at http://erd.dli.mt.gov/wcstudyproject/mffsoverview.asp.
If you encounter incorrect payments during the transition for the new payment system, please contact a member of the medical team with the bill numbers and we will research and request a correction, if needed.
Professional Services: Medical providers who furnish professional services in a hospital, ASC or other facility setting must bill insurers separately and will be reimbursed using the MNFS. Providers must bill on a CMS 1500 Form.
NOTE: DO NOT use the Montana State Fund Attending Physician’s First Report and Initial Treatment Bill or the Chiropractor’s First Report for billing or documentation purposes. These forms are no longer used for workers’ compensation purposes.
Ambulance Fee Schedule: The Montana Ambulance Fee Schedule is based on data in CMS but it contains ONLY wokers’ compensation reimbursement rates and calculation for Montana. It includes both ground and air ambulance services. See the DLI website for the complete fee schedule.