Provider Connection

Physical Therapy in the Outpatient Hospital Setting

As of 7/1/14, outpatient hospital physical therapy services must follow the same rules as outpatient clinical services. Providers must follow the “Rule of 8” so all timed procedures andPT modalities must have time documented by code (in minutes – not units) within the record. See the Facility Fee Schedule Instruction Set Effective July 1, 2014 for instructions at  http://assets.dli.mt.gov/erd/mrdocs/dli-erd-mr029.pdf page 13.

 

Passive Therapeutic Procedures versus Passive Modalities

Passive modalities utilize a tool to cause an effect (i.e. electrical stimulation, hot/cold packs, iontophoresis, ultrasound, etc.).

Passive therapeutic proceduresare procedures that do not require energy on the part of the patient (i.e. massage, manual therapy, etc.) and are considered with the active therapy for purposes of the rule of Eights.

Rule of Eights: Providers are allowed a total of 8 units of active/passive therapeutic procedures per visit with these exceptions:

  • If active/passive therapeutic procedures are utilized, only 1 unit may be a passive modality per visit. 
  • If only passive modalities and/or passive therapeutic procedures are being utilized, only 4 units may be billed per visit. 

NOTE: If a physical therapy/modality is not listed in the Utilization and Treatment Guideline (U&T) or goes over the maximum threshold, services must be pre-authorized by Montana State Fund.      

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, each 15 minutes
97033 Iontophoresis, each 15 minutes
97034 Contrast Baths, each 15 minutes
97035 Ultrasound, each 15 minutes
97036 Hubbard tank, each 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 Passive
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, each 15 minutes Passive
97150 Therapeutic procedure(s), group (2 or more individuals) Active
97530 Therapeutic activities, direct (one-on-one) pt contact, each 15 minutes. Active
97532 Development of cognitive skills to improve attention, memory, problem solving, direct (one-on-one) pt contact, each 15 minutes. Active
97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) pat contact, each 15 minutes. Active
97535 Self-care/home management training, direct (one-on-one) pt contact, each 15 minutes. Active
97537 Community/Work reintegration training, direct (one-on-one) pt contact, each 15 minutes. Active
97542 Wheelchair management each 15 minutes Active
97545 Work hardening/conditioning, initial 2 hours Active
97546 Work hardening/conditioning, each 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

 

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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)