Provider Connection

Prolonged E/M Service Codes and Non-Treating Impairment Ratings

Treating Physician (under Montana Department of Labor and Industry rules) is the person primarily responsible for the treatment of an individual with a workers’ compensation injury and overseeing those under his/her supervision.

The “non-treating” or consulting physician is a provider who does not routinely treat the injured employee and is not familiar with his condition or injury. This provider is usually contacted by the treating provider or by MSF (or by Montana Health Systems on behalf of MSF) to provide an impairment rating.

Code 99455 is used by the treating provider to render an impairment rating. DLI established a relative value of 2.5 for reimbursement of this code.

Code 99456 is used by a non-treating provider to render an impairment rating. DLI established a relative value of 2.8 for reimbursement of this code. Consultation codes will no longer be allowed for a non-treating provider to render impairment ratings with the 2010 CPT revision to codes 99358 and 99359.

The following elements are included in the impairment rating codes

99455 and 99456:

  • The completion of medical history commensurate with thepatient’s condition.
  • An examination commensurate with the patient’s condition
  • The formulation of a diagnosis assessment of capabilities and stability, and calculation of impairment.
  • The development of future medical treatment plan
  • Completion of necessary documentation/certificates and report

For the non-treating provider, codes 99358 and 99359 may be used for review of records. Code 99358 was previously designated as an add-on code through December 31, 2009.

Beginning January 1, 2010, code 99358 and 99359 can be used for care not involving direct face to face that is beyond the usual non- face-to-face component of physician service time. However, these codes cannot be used for time spent in medical conferences, online medical evaluations, care plan oversight services, anticoagulation management or other non-face-to-face services that have more specific codes and no upper time limit in the CPT code set. The total time spent on prolonged service activity must be documented in the note in order to be eligible for reimbursement. See below:

99358: Prolonged evaluation and management service before and/or after direct (face-to-face) patient care; first hour. Note: Service time of less than 30 minutes is not reported separately.

+99359: Each additional 30 minutes. This code cannot be billed alone. Note: prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 20 minutes is not reported separately.

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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

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

Justin Kennedy
Nurse Manager

Shannon Hadley
Provider Relations Specialist

Kym Vonada
Medical Auditor

Annalyn Stewart
Medical Payment Auditor

Sheryl Semans
Pharmacy Liaison

Susan Bomar
Medical Payment Auditor

Cindy Gallus
Medical Customer Service Liaison

Sherri Sprenger
Medical Customer Service Liaison

Shannon Mergenthaler
Medical Customer Service Liaison

Maggie Pentecost
Medical Customer Service Liaison

Jamie Statton
Medical Customer Service Liaison

Website Information

Montana State Fund

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)