Provider Billing Update
Here are some of the highlights (see the Department of Labor & Industry website for more information):
Conversion Factor Changes
Inpatient Hospital $8,120.00
Outpatient Hospital $111.00
Surgery Center (ASC) $83.00
New Drug Screen Codes:
The following drug screen codes will replace G0431 – G0434:
Presumptive screening codes:
For drug screens that are presumptive (screening and confirmation, qualitative or semi-quantitative are billed using G0477 – G0479:
G0477 – Used to test any number of drug classes by any number of devices or procedures capable of being ready direct optical observation ONLY (eg, Dipsticks, cups, cards, cartridges, etc. and includes sample validation when performed, per date of service.
G0478 – Used to test any number of drug classes by any number of devices or procedures read by instrument-assisted direct optical observation (eg, Dipsticks, cups, cards, cartidges, etc), and includes sample validation when performed, per date of service.
G0479 – Used to test any number of dug classes by any number of devices or procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme assay, TOF, ALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), and includes sample validation when performed, per date of service.
Definitive screening codes:
For drug screens that are definitive (quantitative) in nature and utilize drug identification methods
G0480 1-7 drug classes
G0481 – 8-14 drug classes
G0482 – 15-21 drug classes
G0483 – 22 or more drug classes
Note: Only one code from each category (presumptive and definitive) is to be utilized per date of service or patient encounter resulting in no more than 2 billing codes per bill.
A change in the Instruction Set for physical therapy will now allow two units of passive therapies/modalities if active therapies are provided at the same visit.
There is no change if only passive therapies/modalities are being provided. If only passive therapies/modalities are provided during a visit, only total of 4 passive therapeutic procedures or modalities may be billed.
DLI clarified the radiology codes where multiple procedure rules apply. An April 13, 2016 Guidance/Clarification was published with a list of Diagnostic imaging services that are subject to the multiple procedure reduction. From the DLI website: http://erd.dli.mt.gov/Portals/54/Documents/Work-Comp-Claims/Medical-Regs/dli-erd-mr128.pdf.
Diagnostic Imaging Service subject to the Multiple Procedure Reduction for PC and TC services
70336 70492 70551 72125 72147 72196 73223 73725 74185 76604
70450 70496 70552 72126 72148 72197 73225 74150 74261 76700
70460 70498 70553 72127 72149 72198 73700 74160 74262 76705
40470 70540 70554 72128 72156 73200 73701 74170 75557 76770
70480 70542 71250 72129 72157 73201 73702 74174 75559 76775
70481 70543 71260 72130 72158 73202 73706 74175 75561 76776
70482 70544 71270 72131 72159 73206 73718 74176 75563 76831
70486 70545 71275 72132 72191 73218 73719 74177 75571 76856
70487 70546 71550 72133 72192 73219 73720 74178 75572 76857
70488 70547 71551 72141 72193 73220 73721 74181 75573 76870
70490 70548 71552 72142 72194 73221 73722 74182 75574 77058
70491 70549 71555 72146 72195 73222 73723 74183 75635 77059
OUTPATIENT CLINICAL LABORATORY TEST PAYMENT AND BILLING
DLI added the Guidance/Clarification when the only service provided is laboratory to the Instruction Set. Effective July 1, 2016 outpatient providers who are only billing for outpatient laboratory services (and no other services are provided for that encounter) will need to bill with TOB 13X and append the laboratory CPT codes with L1 modifier.
This rule applies to the following situations:
(1) Non-patient laboratory specimen tests; non-patient continues to be defined as an injured worker that is neither an inpatient nor an outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital and the injured work is not physically present at the hospital;
(2) When the hospital only provides laboratory tests to the injured worker (directly or under arrangement) and the injured worker does not also receive other hospital outpatient services during that same encounter; and
(3) When the hospital provides a laboratory test (directly or under arrangement) during the same encounter as other hospital outpatient services that is clinically unrelated to the other hospital outpatient services, and the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services provided in the hospital outpatient setting.
Codes 81200 – 81383, 81400 – 81408 and 81479 are not packaged and should be billed with TOB 13X.
Hospital Clinic Visits
On January 21, 2016, DLI published Guidance/Clarification to address outpatient hospital clinic visits under the Montana Facility Fee Schedule. From the DLI website: http://erd.dli.mt.gov/Portals/54/Documents/Work-Comp-Claims/Medical-Regs/erd-dli-mr119.pdf
In the definition of the Hospital in ARM 24.29.1401A, the following outpatient centers are not included in the term facility and cannot bill facility charges:
- Centers for primary care
- Provider-based clinics
- Offices of private physicians
- Physical or mental health care workers
- Licensed addiction counselors
Providers who are in the above categories will bill their services on a CMS1500 using the place of service code (POS) 11 (or POS 19) and be reimbursed under the Professional Fee Schedule using the Professional Reimbursement Column. Providers using POS 22 will be paid from the Facility Reimbursement column. This is primarily for E & M clinic visits and doctor office surgeries. Facilities may not bill clinic visits if the provider is in one of the above categories.
For surgeries performed in a surgery center or in an outpatient hospital setting, the physicians will bill for their services using POS 22 and be reimbursed under the Professional Fee Schedule under the Facility Reimbursement Column. The facilities will bill on a UB04 for the surgery center services using bill type (83X for MSF) and 131 for outpatient services. They will be reimbursed under the appropriate column in the Facility Fee Schedule.
MSF will be processing bills according to this guidance beginning July 1, 2016. It has been in the rule for several years but has not been enforced. See the DLI website at: http://erd.dli.mt.gov/Portals/54/Documents/Work-Comp-Claims/Medical-Regs/erd-dli-mr119.pdf.
Montana Department of Labor & Industry Fee Schedule websites:
Professional – https://mtwcfeeschedule.optum.com/overview.aspx
For more information regarding Department of Labor and Industry Regulation, contact Maralyn Lytle at 406-444-6604.