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(1) The department's schedule of fees for medical nonhospital services is known as the Montana Workers' Compensation Medical Fee Schedule. Effective July 1, 2002, to December 31, 2007, the fee schedule in this rule is hereby adopted. The fee schedule is comprised of the following:

(a) The relative value scales given in the most current edition of the Relative Values for Physicians (RVP), published by Ingenix Inc. to be used by doctors of medicine, doctors of podiatry, doctors of osteopathy, doctors of chiropractic, and practitioners licensed as occupational therapists and physical therapists for the following specialty areas:

(i) surgery;

(ii) anesthesia;

(iii) radiology;

(iv) pathology;

(v) medicine;

(vi) chiropractic;

(vii) occupational therapy; and

(viii) physical therapy.

(b) The relative unit values provided by the department in separate fee schedules developed for medical nonhospital services provided by the following health care providers:

(i) acupuncture; and

(ii) dental.

(c) The conversion factors as established by the department.

(2) Relative values have not been developed for nurse specialists, physicians assistants-certified, optometrists, psychologists, licensed social workers, or licensed professional counselors.

(3) Copies of Relative Values for Physicians are available from the publisher. Ordering information may be obtained from the department.

(4) Relative Values for Physicians uses procedure codes listed in the copyrighted publication known as Current Procedure Terminology, or CPT, published by the American Medical Association. The edition in effect at the time the medical service is furnished shall be used to determine the proper procedure code, unless a special code or description is provided by rule.

(5) Interim unit values given in Relative Values for Physicians (designated by a box and the letter "I") are included in the fee schedule and are used to calculate maximum fees payable.

(6) Unit values given in the Relative Values for Physicians section titled "HCPCS Codes" are not included in the fee schedule; services listed in this section are considered to have unit values of "RNE" (relativity not established) for purposes of maximum fee calculation.

(7) All instructions, definitions, guidelines, and other explanations given in the most current edition including updates of the RVP, affecting the determination of individual fees, except as specifically revised or deleted by the department, apply.

(8) Revisions to the conversion factors contained in the Medical Fee Schedule become effective January 1 except as otherwise provided for in these rules. An insurer is not obligated to pay more than the fee provided by the Medical Fee Schedule for a service provided within the state of Montana. The conversion factor in effect on the date the service is provided must be used to calculate the fee.

(9) The maximum fee that an insurer is required to pay for a particular procedure is computed by the unit value times the conversion factor except as otherwise provided for in these rules. Use the conversion factor approved by the department for each specialty area. For example, if the conversion factor is $5.00, and a procedure has a unit value of 3.0, the most that the insurer is required to pay the provider for that procedure is $15.00.

(10) Where a procedure is not covered by these rules, the insurer must pay a reasonable fee, not to exceed the usual and customary fee charged by the provider to nonworkers' compensation patients unless the procedure is not allowed by these rules.

(11) Where a unit value is listed as "BR", it means that the fee is calculated on a "by report" basis. The fee charged is to be reasonable, and may not exceed the usual and customary fee charged by the provider to nonworkers' compensation patients.

(12) It is the responsibility of the provider to use the proper procedure code(s) on any bills submitted for payment. The failure of a provider to do so, however, does not relieve the insurer's obligation to pay the bill, but it may justify delays in payment.

History: 39-71-203, MCA; IMP, 39-71-704, MCA; NEW, 2002 MAR p. 1758, Eff. 7/1/02; AMD, 2007 MAR p. 1670, Eff. 10/26/07.

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