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(1) The department adopts the fee schedule provided by this rule to determine the reimbursement amounts for medical services provided by an individual provider at a nonfacility or facility furnished on or after January 1, 2008. An insurer is not obligated to pay more than the fee provided by the fee schedule for a service provided within the state of Montana. The fee schedule is comprised of the following elements:

(a) the HCPCS codes, including CPT codes, which are incorporated by reference, and discussed in greater detail in (3);

(b) the RVU given in the 2008 edition of the RBRVS, which is incorporated by reference, unless a relative value is otherwise specified in these rules.

(i) The 2007 edition of the RBRVS applies to services provided from January 1, 2008, through December 31, 2008;

(c) the publication "Montana Workers' Compensation Nonfacility Fee Schedule Instruction Set for 2009", which is incorporated by reference.

(i) The "Montana Workers' Compensation Nonfacility Fee Schedule Instruction Set for 2008", September 2007 edition, applies to services provided from January 1, 2008, through December 31, 2008;

(d) the conversion factors established by the department in ARM 24.29.1538;

(e) modifiers, as found in the instructions; and

(f) the Montana unique code, MT001, described in greater detail in (8).

(2) The conversion factors, the CPT codes, and the RVU used depends on the date the medical service, procedure, or supply is provided. The reimbursement amount is generally determined by finding the proper CPT code in the RBRVS then multiplying the RVU for that code by the conversion factor. For example, if the conversion factor is $5.00, and a procedure code has a unit value of 3.0, the most that the insurer is required to pay the provider for that procedure is $15.00.

(3) Unless a special code or description is otherwise provided by rule, pursuant to 39-71-704, MCA, the edition of the CPT publication in effect at the time the medical service is furnished must be used to determine the proper procedure code.

(4) Instructions for the fee schedule are available on the department's web site, along with already calculated reimbursement amounts by CPT code. All the definitions, guidelines, RVUs, procedure codes, modifiers, and other explanations provided in the instructions affecting the determination of individual fees apply. A copy of the instructions is available on the department web site at http://erd.dli.state.mt.us/wcregs/medreg.asp or may be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011.

(5) The maximum fee that an insurer is required to pay for a particular procedure is listed on the department web site and was computed using the RVU in the total facility or nonfacility column of the RBRVS times the conversion factor, except as otherwise provided for in these rules.

(6) Each provider is to limit services to those which can be performed within the limits and restrictions of the provider's professional licensure. For nonlicensed providers, the insurer is not required to reimburse above the related CPT codes for appropriate services.

(7) RVUs have not been established in the RBRVS for CPT codes 99455 and 99456. The RVU established by the department for:

(a) code 99455 is 2.5 RVU; and

(b) code 99456 is 2.8 RVU.

(8) When billing the services listed below, the Montana unique code, MT001, must be used and a separate written report is required describing the services provided. The reimbursement rate for this code is 0.5 RVUs per 15 minutes. These requirements apply to the following services:

(a) face-to-face conferences with payor representative(s) to update the status of a patient upon request of the payor;

(b) a report associated with nonphysician conferences required by the payor; or

(c) completion of a job description or job analysis form requested by the payor.

(9) 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.

(10) Where a service is listed as "by report", the fee charged may not exceed the usual and customary fee charged by the provider to nonworkers' compensation patients.

(11) It is the responsibility of the provider to use the proper procedure, service, and supply codes 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 until proper coding of the services provided is received by the insurer.

(12) Copies of the RBRVS are available from the publisher. Ordering information may be obtained from the department at the address listed in (4).

History: 39-71-203, MCA; IMP, 39-71-704, MCA; NEW, 2007 MAR p. 1670, Eff. 10/26/07; AMD, 2009 MAR p. 8, Eff. 1/16/09.

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