(1) The department adopts the professional fee schedule provided by this rule to determine the reimbursement amounts for medical services provided by a professional provider at a nonfacility or facility furnished on or after July 1, 2013. An insurer must pay the fee schedule or the billed charge, whichever is less, for a service provided within the state of Montana. The fee schedules are available online at the Employment Relations Division web site and are updated as soon as is reasonably feasible relative to the effective dates of the medical codes as described below. The fee schedules are comprised of the following elements, which apply unless a special code or description is otherwise provided by rule:
(a) the CPT codes, including the HCPCS Level II codes. Pursuant to 39-71-704, MCA, the CPT and HCPCS in effect on March 31 of each year are to be applied to a medical service for billing and reimbursement purposes;
(b) the RVU given in the RBRVS, based on the January 1, 2013 version of the RBRVS for services provided from July 1, 2013 to March 30, 2014. Pursuant to 39-71-704, MCA, the RVU given in the RBRVS in effect on March 31 of each year are to be applied to a medical service for billing and reimbursement purposes;
(c) the Correct Coding Initiative (CCI) Edits, including the Medically Unnecessary Edits (MUE). Pursuant to 39-71-704, MCA, the CCI Codes Edits and MUE in effect on March 31 of each year are to be applied to a medical service for billing and reimbursement purposes;
(d) the instruction set for the fee schedule as adopted in this subsection. All the definitions, guidelines, RVUs, procedure codes, modifiers, and other explanations provided in the instructions set affecting the determination of individual fees apply. A copy of the instruction set may also be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011;
(i) The "Montana Workers' Compensation Professional Fee Schedule Instruction Set for 2013" applies to services provided from July 1, 2013 through June 30, 2014; and
(ii) The "Montana Workers' Compensation Professional Fee Schedule Instruction Set Effective July 1, 2014" applies to services on or after July 1, 2014.
(e) the conversion factors established by the department in ARM 24.29.1538;
(f) modifiers, listed on the ERD web site;
(g) the Montana unique code, MT001, described in (7); and
(h) the Montana unique code, MT003, adopted and described in ARM 24.29.1433.
(2) The conversion factors, the CPT codes, and the RVUs used depend 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) Where a procedure is not covered by these rules or uses a new code, the insurer must pay 75 percent of the usual and customary fee charged by the provider to nonworkers' compensation patients unless the procedure is not allowed by these rules.
(4) 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.
(5) Professionals, including those who furnish services in a hospital, CAH, ASC, or other facility setting must bill insurers using the CMS 1500, with the exception of PT, OT, and ST services provided on an outpatient basis and billed on a UB04.
(6) Each provider is to limit services to those which can be performed within the provider's scope of license. For nonlicensed providers, the insurer is not required to reimburse above the related CPT codes for appropriate services.
(7) 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 0.54 RVUs per 15 minutes with time documented by the provider. 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; or
(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; or
(d) written questions that require a written response from the provider, excluding the Medical Status Form.
(8) 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.
(9) 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.
(10) Copies of the RBRVS are available from the publisher. Ordering information may be obtained from the department.