Category: Provider Bulletin

Red Lodge, MT will be the site for the 2024 Medical Conference slated for May 15-17, 2024. Details coming soon.

Click here to view the presentations from the 2023 conference.

What is an NPI?
The NPI is the National Provider Identifier that is used by Medicare to be able to track where practitioners are providing services.  MSF uses them for similar reasons but these numbers are also required for reporting information to National Council on Compensation Insurance (NCCI).  The NPI Registry is found at NPPES NPI Registry (hhs.gov) which is also where providers can apply for an NPI.  Providers generally receive a number within a day or so.  MSF requires NPI’s for all providers who bill for services for workers compensation.

Where are NPI’s used?

• UB04 form:  NPI’s are required in Box 56 (service facility), Box 76 (attending provider and Box’s 77 – 79 (operating and other) if applicable.
• CMS 1500:  Box 24J (service provider), 32a (service facility location) and 33a (billng provider). 

The names the NPI’s are registered needs to match the billing form used.

Please be sure the NPI’s entered are correct and match the NPPES registry.  This will help eliminate denials and having to submit corrected bills for reconsideration.  If you have questions, please contact the Medical Audit Team at 406-495-5011.

When you submit reconsideration requests or any other type of information you want us to notice, please do not highlight. Highlighted materials do not image. And when scanned, it is blacked out.  

For best results, only use a black or blue pen (red pen disappears in a scan) and emphasize with the following:

• Circle the information
• Draw a star ** or an arrow à next to the information
• Underline the information

We are approaching the anniversary of the timely filing rule that took effect July 1, 2022.  The Montana Department of Labor and Industry (DLI) added the Administrative Rules of Montana (ARM) rule 24.29.1402(1)(c) which in part states:

(c)A provider of medical treatment or services shall only be paid for services under this chapter if the bill for medical treatment or services is timely received by the employer or appropriate payer.  Absent a showing of good cause, a bill for treatment or services is timely received by the employer or appropriate payer when it is actually received within 365 days of the later of:

• The date of service; or
• The date the provider of medical treatment or services knew the treatment or services was related to a claim for benefits under this chapter.

The rule can be found at https://rules.mt.gov/gateway/ruleno.asp?RN=24%2E29%2E1402.  If you have questions about this rule, contact Celeste Ackerman, Administrative Officer (DLI) at 406-444-6604.

When you submit a reconsideration request, please attach a copy of the EOR with the request.  This readily identifies it as a reconsideration request and does not get processed as a duplicate.

When you submit a corrected bill, please mark the billing form as a correction. The original billing should remain the same, with the exception of the line/code that has been corrected.  If you only submit a corrected code, or a code that was previously denied on a multiple line billing, it could appear as a replacement bill or as unbundling etc.  It also makes it easier to process the request.

To prevent denials due to the timely file rule, request a reconsideration as soon as possible.  This ensures providers have revenue coming in and helps MSF keep claim costs current. 

Requests can be sent via mail to:
Montana State Fund
PO Box 4759
Helena, MT  59604

Or faxed to:
406-495-5020.

When requesting bill status, please first call Rising Medical Solutions (RMS).

Phone:  1-866-274-7464
Fax:  1-312-559-8450
Email:  help@risingms.com

If RMS cannot help you, they will refer you to Montana State Fund’s Medical Payment Auditors.

DME requests that are outside of what a provider clinic dispenses can be sent directly to RMS at RisingDME@risingms.com.  RMS will take care of getting authorization from MSF and in obtaining the DME items as well as negotiating the fees.  They can also be contacted by phone at 1-888-959-0043.

Items that are dispensed and billed for under the provider clinic do not need to go to RisingDME.  DME is processed under the Department of Labor and Industry (DLI) Administrative Rules of Montana 24.29.1523: 

(1) For both facility and professional services, reimbursement for DME dispensed through a medical provider is determined by the professional fee schedule in effect on the date of service, except for prescription medicines as provided by ARM 24.29.1529. On March 31 of each year, or as soon thereafter as is reasonably feasible, the professional fee schedule with updated HCPCS will be posted on the web site. If a RVU is not listed or if the RVU is listed as null, reimbursement is limited to a total amount that is determined by adding the cost of the item plus the lesser of either $30.00 or 30 percent of the cost of the item plus the freight cost. An invoice documenting the cost of the equipment or supply must be sent to the insurer upon the insurer’s request.

(a) Copies of the instructions are available on the department web site or may be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011.

(2) If a provider adds value to DME (such as by complex assembly, modification, or special fabrication), then the provider may charge a reasonable fee for those services. Merely unpacking an item is not a “value-added” service. While extensive fitting of devices may be billed for, simple fitting (such as adjusting the height of crutches) is not billable.

Summary: Petitioner alleges that his industrial accident caused a left shoulder injury and a permanent aggravation to his preexisting cervical spine condition.

Held: Respondent is not liable for Petitioner’s left shoulder injury nor his cervical spine condition because Petitioner failed to meet his burden of proving that his industrial accident caused his left shoulder injury nor that his industrial accident caused an aggravation to his cervical spine condition. Because neither Petitioner nor his wife was a credible witness, this Court was not convinced that Petitioner’s symptoms started with his industrial accident. In turn, because the physicians on whom Petitioner relied for his medical causation opinions based their opinions on Petitioner’s history, this Court did not give their opinions any weight. Moreover, the physician on whom Petitioner relied for his medical causation opinion regarding his cervical spine condition opined that the industrial accident did not aggravate his preexisting cervical spine condition.

Read more.

This summer we said goodbye as Lanny Hubbard retired after many years of dedicated leadership. I’m honored to take the helm as MSF’s new President and CEO and would like to introduce myself just a bit to you. 

I’m a nurse, an attorney, and a businesswoman. I’m here because I strongly believe in the impact a healthy Montana State Fund has in promoting safety and financial well-being.

As a nurse responding to accidents, I developed a passion for working with people, and came to personally understand the impact an injury has on a person’s life, and the life of their family. 

As an attorney leading legislative strategy at the state fund in Oregon, I saw firsthand how a strong, balanced, workers’ comp system can create a significant positive impact for employers statewide.

And most recently as I’ve leaned in on the finance/MBA side, I strengthened my belief in the importance of having a stable, well-run, financially secure state fund to make sure insurance is available and affordable for Montanans.

Since I started in May, my daughter and I have traveled (almost) all around the state. We’ve discovered warm, engaging people; breathtaking scenery; and a shared passion for making sure Montana is an amazing place to live, work, and play for generations to come. It feels like home already. I can’t wait to explore even more. 

And I have awesome colleagues. Montana State Fund’s employees are mission driven, have a long history of successfully partnering with workers and employers across the state, and are proud to be Montanans serving Montanans. 

I’m committed to continuing to figure out together what works for Montanans – what works for our business, and what works for our workers.

Thank you for choosing Montana State Fund as your workers’ comp carrier. I look forward to meeting many of you.  

Stay safe out there.

Holly O’Dell

Managing Recovery & Return to Work is the theme of Montana State Fund’s 21st annual medical conference. The event will be held at the Lodge at Whitefish Lake, April 26-28, 2023 in Whitefish, MT.

The Conference Benefits
Physicians, Physicians Assistants, Nurses, Physical Therapists, Medical Case Managers, Vocational Rehabilitation Consultants, Claims Examiners, Attorneys and Insurance agents.

Conference Topics

• Claims: A Medical Perspective
• Medical Technology in Workers’ Compensation
• Preventing Delayed Recovery by Addressing Psychosocial Barriers
• A Comprehensive Approach to Pain Medicine
• Successes and Challenges with Return to Work
• Medical Expert Testimony – Imperatives, Principles and Methodologies
• A Perspective from the Workers’ Compensation Court
• Tears and Lies My Radiologist Told Me
• The Story You Don’t Hear About: How Caregivers Changed My Life for the Better

Register for Conference and Book Hotel Accommodations.

For questions or more information, contact Shannon Hadley at shadley@mt.gov or call 406-495-5245.

The benefits of a Return to Work (RTW) program are numerous. Medical providers play a key role in the success of returning an injured employee back to work as soon as is medically capable. 

Studies show that RTW programs help injured employees heal more quickly and completely while reducing depression and alleviate emotional stress.  Most employees look forward to adding to the productivity of their company through transitional duties. They welcome the chance to be back alongside their friends and co-workers as soon as is medically appropriate. 

In addition, workers’ compensation insurance payments cover just two-thirds of an injured employee’s pay. By returning to work as soon as possible, injured employees receive their normal compensation sooner, minimizing lost wages and time.

Click for more information about Montana State Fund’s RTW program.

MICHAEL RAY
Petitioner
vs.
OHIO SECURITY INSURANCE CO.
Respondent/Insurer.

FINDINGS OF FACT, CONCLUSIONS OF LAW, AND JUDGMENT
Summary: Petitioner alleges that his industrial accident caused a left shoulder injury and a permanent aggravation to his preexisting cervical spine condition.

Read more.

Technology services company Data Dimensions, recently merged with MSF’s electronic billing provider  WorkCompEDI®.  Moving forward, Data Dimensions will process our electronic billing.  

This merger will be seamless for those of you already using electronic billing. https://datadimensions.com/montanastatefund/.  However, if you are not utilizing electronic billing, we encourage you to sign up.  This easy billing method ensures your transactions are received and processed in the most efficient and prompt manner.

Sign Up
Contact Data Dimensions at 800-782-2907 or go to info@datadimensions.com. For more information about Data Dimensions visit their website datadimensions.com.

A new timely filing rule took effect (for dates of service on or after) 7/1/2022.   The Department of Labor and Industry (DLI) added the rule under the Administrative Rules of Montana (ARM) 24.29.1402(1)(c):

(c)A provider of medical treatment or services shall only be paid for services under this chapter if the bill for medical treatment or services is timely received by the employer or appropriate payer.  Absent a showing of good cause, a bill for treatment or services is timely received by the employer or appropriate payer when it is actually received within 365 days of the later of:

• The date of service; or
• The date the provider of medical treatment or services knew the treatment or services was related to a claim for benefits under this chapter.

The rule can be found at:  https://rules.mt.gov/gateway/ruleno.asp?RN=24%2E29%2E1402.  For more information contact DLI’s Celeste Ackerman at 406-444-6604.

When calling about the status of a bill, first contact Rising Medical Solutions (RMS) at 866-274-7464.  If you need further assistance, you can call MSF’s Medical Auditors at 406-495-5011.  Please give RMS the maximum 30 days processing time before calling about payment status. However, if you do have payment issues, it is best to bring them to our attention in a timely manner. An extensive list of payments can be time consuming to reconcile.

In February 2021, MSF contracted with RisingDME to provide DME for injured workers.  All pre-authorizations for DME that is not dispensed directly by a provider’s office or clinic should go directly to RisingDME@risingms.com or faxed to 312-224-1327.  This includes authorizations for Bone Growth Stimulators, TENS/Muscle Stimulation units and other name brand items.  If you have questions about a pending authorization or need to relay more information, please call 888-959-0043. 

For DME that is dispensed directly from your clinic, continue to bill it out as usual – it will be paid per the DLI fee schedule rules under ARM 24.29-1523:

24.29.1523    MEDICAL EQUIPMENT AND SUPPLIES FOR DATES OF SERVICE ON OR AFTER JULY 1, 2013

(1) For both facility and professional services, reimbursement for DME dispensed through a medical provider is determined by the professional fee schedule in effect on the date of service, except for prescription medicines as provided by ARM 24.29.1529. On March 31 of each year, or as soon thereafter as is reasonably feasible, the professional fee schedule with updated HCPCS will be posted on the web site. If a RVU is not listed or if the RVU is listed as null, reimbursement is limited to a total amount that is determined by adding the cost of the item plus the lesser of either $30.00 or 30 percent of the cost of the item plus the freight cost. An invoice documenting the cost of the equipment or supply must be sent to the insurer upon the insurer’s request.

(a) Copies of the instructions are available on the department web site or may be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011.

(2) If a provider adds value to DME (such as by complex assembly, modification, or special fabrication), then the provider may charge a reasonable fee for those services. Merely unpacking an item is not a “value-added” service. While extensive fitting of devices may be billed for, simple fitting (such as adjusting the height of crutches) is not billable.

Please circle, underline or star* (instead of highlighting) any re-evaluation item requests.  Once imaged, the highlighted documents are blacked out and illegible.  Thank you for your help on this issue.

MMI is a point in the healing process when further material functional improvement is not reasonably expected from primary medical treatment and a permanent work capacity is defined.  Reaching MMI is a critical decision point in the life of a workers’ compensation claim. At this point the insurance company will determine any additional benefit entitlement based on any permanent loss of function and permanent wage loss that occurred as a result of the injury.  Reaching MMI does not necessarily mean that workers’ compensation will not cover further treatment.

Summary: An insurer appeals an order from the DLI awarding interim benefits under
§ 39-71-610, MCA. The insurer asserts that the claimant’s treating physician gave him a
full duty release and contends that it had the right to immediately terminate his TTD
benefits without complying with § 39-71-609(2)(a)-(d), MCA, which are commonly called
the “Coles criteria.”

Held: The DLI correctly awarded interim benefits. As one of the insurer’s adjusters noted,
the full duty release generated by the treating physician’s office was most likely a mistake
because it could not be reconciled with the claimant’s other medical records, which
indicate that his physical restrictions preclude him from returning to his time-of-injury job.
Moreover, even if the physician intended to release the claimant to work, a general
release to work in some unknown job is insufficient grounds for an insurer to terminate
TTD benefits under the first sentence of § 39-71-609(2), MCA. Montana law requires an
insurer to have a physician approve a job analysis for an actual job that the claimant is
physically able, and vocationally qualified, to perform. Finally, the insurer did not have
grounds to terminate the claimant’s TTD benefits under the first clause of the second
sentence of § 39-71-609(2), MCA, because the Medical Status Form purporting to release
him to full duty cannot reasonably be construed as the treating physician’s determination
that he had reached MMI, had fully recovered, and could return to his time-of-injury job.

Read Entire Case

Register now for our 20th Annual Medical Conference. The theme is Harnessing the Future of Workers’ Compensation. It takes place at the Delta Hotel in Helena, May 19-20, 2022.

This conference is valuable for Physicians, Physicians Assistants, Nurses, Physical Therapists, Medical Case Managers, Vocational Rehabilitation Consultants, Claims Examiners and Attorneys. Continuing education credits are pending approval.

Agenda Topics:

• Occupational Injury Causation, Mark Melhorn, MD
• Reducing Costs and Improving Outcomes, Marcus Nynas, DC
• The Top Ten Predictions in Workers’ Compensation, Stuart Colburn, AAL
• Medical Marijuana, Kathy Collins, PharmD
• IME’s from the Workers’ Compensation Court, Judge David Sandler
• Claims Advocacy, Denise Zoe- Algire, MBA
• When Change Chooses You, Dale Hull, MD
• An Overview of Traumatic Brain Injury, Tutankhamen Pappoe, MD

Continuing education credits are pending approval. Click for full agenda and hotel information.

For questions or more information, contact Shannon Hadley or call 406-495-5245.

We’re in a full year now on the new documentation guidelines for Evaluation and Management Services.  It has been a learning experience and most of us are getting it figured out.  The biggest issue MSF is seeing is due to the changes in the way time is used to determine the level of service.  The changes affect code range 99202 – 99215.

Total Time spent – (Codes 99202-99205 and 99212-99215):

When using time as a basis for code selection, use the total time on the date of service only.  Time includes both the face-to-face and non-face-to-face time that is personally spent by the physician and/or other qualified health care professionals on the day of the visit – this includes time in activities that require the physician or other qualified health care professional but not time spent by clinical staff.  Time spent on activities that are separately billable are also not included.  Counseling and coordination of care no longer has to dominate the time spent with a patient when using time for code selection, so the statement “of which more than 50%” is no longer applicable and should not be used. 

Per AMA, time includes the following:

• preparing to see the patient (such as review of tests etc)
• obtaining and/or reviewing separately obtained history
• performing a medically appropriate examination and/or evaluation
• counseling and educating the patient/family/caregiver
• ordering medications, tests, or procedures
• referring and communicating with other health care professionals (when not separately reported)
• documenting clinical information in the electronic or other health record
• independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver
• care coordination (not separately reported)

Time does not include the following:

• the performance of other services that are reported separately (such as xrays, minor procedures, labs etc)
• travel
• teaching that is general and not limited to discussion that is required for the management of a specific patient

Time Ranges for CPT codes 99202-99215:

Code	Time (Minutes)	Code	Time (Minutes)
99202	15-29	99212	10-19
99203	30-44	99213	20-29
99204	45-59	99214	30-39
99205	60-74	99215	40-54

Prolonged time codes 99354 – 99359 can no longer be used with the above codes for services on the same day.   Two new codes (99417/G2212) may be used with 99205 and 99215. 

When using 99417 – providers must spend at least 15 minutes beyond the minimum time listed for 99205/99215 and documentation needs to support services where the time was spent.

When using G2212 – providers must spend at least 15 minutes beyond the maximum amount of time listed for 99205/99215.  This is the only code that Medicare will accept for prolonged services with 99205/99215. 

Total Duration of New Patient Office or Other Outpatient Services (use with 99205):

Code(s) less than 75 minutes Not reported separately 75-89 minutes 99205 X 1 and 99417 X 1 90-104 minutes 99205 X 1 and 99417 X 2 105 or more 99205 X 1 and 99417 X 3 or more for each additional 15 minutes.

Total Duration of Established Patient Office or Other Outpatient Services (use with 99215)

Code(s) less than 55 minutes Not reported separately 55-69 minutes 99215 X 1 and 99417 X 1 70-84 minutes 99215 X 1 and 99417 X 2 85 or more 99215 X 1 and 99417 X 3 or more for each additional 15 minutes.

Medical necessity is still the overarching criteria for the level of service – which includes the decision making process of the care provider in addition to the requirements of the CPT code. 

Click for a helpful publication put out by the American Medical Association (AMA) and CMS .   Other resources are the CPT Manual and Medicare.

We are still seeing a number of billing forms where the ICD-10 diagnosis codes are incomplete.  Placeholder and the sequence are the most common missing characters.  Please ensure the codes are complete to prevent denials.

When submitting a request for re-evaluation or reconsideration, attach a copy of the EOR with your submission. Please indicate on the billing form that it is a reconsideration request along with any additional records needed for review. 

Please use a black or blue ink pen and circle or star * any information you would like to draw attention. If a highlighter is used, the information does not scan well and it is often too dark to read what is under it.

Summary: Petitioner seeks additional benefits, asserting that his industrial accident permanently aggravated his preexisting conditions, including his chronic pain, cervical spine condition; lumbar spine condition; and right foot condition. Petitioner also asserts that his industrial accident caused a brain injury, resulting in headaches and tinnitus.

Held: Respondent is not liable for additional benefits. Respondent is liable only for those medical conditions caused or materially aggravated by Petitioner’s industrial accident. In his industrial accident, Petitioner suffered a left-wrist sprain, which has completely resolved; a low-back sprain, which has completely resolved; and a herniated disc at C5-6, which has been surgically repaired and which resulted in no additional physical restrictions. Petitioner did not suffer a permanent aggravation to any of his preexisting conditions. Petitioner’s current need for medical treatment and his alleged current inability to return to his time-of-injury job or otherwise work is a result of his preexisting conditions and a nonindustrial left-ankle injury, conditions and injuries for which Respondent is not liable.

View the entire case

The  purpose behind the Montana Department of Labor and Industry (DLI) Medical Status Form is to evaluate an injured workers return to the workplace. It is a communication tool between a physician, injured worker, and the employer that outlines the current work abilities of the injured worker and whether they return on a part or full-time basis.

By law, the treating physician or designee must complete the form after each visit. This practice gives the insurer the information they need to handle the claim properly and pay any benefit entitlement promptly. 

When the provider fills out the form, it should eliminate requests for the same information from the insurer. However, if the insurer asks the provider to answer the same questions outlined on the sent Medical Status Form, the provider may bill the insurer for their time. In addition, providers may bill insurers who ask for more information not contained in the DLI form. Providers should use code MT001.

The form and instructions are available on MSF’s webpage  or on DLI’s site. You may also request a duplicate hard copy free of charge from DLI. Contact Celeste Ackerman at 406-444-6543 or celeste.ackerman@mt.gov. 

Medical providers also have permission to have the form programmed into their medical records system if the name of the form still is the same and all the data fields are included in the same order as DLI’s form. Insurers and medical providers have requested a universal form that is easily recognized by all stakeholders.

As of April 14, 2021, the Montana Department of Labor and Industry (DLI) Legacy Claim Guidance issued March 30, 2020 due to the COVID-19 crisis, is no longer in effect.

Background
On March 30, 2020, DLI issued a guidance requesting all TPAs and insurers delay adherence to the Drug Formulary requirements for Legacy Claims (ARM 24.29.1607) due to COVID-19 crisis and concerns of healthcare capacity.

Medical providers treating Montana State Fund injured employees may receive this type of letter from us that explains the change.

If you have questions or concerns about this notice, please contact Montana State Fund’s Provider Relations Specialist Shannon Hadley, 406-495-5245.

Montana State Fund’s annual medical conference will be held at Helena’s Delta Hotel, May 19 – 20, 2022. The theme is Harnessing the Future of Workers’ Compensation. 

Physicians, Physicians Assistants, Nurses, Physical Therapists, Medical Case Managers, Vocational Rehabilitation Consultants, and Claims Examiners are encouraged to attend. 

Continuing education credits are pending approval.

For questions or more information, contact Shannon Hadley or call 406-495-5245.

Montana Code Annotated 2021

TITLE 39. LABOR
CHAPTER 71. WORKERS’ COMPENSATION
Part 11. Treatment by Designated Providers

Please take special note of sections (4) (5) (6) in the below document
https://leg.mt.gov/bills/mca/title_0390/chapter_0710/part_0110/section_0010/0390-0710-0110-0010.html

One of the unusual components of the Montana Workers’ Compensation system is the Lockhart lien that exists against medical benefits to be paid to medical providers.  The basis for Lockhart liens is a decision by the Montana Supreme Court in Lockhart v. New Hampshire Ins. Co., et al, 295 Mont 4677, 984 P.2d 744 (1999).  In that case, the Supreme Court held that an attorney representing an injured worker in a workers’ compensation insurance claim has a lien for any medical benefit that the attorney obtains for the injured worker.  The lien can be in place for all medical benefits on a claim if the attorney was successful in getting the insurer to accept a previously denied claim or the lien can exist for a specific benefit such as a surgery if the attorney gets the insurer to cover the previously denied surgery.  The lien amount will be 20% of the fee schedule amount payable unless the dispute was resolved by the Workers’ Compensation Court or Montana Supreme Court; in which case the attorney lien will be 25% of the fee schedule amount.

Lockhart Decision

Montana State Fund’s medical team is here to help. We focus our energy on what matters for you and our injured employees. From coding questions to provider authorizations, we want your experience with us to be seamless and stress free.

Click to access our team directory

As most providers are aware, the rules/guidelines changed effective 1/1/21.  The changes affect code range 99202 – 99215.

These changes should help reduce the amount of redundant and overwhelming documentation that was required under the old rules for selecting an E/M level of service.  The level of service is now selected by:

1. The level of medical decision making as defined for each service, or
2. The total time spent for that date of service.

Level of Medical Decision Making – (Codes 99202-99215) consist of 3 components:

1.  Problem:  the number and complexity of problems addressed
2. Data:  amount and /or complexity of data to be reviewed and analyzed
3. Risk:  risk of complications and/or morbidity or morality of patient management

When using MDM for code selection, two of the above three elements must be met.  See your CPT manual for additional information. 

Total Time spent – (Codes 99202-99205 and 99212-99215):

When using time as a basis for code selection, use the total time on the date of service only.  Time includes both the face-to-face and non-face-to-face time that is personally spent by the physician and/or other qualified health care professionals on the day of the visit – this includes time in activities that require the physician or other qualified health care professional but not time spent by clinical staff.  Time spent on activities that are separately billable are also not included.  Counseling and coordination of care no longer has to dominate the time spent with a patient when using time for code selection.

Code	Time (Minutes)	Code	Time (Minutes)
99202	15-29	99212	10-19
99203	30-44	99213	20-29
99204	45-59	99214	30-39
99205	60-74	99215	40-54

Prolonged time codes 99354 – 99359 can no longer be used with the above codes.  New codes 99417/G2212 may be used with 99205 and 99215.  See your CPT code book for additional information.

Medical necessity is still the overarching criteria for the level of service – which includes the decision making process of the care provider in addition to the requirements of the CPT code. 

These changes have added some major confusion to the E/M coding process and it will take some time for everyone to get comfortable with it.  There are many resources out there and some great webinars to help alleviate some that. 

IN THE WORKERS= COMPENSATION COURT OF THE STATE OF MONTANA WCC No. 2008-2103 2013 MTWCC 21

Click to review case.

Montana State Fund is pleased to announce our new relationship with Rising Medical powered by VGA/Homelink as our exclusive Home Respiratory Services and Durable Medical Equipment (DME) provider. This expanded partnership with Rising Medical will provide to MSF and its employers/insured all DME and Home Respiratory Services. The partnership took effect February 1, 2021.

For providers who would like to order Home Respiratory Services or DME supplies for MSF claimants/insured, we have available the below options to send your referrals.

Physician Referrals can be emailed, completed on-line, call or fax us:

Rising Medical Solutions’ Customer Contact Information for Montana State Fund DME Program

To Submit a Referral via e-Mail RisingDME@risingms.com

To Submit a Referral Online Under Ancillary Medical Service – Click Durable Medical Equipment

https://vision.risingms.com/vision/referral/referralrequest

To Submit a Referral via Fax 312- 224- 1302

Rising Medical powered by Homelink offers 24/7 customer service, clinical advice and equipment troubleshooting if you have any questions about your home respiratory or DME. A team of highly trained professionals will help coordinate the delivery, setup, proper usage, maintenance and ongoing support of your DME and supplies.

For DME Dispensed from a provider office

24.29.1523    MEDICAL EQUIPMENT AND SUPPLIES FOR DATES OF SERVICE ON OR AFTER JULY 1, 2013

(1) For both facility and professional services, reimbursement for DME dispensed through a medical provider is determined by the professional fee schedule in effect on the date of service, except for prescription medicines as provided by ARM 24.29.1529. On March 31 of each year, or as soon thereafter as is reasonably feasible, the professional fee schedule with updated HCPCS will be posted on the web site. If a RVU is not listed or if the RVU is listed as null, reimbursement is limited to a total amount that is determined by adding the cost of the item plus the lesser of either $30.00 or 30 percent of the cost of the item plus the freight cost. An invoice documenting the cost of the equipment or supply must be sent to the insurer upon the insurer’s request.

(a) Copies of the instructions are available on the department web site or may be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011.

(2) If a provider adds value to DME (such as by complex assembly, modification, or special fabrication), then the provider may charge a reasonable fee for those services. Merely unpacking an item is not a “value-added” service. While extensive fitting of devices may be billed for, simple fitting (such as adjusting the height of crutches) is not billable.

If you have questions please contact Montana State Fund Medical Services Director Michele Fairclough at mfairclough@mt.gov or call 406-495-5362.

Due to the COVID-19 virus outbreak and in the interest of keeping everyone safe and healthy,  MSF has made a decision to allow for more telephone health care services to keep our injured employees at home, but continuing on their way to recovery. These guidelines will be in effect until further notice.

Note:  Please use POS 02 in Box 24B of the CMS 1500 form to indicate that the services provided have been via a telephonic/video type method. The GT modifier may also be applied for audio/video telecommunications. For timed codes, please document total time spent in the record.

99201 – 99215 Evaluation and Management visits that normally require face to face time will be allowed as audio/video visits. Documentation does need to support the services billed.

Psychotherapy services

90832:  30 minutes 90834:  45 minutes 90837:  60 minutes

Psychological Evaluations will need to be authorized prior to service by calling Michele Fairclough at the number listed at the end of this publication.

Online Digital Evaluation and Management service, for an established patient, for up to 7 days, cumulative:

99421:  5-10 minutes 99422:  11-20 minutes 99423:  21 or more minutes

Telephone Evaluation and Management (E/M) services by a physician or other qualified health care professional who may report E/M services provided to an established patient:

99441:  5-10 minutes 99442:  11-20 minutes 99443:  21-30 minutes

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient or episode of care initiated by an established patient:

98966:  5-10 minutes 98967:  11-20 minutes 98968:  21-30 minutes

Qualified non-physician health care professional online digital (non-face to face) E/M service utilizing internet resources for an established patient, for up to 7 days, cumulative time during those 7 days:

98970:  5-10 minutes98971:  11-20 minutes 98972:  21 or more minutes

Physical/Occupational Therapy can use the above codes as applicable; also, MSF will allow the following re-evaluation codes:

97164 – Physical Therapy Re-evaluation 97168 – Occupational Therapy Re-evaluation

The following Physical or Occupational Therapy initial evaluations will need to be pre-authorized by calling Michele Fairclough at the number listed at the end of this publication:

97161 97162 97163 97165 97165 97167

For physical/occupational therapies, MSF will allow the following codes for a total of 2 units (30 minutes) for the management of home exercise:

97110 97530 97535

We understand that there may be questions regarding different circumstances as we go along.  Please call Michele Fairclough, Director of Medical Services, at 406-495-5362 or Kym Vonada at 406-495-5389 and we will work toward getting these issues resolved.

Montana State Fund and WorkCompEDI have teamed up to maximize electronic submissions for Montana State Fund clients. We have invested a great deal of resources to maximize the value of the partnership.  Montana State Fund bills sent through WorkCompEDI ensure your transactions are received and processed in the most efficient and timely manner.

To sign up, or schedule a web presentation, please call Work Comp EDI at 800-297-6909 or email mt@wcedisupport.com. https://www.workcompedi.com/montanastatefund.

IN THE WORKERS’ COMPENSATION COURT OF THE STATE OF MONTANA 2020 MTWCC 14 WCC No. 2020-5018

Read More – Walters_2020MTWCC14.pdf

With the COVID-19 pandemic being prevalent at this time, Montana State Fund (MSF) has released  recommendations for clinics who are providing telephonic or virtual services to our injured workers during this crisis:

We thank you for being flexible during this time and if you have any questions, please let us know.  We want to thank providers for continuing to see our injured workers in this time of uncertainty and wish everyone safety and wellness!  Please see below for approved telemedicine services for MSF:

Note:  Please use POS 02 in Box 24B of the CMS 1500 form to indicate that the services provided have been via a telephonic/video type method.  The GT modifier may also be applied for audio/video telecommunications.  For timed codes, please document total time spent in the record.

99201 – 99215 Evaluation and Management visits that normally require face to face time will be allowed as audio/video visits.  Documentation does need to support the services billed.

Psychotherapy services

90832:  30 minutes 90834:  45 minutes 90837:  60 minutes

Psychological Evaluations will need to be authorized prior to service by calling Michele Fairclough, Director of Medical Services, at 406-495-5362.

Online Digital Evaluation and Management service, for an established patient, for up to 7 days, cumulative, for up to seven days:

99421:  5-10 minutes 99422:  11-20 minutes 99423:  21 or more minutes

Telephone Evaluation and Management (E/M) services by a physician or other qualified health care professional who may report E/M services provided to an established patient:

99441:  5-10 minutes 99442:  11-20 minutes 99443:  21-30 minutes

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient or episode of care initiated by an established patient:

98966:  5-10 minutes 98967:  11-20 minutes 98968:  21-30 minutes

Qualified non-physician health care professional online digital (non-face to face) E/M service utilizing internet resources for an established patient, for up to 7 days, cumulative time during those 7 days:

98970:  5-10 minutes98971:  11-20 minutes 98972:  21 or more minutes

Physical/Occupational Therapy can use the above codes as applicable; also, MSF will allow the following re-evaluation codes:

97164 – Physical Therapy Re-evaluation 97168 – Occupational Therapy Re-evaluation

The following Physical or Occupational Therapy initial evaluations will need to be pre-authorized by calling Michele Fairclough at the number listed at the end of this publication:

97161 97162 97163 97165 97166 97167

For physical/occupational therapies, MSF will allow the following codes for a total of 2 units (30 minutes) for the management of home exercise:

97110 97530 97535

We understand that there may be questions regarding different circumstances as we go along.  Please call Michele Fairclough, Director of Medical Services, at 406-495-5362 or Kym Vonada at 406-495-5389 and we will work toward getting these issues resolved.

ECHO has been processing provider payments for Rising Medical Solutions on behalf of MSF for the past year. Payments automatically default and are made via Virtual Card.  For providers who are unable to accept payments via Virtual Card or prefer to receive a check or EFT, you will need to contact ECHO at 877-705-4230 and ask to “Opt out”.  This first opt out will only be valid for 300 days.  After 300 days, the payment will revert back to a Virtual Card.

After 300 days, if you still wish a method of payment other than a Virtual Card, you must call ECHO and “Opt Out Permanently”. At that time the change will be permanent unless you choose to change the payment method in the future.

The Montana Department of Labor & Industry (DLI) has published the new Proposed amendments to the Professional and Facility fee schedules.  Hearing information can be found on the DLI website at http://dli.mt.gov/events/calendar.asp.  Highlights of changes are:

Base Rates for Facility:

Inpatient Hospital	$8,909.00
Ambulatory Surgery Center	$       92.00
Outpatient Hospital	$     123.00

Conversion Rates for Professional Services:

Standard	$63.41
Anesthesia	$67.32

99080 – This code will be used to bill when a provider is responding to the Drug Formulary letters.

See http://erd.dli.mt.gov/work-comp-claims/medical-regulations/montana-facility-fee-schedule-agreement​ for the July 2020 Instruction Set for the Facility Fee Schedule and https://mtwc.optum.com/ for the July 2020 Instruction Set for Professional Fee Schedule.  For any questions, contact Celeste Ackerman at 406-444-6604.

Highlighting Reminder – Please do not use a highlighter to draw attention to information that needs to be considered.  It does not scan well and may actually black out the information intended to be noticed.  Use a “star” method or underline/circle the information that you want highlighted.

Time Codes When billing codes where time is an element, the time spent must be documented in the record for each timed code.  This information supports the number of units billed on the CMS 1500 or UB04 billing forms.

Submit Medical Records Submit any medical records to STFMEDICALPROVIDER@MT.GOV .

We are excited to announce that our 2021 medical conference will be held in the Fall of 2021 in Whitefish, MT at the Lodge at Whitefish Lake. This will be the first time we have hosted a medical conference outside of Helena.

This conference promises to have a  dynamic line up of speakers and educational topics.

In the meantime, if you have any questions please contact Shannon Hadley at 406-495-5245.

FINDINGS OF FACT, CONCLUSIONS OF LAW, AND JUDGMENT

Summary: Petitioner suffered a compensable left-leg injury and had surgery to repair his torn quadriceps. Thereafter, Petitioner developed severe low-back pain, with pain radiating into his hips and legs. Petitioner contends that his industrial accident aggravated his preexisting lumbar spine condition. Petitioner relies on the causation opinions of physicians and chiropractors, who in large part based their opinions on Petitioner’s statements that he had an immediate onset of pain from his lumbar spine at the time of his industrial accident or shortly thereafter. Respondent denied liability for Petitioner’s lumbar spine condition, maintaining that his industrial accident did not aggravate his preexisting lumbar spine condition. Respondent relies on the causation opinion of an IME physician, who determined that, based on Petitioner’s medical records, his onset of symptoms was approximately ten months after his industrial accident.

Held: Respondent is not liable for Petitioner’s lumbar spine condition. Although Petitioner’s symptoms significantly worsened after his industrial accident, he did not meet his burden of proving that the industrial accident was the cause of the worsening. This Court gave more weight to the opinion of the IME physician because he was correct that the onset of Petitioner’s symptoms was approximately ten months after his industrial accident.

Neisinger vs New Hampshire Ins. CO.

Summary: Claimant appeals an Amended Order Directing Medical Examination, in which the DLI ordered her to attend a panel IME. Claimant argues that the DLI erred because: (1) it declined her request to allow her to make an audio recording of the history portion of her examination; (2) it did not require the IME provider to send a copy of its report directly to her, despite the provider’s policy not to do so being in violation of § 39- 71-605(2), MCA; and (3) it directed her to attend a panel IME, which she contends is three IMEs, without good cause for “multiple” IMEs.

Held: The Amended Order Directing Medical Examination is affirmed in part and modified in part. The DLI correctly determined that claimant did not have good cause to make an audio recording of the history portion of her examination. The DLI also correctly determined that good cause exists for a panel IME, which is not “multiple” IMEs. However, Claimant is correct that she has a statutory right to a copy of the IME report directly from the IME provider. Thus, the DLI’s order is modified to require the IME provider to provide its report directly to Claimant at the same time it provides it to the Insurer. The Insurer is ordered to file a written declaration from the IME provider that the provider will provide its report directly to Claimant.

Read More
HeffernanvsSafetyNationalCasualty

The designated treating physician is responsible for the coordination and management of all medical care for the injured employee.  Once the provider is designated  the Primary Care Provider (PCP), she/he will be paid 110% of fee schedule and all other non-facility providers will be paid at 90% of fee schedule.  The increased reimbursement rate is to compensate the PCP for the additional responsibilities associated with this role.

ARM 24.29.1513 Documentation Requirements http://www.mtrules.org/gateway/ruleno.asp?RN=24.29.1513

ARM 24.29.1515 Improvement Status http://www.mtrules.org/gateway/RuleNo.asp?RN=24291515

When using time to support a level of service under Evaluation and Management, total time spent face to face with the patient must be documented along with documentation of what was included in the counseling and/or coordination of care.  Simply stating “45 minutes spent with more than 50% being counseling and coordinating care” is not sufficient to support a level 5 established patient visit if the documentation submitted does not otherwise support the service.  Per CPT “the extent of counseling and/or coordination of care must be documented in the medical record”. Physical/Occupational Therapies Rule of 8 and timed modalities – when more than 1 timed modality or therapeutic procedure is utilized during the same encounter, the total minutes spent is combined to determine the # of timed units that may be billed.  For example:  97110 – 8 minutes + 97140 – 9 minutes.  Total time is 17 minutes.  Using the table below, only 1 unit of service is billable:

8 – 22 minutes	1 unit
23 – 37 minutes	2 units
38 – 52 minutes	3 units
53 – 67 minutes	4 units

Time spent on untimed codes such as 97010 or 97014 would not be included in the total calculation as they are not designated as timed modalities although they would count toward the 8 units allowed per visit. Remember:  A total of 8 units of active/passive therapeutic procedures per visit with these exceptions:

• If active/passive therapeutic procedures are utilized:
  • only 2 units may be a passive modality per visit.
• If only passive modalities and/or passive therapeutic procedures are being utilized, only 4 units may be billed per visit.

 

It has been nine months since Rising Medical Solutions (RMS) started reviewing and processing bills for Montana State Fund (MSF).  While we are off to a good start, the following are some of the most common calls we are fielding here at MSF:

1. Bill Status – when calling for bill or reconsideration request status you can contact RMS at 800-274-7464. Their Customer Success staff will be able to help you with questions regarding bill status, reconsideration request status and payment information.
2. Check status – MSF is unable to answer any questions regarding check status. Please call RMS for any questions related check or virtual card status.
3. Crefunds – When a recovery is done on a bill where a payment had previously been made, it will result in an automatic “crefund” from the next payment made. If RMS is unable to recover an overpayment through a crefund, you will be notified of the overpayment and instructed where to send the payment.
4. ECHO – RMS has contracted with ECHO to process payments after the bill review process. Payments are made via Virtual Card.  If you are unable to accept payments via Virtual Card or prefer to receive an actual check, you will need to contact ECHO at 877-705-4230 and ask to “Opt out permanently”.  They will then make that change for you.
5. Frequently Asked Questions – are currently being updated with current information and will be available at: https://montanastatefund.com/web/provider/docs/ProviderQAMedicalBillReviewPaymentProcess.pdf.

Effective for claims arising on or after April 1, 2019. In May 2017, the Montana Legislature passed SB312, authorizing the Montana Department of Labor & Industry to adopt a drug formulary for the workers’ compensation system. The formulary will work in conjunction with the Montana Utilization & Treatment Guidelines and is intended to provide uniformity in prescribing medications to injured workers. Click to read more details. Workers Comp Drug Formulary Flyer

Dry Needling – The Code Dilemma Billing for dry needling tends to bring up questions regarding code selection as there isn’t a code that specifically describes this procedure.  Some publications advise using 97140 (manual therapy techniques) or 97112 (neuromuscular re-education) depending upon the purpose of the service.  Others advise using 97799 (unlisted physical medicine/rehabilitation service or procedure) or 97139 (unlisted therapeutic procedure).  Montana State Fund has determined that 97139 may be billed for dry needling services when billing Montana State Fund.   NOTE:  This is only a Montana State Fund recommendation and may be different from other carriers. Physical Therapy Timed Codes Time is an element of many physical rehabilitation modalities and procedure codes.  When billing these services, time for each timed code must be documented in the record to support what is billed.  If the time spent on a timed code is less than 8 minutes and is not the only timed service billed, then the time can be added to the total time to determine the number of units that can be billed: 8-22 minutes = 1 unit 23-37 minutes = 2 units 38-52 minutes = 3 units 53-67 minutes = 4 units etc Note:  Please bill for services provided – do not combine total time and bill for the highest reimbursed service only, this will result in a denial. When more than one service of a timed modality is performed in a single day, the total minutes of the service performed should be included in the patient record to substantiate the level of service.  A total of 8 units of active and passive therapy may be billed per visit.  If active therapy is being applied, only two units of a passive modality may be included in the 8 units.

• Passive therapies (listed in U&T Guidelines) will be limited to 4 units per visit, if only passive therapy is being applied.  Note:  Only 2 units may be billed if active therapy is being applied.
• All timed codes must have the actual time spent documented (in minutes) in the office notes submitted for each code billed for reimbursement.

Therapy codes billed must have part of body documented or it must be clearly identified in a flow sheet or other attached documentation and must be related to the injury. If the procedures are clearly documented in the notes, a flow sheet is unnecessary. If the notes do not support the procedures billed but refers to a flow sheet, please include the flow sheet with the bill and other documentation. Rule of Eights:  Providers are allowed a total of 8 units of active/passive therapeutic procedures per visit with these exceptions:

• If active/passive therapeutic procedures are utilized:
  • only 2 units may be a passive modality per visit.

• If only passive modalities and/or passive therapeutic procedures are being utilized, only 4 units

may be billed per visit. NOTE:  If a physical therapy/modality is not listed in the Utilization and Treatment Guideline (U&T) or goes over the maximum threshold, be sure to get pre-authorization.   Passive Modalities

CPT Code	Description
97010	Hot or cold packs – one or more regions
97012	Traction – mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy (e.g. microwave)
97026	Infrared
97028	Ultraviolet
97032	Electrical stimulation (manual) one or more areas, ea 15 minutes
97033	Iontophoresis, ea 15 minutes
97034	Contrast Baths, ea 15 minutes
97035	Ultrasound, ea 15 minutes
97036	Hubbard tank, ea 15 minutes
97039	Unlisted modality, specify type and time if constant attendance

  Active/Passive Therapeutic Procedures:

CPT Code	Description	Passive or Active
97110	Therapeutic Procedure, 1 or more areas, ea 15 minutes.  Therapeutic exercises to develop strength, endurance, range of motion and flexibility.	Active
97112	Neuromuscular re-education, ea 15 minutes	Active
97113	Aquatic therapy with therapeutic exercises, ea 15 minutes	Active
97116	Gait training (includes stair climbing), ea 15 minutes	Active
97124	Massage, ea 15 minutes	Passive
97139	Unlisted therapeutic procedure.  ** Passive or Active will depend upon the procedure.	Passive or Active**
97140	Manual therapy, ea 15 minutes.  NOTE:  This is passive unless billed with an active procedure – in that case it would be considered active.	Passive
97150	Therapeutic procedure(s), group (2 or more individuals)	Active
97530	Therapeutic activities, direct (one-on-one) pt contact, ea 15 minutes.	Active
97532	Development of cognitive skills to improve attention, memory, problem solving, direct (one-on-one) pt contact, ea 15 minutes.	Active
97533	Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) pat contact, ea 15 minutes.	Active
97535	Self-care/home management training, direct (one-on-one) pt contact, ea 15 minutes.	Active
97537	Community/Work reintegration training, direct (one-on-one) pt contact, ea 15 minutes.	Active
97542	Wheelchair management ea 15 minutes	Active
97545	Work hardening/conditioning, initial 2 hours	Active
97546	Work hardening/conditioning, ea addl hour	Active
97799	97799 Unlisted physical medicine/rehabilitation service or procedure.  **Passive or Active will depend upon the procedure.	Passive or Active**
98940	Chiropractic manipulative treatment, spinal 1-2 regions	Passive
98941	Chiropractic manipulative treatment, spinal 3-4 regions	Passive
98942	Chiropractic manipulative treatment, spinal 5 regions	Passive
98943	Extraspinal, 1 or more regions	Passive

   

Work Comp EDI
Now that we are up and running with Rising Medical Solutions (RMS), electronic billing is an option for those providers who want to switch from paper billing.  To get signed up please call Work Comp EDI at 800-297-6909 or email mt@wcedisupport.com. https://www.workcompedi.com/montanastatefund

ECHO
Rising Medical Services has contracted with ECHO for provider payments.  The default payment method under ECHO is the ECHO Mastercard.  Providers can opt out of this method and continue to get paid by check or EFT but you will need to call ECHO directly at (877) 705-4230 or go to their website.

Please continue to submit bills and records to:
Montana State Fund
PO Box 4759
Helena, MT  59604

Status Requests/Re-evaluation Requests
When checking bill status of a current bill or requesting a reconsideration of a bill that has been previously processed, please contact Rising Medical Solutions at 866-274-7464.

Highlighting Revisited
If a line or an item needs to be “showcased or noted” on a document MSF recommends that a circle or a line and arrow be used.  Highlighting scans as a blackout so the information cannot be read.  Red ink or pencil is dropped out of any document sent through Optical Character Recognition (OCR) scanning process.

Multiple Page Bills
When submitting a multiple page bill (CMS 1500/HCFA only) with a total on each page, be sure to submit them separately with the corresponding notes attached for each bill.  Submitting these as a group with the attached notes delay processing as the bills are returned to MSF to separate the bills and notes and get them rescanned for processing.  If you want to send them as a multiple page bill, do not total each page, add the total of all bills on the last page and indicate on each bill page that it is page 1 of XX (# of bills) to indicate it is a multiple page bill.

FINDINGS OF FACT, CONCLUSIONS OF LAW, AND JUDGMENT

Summary:  Petitioner asserts that he injured his shoulder in an industrial accident in which a rung on a ladder broke, causing him to fall down and backwards, partially into a crawlspace.  Respondent denied liability, at first because Petitioner’s medical providers did not identify any objective medical evidence of a shoulder injury.  Respondent then relied on the opinion of its IME physician, who determined that while there is objective medical evidence of a shoulder injury or disease, there is no mechanism of a shoulder injury and that the time between the accident and the onset of Petitioner’s shoulder pain is too great to support a causal relationship.

Held:  Petitioner injured his left shoulder in his industrial accident.  Respondent’s IME physician failed to take an accurate history and, as a result, did not understand that the Petitioner used his arms to arrest his backwards fall.  Respondent’s IME physician also did not understand that Petitioner reported shoulder pain immediately after his fall and suffered shoulder pain again within two weeks of his fall.  Thus, this Court gave more weight to the evidence from the orthopedist treating Petitioner’s shoulder, which is sufficient to prove on a more-probable-than-not basis that Petitioner injured his shoulder in the fall.

Read More: Pate_2019MTWCC2 (1)

Thank you to all who attended our 19th Annual Medical Conference. Please find the  2019 Medical Conference Program from the two-day event. You can also review all of the speaker presentations on our website.

Mark your calendar for next year’s conference scheduled for May 7-8, 2020 in Helena.

ORDER DENYING RESPONDENT’S MOTION FOR SUMMARY JUDGMENT AND GRANTING PETITIONER’S MOTION FOR SUMMARY JUDGMENT

Summary: Respondent moved for summary judgment, asserting that Petitioner’s medical benefits terminated under the 60-month rule at § 39-71-704(1)(f), MCA (2005). It is undisputed that Petitioner saw his treating physician within the 60-month period, but his physician’s office made a mistake and did not bill Respondent for the appointment within the 60-month period. Because Petitioner’s physician did not send Respondent the bill, Respondent asserts that the appointment does not constitute use of medical benefits. Petitioner moved for summary judgment, arguing that he used his medical benefits within the 60-month period by obtaining treatment from his physician, and that he cannot suffer a consequence because of his physician’s office’s mistake in failing to bill Respondent for the appointment.

Held: Respondent’s Motion for Summary Judgment is denied, and Petitioner’s Motion for Summary Judgment is granted. Petitioner used his medical benefits within the 60-month period when he saw his treating physician for treatment. As a matter of law, the physician’s office had the duty to bill Respondent, and Petitioner cannot suffer a consequence because of his physician’s office’s mistake in failing to bill Respondent.

Click to view entire case: Westre vs LibertyNorthwest

Montana State Fund will hold our 19^th annual medical conference May 16 – May 17, 2019 in Helena at the Delta Hotels Colonial. More details about the conference will be coming after the new year.

If you have any questions please contact Shannon Hadley at 406-495-5245.

In May 2017, the Montana Legislature passed SB312, authorizing the Montana Department of Labor & Industry (DOLI) to adopt a drug formulary for the workers’ compensation system. The formulary will work in conjunction with the Montana Utilization & Treatment Guidelines and is intended to provide uniformity in prescribing medications to injured workers. This new drug formulary will affect claims arising on or after April 1, 2019.

Education
To educate providers, MSF and DOLI are holding two informative drug formulary medical forums in December.

December 12 – Helena: Webinar hosted at Montana State Fund  – 11:30 am – 1:00 pm. (More details coming soon)

December 18 – Great Falls: Holiday Inn (1100 5th Street) 11:30 am – 1:00 pm.

For information about our educational opportunities, contact MSF Provider Relations Specialist Shannon Hadley at 406-495-5245.

The NPI is a required element for all bill types. A provider can obtain the number by contacting the National Plan and Provider Enumeration System (NPPES). When a bill is input in the system for processing, a validation process is used.  If you have been receiving denials due to an NPI issue, the following may be the reason:

1. Rendering provider NPI missing – this means that the individual NPI for the actual service provider is missing from Box 24J of the CMS 1500 form;
2. Rendering provider NPI incorrect – The NPI entered in Box 24J of the CMS 1500 form does not match the actual service provider submitted in the documentation. The NPI used must be that of the provider who has provided the service and signed the medical record;
3. Practice Provider NPI missing or does not match – this NPI is required in Box 32a of the CMS 1500 form and must match or closely match the name that is registered on the NPPES website. Exception is if the Place of Service is 12 (home) in Box 24B;
4. Billing Provider NPI is missing or does not match – this NPI is required in Box 33a of the CMS 1500 form and must match or closely match the name that is registered on the NPPES website;
5. Attending Provider NPI missing or does not match – the attending provider NPI in Box 76 of the UB04 form is required for all services. This should be the NPI of the attending provider or the provider responsible for the care of the patient.

Please see the NPPES website for more information.

Effective January 1, 2019, Rising Medical Solutions (RMS) will be our new bill review and payment vendor. We believe this partnership will make the bill review process timelier and more accurate for our providers and claim examiners. One major enhancement that RMS offers, is the ability for electronic billing and the issuance of electronic funds transfer payments.

In addition, RMS is staffed with Certified Professional Coders (CPC’s) and nursing staff which we expect to mean a higher level of accuracy when reviewing your bills for payment.

We are working hard to ensure a smooth and easy transition with as little interruption and changes to your business processes as possible.

Below is a transition timeline

• Up to December 15, 2018: Providers continue to contact CONDUENT/ACS about payment status or bill review. Contact CONDUENT/ACS at 888-208-2116 or by emailing: MSFBillReviewInquiries@Conduent.com.
• December 15 – 31, 2018: Contact Montana State Fund directly at 406-495-5011 about payment status or bill review :CONDUENT/ACS (our current vendor) will cease bill review services and the processing of bills and payments. (Completion of our billing process with them is 12/31/18).
• January 1, 2019: Rising Medical Solutions (RMS) will begin automated and standardized bill review and payment services to MSF. (We will provide RMS contact information in the future).
• 2018 1099’s:  ACS/Conduent will process them.

Click to view Medical Bill Review FAQ

If you have any further questions about the change from Conduent/ACS to RMS, please contact Michele Fairclough at 406-495-5362.

Thank you to all who attended our 18th Annual Medical Conference. Please find the  Medical Conference Program from the two-day event. You can also review all of the speaker presentations on our website.

Mark your calendar for next year’s conference scheduled for May 16-17, 2019 in Helena.

Montana State Fund has entered into a contract with Rising Medical Solutions for medical bill review and payment services. During the next few months MSF will be working with Rising to insure that we have a seamless transition from ACS/Conduent. We anticipate the transition will be complete in December of this year. Our hope is that this implementation will be very smooth and not interrupt or change your business processes. Some of the enhancements that Rising offers are the ability to electronically bill, issue EFT payments and a faster, more streamlined process. You will be receiving updates and information from Montana State Fund and Rising in the coming months but, if you have any questions please do not hesitate to contact Michele Fairclough at 406-495-5362.

Bill Status
Please contact Conduent (previously ACS) for Bill Status. Please give 30 days before seeking a bill status or sending in a rebill.  If you are not satisfied with the information from Conduent or have further questions that they are unable to answer, please call MSF.

ACS/Conduent: 1-888-208-2116 or
Email MSFBillReviewinquiries@conduent.com

Montana State Fund
Medical Auditors – 800-332-6012 ext 5011

Bill Changes
If a correction is made to a bill, please be sure the mark the bill as corrected, attach a copy of the Explanation of Review (EOR) if it has already been processed and the records if required.  The corrected bill should include any other lines that were billed with the corrected line even if they have been paid.  This keeps the integrity of the bill intact and makes it easier for processing the change.

Resubmissions
Please wait 30 days before resubmitting a bill for processing after the original submission has been sent unless you have already received an EOR. This allows Conduent ample time to process the bill and will prevent multiple bills for the same services from slowing down the processing function.  You can also call Conduent for a Bill Status check prior to resubmission to see if the bill is in review.

If you are submitting a reconsideration request with additional information or for another reason, please attach a copy of the EOR with the information and/or indicate the reason for the request. Please do not use a highlighter to indicate items or changes as these will scan black.  Use a pen to “circle” or “star” an item you need noted.

Send the requests to:

Montana State Fund
PO Box 4759
Helena, MT  59604

MSF is still receiving a high number of incomplete ICD-10 diagnosis codes. ICD-10 has been in effect since 10/1/2015.  Most of the incomplete ICD-10 we receive are missing the 4^th, 5^th, 6^th or 7^th characters which add a level of specificity to each code.  Codes are 3 to 7 characters (alpha numeric) with a place holder character of X used in many codes to keep open for expansion for future updates.

Correct and complete ICD-10 diagnosis codes are important to MSF for reporting requirements as well as having accurate information for meeting the needs of employers, injured workers and providers.

The Department of Labor & Industry (DLI) updated the fee schedules effective 7/1/18:

Professional Conversion Factors 2018

Standard	$63.50
Anesthesia	$66.97

               Facility Base Rates 2018

Hospital Inpatient	$8,373.00
Hospital Outpatient	$   116.00
Ambulatory Surgery Center	$     87.00

For additional information, please see the DLI website: http://erd.dli.mt.gov/.  Contact Celeste Ackerman at 406-444-6604.

Physical, Occupational and Chiropractic therapies are the cornerstone for healing for many injured workers. This function plays an important role in getting workers back on the job and feeling better.  Department of Labor & Industry posts Instruction sets for physical rehabilitation (see below for website links).  These should be used in conjunction with the Montana Utilization and Treatment Guidelines (U&T) at http://mtguidelines.com/.

Montana Professional Fee Schedule
https://mtwc.optum.com/documentations/2018ProfessionalFeeScheduleInstructionFinalafterRules.pdf

Montana Facility Fee Schedule
http://erd.dli.mt.gov/Portals/54/Documents/Work-Comp-Claims/Medical-Regs/FacilityFeeSchedules/FY2019/2018FacilityFeeScheduleInstructionSet.pdf.

Services should be within the Utilization and Treatment Guidelines at www.mtguidelines.com.

If a physical therapy/modality is not listed in the Utilization and Treatment Guideline (U&T) or goes over the maximum threshold, services must be pre-authorized by Montana State Fund.   Treatment should be directly related to the accepted part of body unless pre-authorized.

Timed Modalities (also applies to Facility services effective 7/1/2014) Services of less than 8 minutes when that is the only service performed during a visit is not billable. Time intervals are incremented in 15 minute units (base is 8 minutes):

8-22 minutes =             1 unit

23-37 minutes =           2 units

38-52 minutes =            3 units

53-67 minutes =           4 units etc

When more than one service of a timed modality is performed in a single day, the total minutes of the service performed should be included in the patient record to substantiate the level of service. A total of 8 units of active and passive therapy may be billed per visit.  If active therapy is being applied, only two units of a passive modality may be included in the 8 units.

Passive therapies (listed in U&T Guidelines) will be limited to 4 units per visit, if only passive therapy is being applied. Note:  Only 2 units may be billed if active therapy is being applied.

All timed codes must have the time documented (in minutes) in the office notes submitted for each code billed for reimbursement.

Therapy codes billed must have part of body documented or it must be clearly identified in a flow sheet or other attached documentation. If the procedures are clearly documented in the notes, a flow sheet is unnecessary. If the notes do not support the procedures billed but refers to a flow sheet then the flow sheet must be attached.

Passive vs Active

Passive modalities utilize a tool to cause an effect (i.e. electrical stimulation, hot/cold packs, iontophoresis, ultrasound, etc.).

Passive therapeutic procedures are procedures that do not require energy on the part of the patient (i.e. massage, manual therapy, etc.) and are considered with the active therapy for purposes of the rule of Eights.

Passive Modalities

CPT Code	Description
97010	Hot or cold packs – one or more regions
97012	Traction – mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy (e.g. microwave)
97026	Infrared
97028	Ultraviolet
97032	Electrical stimulation (manual) one or more areas, ea 15 minutes
97033	Iontophoresis, ea 15 minutes
97034	Contrast Baths, ea 15 minutes
97035	Ultrasound, ea 15 minutes
97036	Hubbard tank, ea 15 minutes
97039	Unlisted modality, specify type and time if constant attendance

Active/Passive Therapeutic Procedures:

CPT Code	Description	Passive or Active
97110	Therapeutic Procedure, 1 or more areas, each 15 minutes. Therapeutic exercises to develop strength, endurance, range of motion and flexibility.	Active
97112	Neuromuscular re-education	Active
97113	Aquatic therapy with therapeutic exercises	Active
97116	Gait training (includes stair climbing)	Active
97124	Massage	Passive
97139	Unlisted therapeutic procedure. ** Passive or Active will depend upon the procedure.	Passive or Active**
97140	Manual therapy, ea 15 minutes. NOTE: This is passive unless billed with an active procedure – in that case it would be considered active.	Passive
97150	Therapeutic procedure(s), group (2 or more individuals)	Active
97530	Therapeutic activities, direct (one-on-one) pt contact, ea 15 minutes.	Active
97532	Development of cognitive skills to improve attention, memory, problem solving, direct (one-on-one) pt contact, ea 15 minutes.	Active
97533	Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) pat contact, ea 15 minutes.	Active
97535	Self-care/home management training, direct (one-on-one) pt contact, ea 15 minutes.	Active
97537	Community/Work reintegration training, direct (one-on-one) pt contact, ea 15 minutes.	Active
97542	Wheelchair management ea 15 minutes	Active
97545	Work hardening/conditioning, initial 2 hours	Active
97546	Work hardening/conditioning, ea addl hour	Active
97799	97799 Unlisted physical medicine/rehabilitation service or procedure. **Passive or Active will depend upon the procedure.	Passive or Active**
98940	Chiropractic manipulative treatment, spinal 1-2 regions	Passive
98941	Chiropractic manipulative treatment, spinal 3-4 regions	Passive
98942	Chiropractic manipulative treatment, spinal 5 regions	Passive
98943	Extraspinal, 1 or more regions	Passive

2018 MTWCC 9; WCC No. 2017-4143

 Neisinger Case

Order Reversing in Part and Affirming in Part Order Directing a Medical Examination

Summary:  Claimant appeals an Order from the DLI directing him to attend a § 39-71-605, MCA, examination with a psychiatrist and an orthopedist.  Claimant asserts that the DLI did not have jurisdiction to order him to attend an IME.  Claimant also asserts the Insurer, which has not authorized him to see a treating psychiatrist or psychologist, is “stacking the deck” with “hired guns,” and that Insurer foes not have good cause for multiple IMEs.  Insurer asserts that the DLI correctly ordered the examination with the psychiatrist because one of Claimant’s treating physician referred him to a psychiatrist or psychologist.  Insurer also asserts that the DLI correctly ordered the examination with the orthopedist because Claimant’s condition has changed.

Held:  The DLI’s order is reversed in part and affirmed in part.  The DLI had jurisdiction.  However, Insurer does not currently have good cause for an IME with the psychiatrist.  Because of the potential for bias, an insurer may not force a claimant to attend an IME with a Psychiatrist of its choosing, who will provide no treatment.  To balance a claimant’s rights with an insurer’s rights, the insurer must first authorize a treating psychiatrist or psychologist.  Insurer has good cause for an IME with the orthopedist because Claimant’s condition has arguably changed, the previous IME was two years ago, and Claimant’s treating physicians can comment on the IME physician’s opinions.

A Request for Proposal (RFP) for medical bill review services was issued on November 1, 2017.  All submitted proposals received have been reviewed.  MSF is currently in the final selection process and will update providers once a decision has been made.  As stated before, MSF will work to make the process as seamless as possible as we transition to the new Bill Review vendor.

If you have further questions, contact Michele Fairclough at 406-495-5362.

On June 28, 1996, the Workers’ Compensation Court entered findings of fact, conclusions of law and judgment denying Petitioner/Appellant Joe Yarborough (Yarborough) compensation and medical benefits for an alleged work-related injury aswell as attorney fees, costs and a penalty. Yarborough appeals only that portion of the judgment denying him compensation and medical benefits for his alleged work-related injury. Read more.

Please do not use a highlighter to draw attention to pertinent information as it turns black during the scanning process. Use a black or blue pen and “star”, circle or underline to indicate the information that is being referenced.  Do not use a red pen as the scanner drops anything that is in red or pink. We appreciate your help on this.

CORRECTED BILLS
When submitting a corrected bill (CMS 1500 or UB04), please mark the bill “CORRECTED BILL” to indicate that there has been a change to the original billing. Please include a copy of the EOR and any records to support the charges.

RESUBMISSIONS
If multiple services were billed on a CMS 1500 but not all services were paid, please resubmit the original bill with the additional information or reason that you are requesting reconsideration. Do not bill those lines on a new bill or add them to a new billing.  This will maintain the integrity of the original billing and reduce denials for duplicate charges.  Submit your request with a copy of the EOR and records or information to support the request.

ADDITIONAL RECORDS
When submitting additional records, please attach a copy of the bill, the EOR and the request for reconsideration and mail to:

MONTANA STATE FUND
PO BOX 4759
HELENA, MT  59604

ICD-10 diagnosis codes are extremely important to MSF for a variety of reasons. We continue to receive bills with incomplete codes.  ICD-10 codes are 3-7 characters (alpha and numeric).  Some codes require a 6^th or 7^th character in order to be complete.   Codes that require additional characters in order to be complete are indicated in the ICD-10 manual with a check mark inside a red box.  Make sure when submitting your bills that the complete ICD-10 code has been chosen.

Evidence Based Medicine: New Opportunities to Improve Outcomes is the theme for Montana State Fund’s 18th annual medical conference, May 31 – June 1, 2018 in Helena.

Topics for the event include:

• Lumbar Fusion in Workers’ Compensation
• Hot Clinical Topics: CRPS, PTSD, Concussion
• The Ethical Dilemma: Patient Advocacy and Medical Science
• Epidemiology in the Courtroom
• ODG Guidelines
• Orthopaedic Updates of Interest
• Causation Utilizing Evidence-Based Medicine
• AMA Guides
• Current Topics in the Worker’s Compensation Court

View the full agenda

Continuing education credits, continuing medical education (CME) and other continuing education credits will be available.

Registration costs include:

• One Day Registration = $160 (Thursday 5/31 or Friday 6/1)
• Full Conference Registration = $190
• Conference Day Registation = $225

For more details, or to register, go to medical conference website.

If you need additional information please contact, Shannon Hadley, Provider Relations Specialist or call 406-495-5245