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Physician Manual

This manual is for Physicians, Mid-Level Practitioners, Podiatrists, Laboratories, Imaging Facilities, Independent Diagnostic Testing Facilities, Public Health Clinics, and Family planning Clinics.  The Manual details billing procedures for Medicaid and Other medical assistance programs.

This publication supersedes all previous Physician, Mid-Level Practitioner, Podiatrist, Laboratory,Imaging Facility, Independent Diagnostic Testing Facility, Public Health Clinic, Family Planning Clinic, EPSDT, and Well-Child Services provider handbooks. Published by the Montana Department of Public Health & Human Services, July 2002.

Updated September 2002, January 2003, June 2003, August 2003, September 2003, December 2003, July 2004, September 2004, November 2004, January 2005, March 2005, September 2005, April 2006, July 2006, March 2008, April 2010, March 2012, July 2014, August 2015, and August 2016. 

CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
 

 

Key Contacts

For a list of contacts and websites, see the Contact Us link in the menu on the Montana Healthcare Programs Provider Information website.

Introduction

Introduction

Thank you for your willingness to serve members of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services.


Manual Organization


This manual provides information specifically for physicians, mid-level practitioners, podiatrists, public health clinics, family planning clinics, independent laboratories independent imaging facilities, and independent diagnostic testing facilities.  

Most chapters have a section titled Other Programs that includes information about other Department programs such as the Mental Health Services Plan (MHSP) and  Healthy Montana Kids (HMK)/CHIP. Other essential information for providers is contained in the separate General Information for Providers manual. Each provider is asked to review both manuals.

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes.  There is a list of contacts on the Contact Us page on the Provider Information website.


Manual Maintenance

Manuals must be kept current. Changes to manuals are provided through provider notices and weekly web posting list published on Fridays. Older manuals are available through the Montana State Library Archive.

Rule References

Providers are responsible for knowing and following current laws and regulations.

Providers, office managers, billers, and other medical staff must be familiar with  current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office.

In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are also applicable to the physician related services programs:

  • Code of Federal Regulations (CFR)
    • 42 CFR 410 Supplementary Medical Insurance (SMI) Benefits
    • 42 CFR 440 Services: General Provisions
    • 42 CFR 441 Services: Requirements and Limits Applicable to Specific Services
  • Montana Code Annotated (MCA)
    • MCA Title 37-2-101 – 37-2-313 General Provisions Relating to Healthcare Practitioners
    • MCA 37-3-101 – MCA 37-3-405 Medicine
    • MCA 37-6-101 – MCA 37-6-312 Podiatry
    • MCA 37-14-101 – MCA 37-14-102 Radiologic Technologists
    • MCA 37-34-101 – MCA 37-34-307 Clinical Lab Science Practitioners
  • Administrative Rules of Montana (ARM)
    • ARM 37.85.220 Independent Diagnostic Testing Facilities
    • ARM 37.86.101 – ARM 37.86.105 Physician Services
    • ARM 37.86.201 – ARM 37.86.205 Mid-Level Practitioner Services
    • ARM 37.86.501 – ARM 37.86.506 Podiatry Services
    • ARM 37.86.3201 – ARM 37.86.3205 Non-Hospital Laboratory and   Radiology (X-Ray) Services
    • ARM 37.86.1401 – ARM 38.86.1406 Clinic Services

Claims Review (MCA 53-6-111, ARM 37.85.406)

The Department is committed to paying Medicaid providers’ claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid, and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by Federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause (42 CFR 456.3).

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, provider relations, or a prior authorization unit). Key contacts and websites, Medicaid manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information  website.

Covered Services

Covered Services

General Coverage Principles

Montana Medicaid covers almost all services provided by physicians, mid-level practitioners, and podiatrists, including preventive care.

This chapter provides covered services information that applies specifically to services performed by physicians, mid-level practitioners, podiatrists, mid-level practitioners within public health clinics, family planning clinics, independent labs, independent imaging facilities, and independent diagnostic testing facilities. Like all healthcare services received by Medicaid members, services provided by these practitioners must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual. 

Services within Scope of Practice (ARM 37.85.401)

Services are covered only when they are within the scope of the provider’s license. As a condition of participation in the Montana Medicaid program, all providers must comply with all applicable state and federal statutes, rules, and regulations.

Services Provided by Physicians (ARM 37.86.101–105)

Physician services are those services provided by individuals licensed under the State Medical Practice Act to practice medicine or osteopathy, which as defined by state law, are within the scope of their practice.

Services Provided by Mid-Level Practitioners (ARM 37.86.201–205)

Mid-level practitioners include physician assistants licensed to practice medicine by the Montana Board of Medical Examiners and advanced practice registered nurses licensed to practice medicine by the Montana Board of Nursing. Advanced practice registered nurses include nurse anesthetists, nurse practitioners, clinical nurse specialists, and certified nurse midwives. Mid-level practitioners also include practitioners outside Montana who hold appropriate licenses in their own states. A mid-level practitioner must bill under his/her own NPI and taxonomy code, rather than under a physician’s. See the Billing Procedures chapter in this manual.

Services Provided by Podiatrists (ARM 37.86.501–506)

Podiatry services are those services provided by individuals licensed under state law to practice podiatry. Refer to Routine Podiatric Care in this chapter and the podiatrist fee schedule on the Provider Information website for specific covered services.

Services Provided by Independent Labs (ARM 37.86.3201–3205)

Medicaid covers tests provided by independent (non-hospital) clinical laboratories when the following requirements are met:

  • Services are ordered and provided by physicians, dentists, or other providers licensed within the scope of their practice as defined by law. Medicaid does not cover lab services ordered by chiropractors.  
  • Services are provided in an office or other similar facility, but not in a hospital outpatient department or clinic.
  • Providers of lab services must be Medicare-certified.
  • Providers of lab services must have a current Clinical Laboratory Improvement Amendments (CLIA) certification number. CLIA certification may be obtained in Montana through the Department. See the Contact Us link in the menu on the Provider Information website.
  • Medicaid does not cover reference lab services. Providers may bill Medicaid only for those lab services they have performed themselves.  Modifier 90, used to indicate reference lab services, is not covered by Medicaid.

Services Provided by Independent Imaging Facilities  (ARM 37.86.3201–3205)

  • Medicaid covers tests provided by independent (non-hospital) imaging facilities when the following requirements are met:
  • Services are ordered and provided by physicians, dentists, or other providers licensed within the scope of their practices as defined by law.
  • Services are provided in an office or similar facility, but not in a hospital outpatient department or clinic.
  • Imaging providers must be supervised by a physician licensed to practice medicine within the state the services are provided.
  • Imaging providers must meet state facility licensing requirements. Facilities must also meet any additional federal or state requirements that apply to specific tests (e.g., mammography). All facilities providing screening and diagnostic mammography services are required to have a certificate issued by the Federal Food and Drug Administration (FDA). For more information contact the FDA at 1-800-838-7715.
  • For most imaging services and some other tests, the fee schedules show different fees depending on whether the practitioner provided only the technical component (performing the test), only the professional component (interpreting the test), or both components (also known as the global service). Practitioners must bill only for services they provided.
  • Technical components of imaging services must be performed by appropriately licensed staff (e.g., x-ray technician) operating within the scope of their practice as defined by state law and under the supervision of a physician.

Services Provided by Independent Diagnostic Testing Facilities  (ARM 37.85.220)

  • Medicaid covers diagnostic testing services provided by independent diagnostic testing facilities (IDTF) under the supervision of a physician. (See the IDTF fee schedule.)

  • Services may be performed in either a fixed location or mobile facility, but must be independent of a hospital.

  • Before enrolling in Medicaid, IDTFs must be enrolled in Medicare.

Services Provided by Public Health Clinics (ARM 37.86.1401–1406)
Public health clinic services are physician and mid-level practitioner services provided in a clinic designated by the Department as a public health clinic.  
Services must be provided directly by a physician or by a public health nurse under a physician’s immediate supervision (i.e., the physician has seen the patient and ordered the service).
Minimal services are covered when provided by a registered nurse operating under protocols. These services do not require that the physician see the patient.  
Non-Covered Services (ARM 37.85.207 and ARM 37.86.205)
Some services not covered by Medicaid include the following:
Acupuncture
Naturopath services
Surgery for weightloss (gastric bypass, banding and other bariatric surgery)
Services provided by surgical technicians who are not physicians or mid-level practitioners
Services considered experimental or investigational
Services provided to Medicaid members who are absent from the state, with the following exceptions:
Medical emergency
Required medical services are not available in Montana. Prior authorization may be required. See the Prior Authorization chapter in this manual and the Prior Authorization Information page on the Provider Information website.
The Department has determined that the general practice for members in a particular area of Montana is to use providers in another state.
Out-of-state medical services and all related expenses are less costly than in-state services. Check the physician’s fee schedule to determine if the code is covered.
Montana makes adoption assistance or foster care maintenance payments for a member who is a child residing in another state.
Medicaid does not cover services that are not direct patient care such as the following:
Missed or canceled appointments
Mileage and travel expenses for providers
Preparation of medical or insurance reports
Service charges or delinquent payment fees
Telephone services in home
Remodeling of home
Plumbing service
Car repair and/or modification of automobile
Importance of Fee Schedules
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type. Fee schedules list Medicaid covered codes and provide clarification of indicators such as whether a code requires prior authorization, can be applied to a co-surgery, or can be billed bilaterally, etc. In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the CPT, HCPCS, and ICD coding books. Take care to use the fee schedule and coding books that pertain to the date of service.

Fee schedules are available on the Provider Information website.
Coverage of Specific Services
The following are coverage rules for specific services provided by physicians, mid-level practitioners, and podiatrists.
Abortions (ARM 37.86.104)
Abortions are covered when one of the following conditions is met:
The member’s life would be endangered if the fetus is carried to term.
The pregnancy is the result of rape or incest.
The abortion is determined by the attending physician to be medically necessary, even if the member’s life is not endangered if the fetus is carried to term.

A completed Medicaid Healthcare Programs Physician Certification for Abortion Services (MA-37) form must be submitted with every abortion claim or payment will be denied. This form is the only form Medicaid accepts for abortion services. Complete only one section of this form.

When using mifepristone (Mifeprex or RU 486) to terminate a pregnancy, it must be administered within 49 days from the beginning of the last menstrual period by or under the supervision of a physician who:
Can assess the duration of a pregnancy.
Can diagnose ectopic pregnancies.
Can provide surgical intervention in cases of incomplete abortion or severe bleeding, or can provide such care through other qualified physicians.
Can assure access to medical facilities equipped to provide blood transfusion and resuscitation.
Has read, understood, and explained to the member the prescribing information for mifepristone.
Cosmetic Services (ARM 37.86.104)
Medicaid covers cosmetic services only when the condition has a severe detrimental effect on the member’s physical and psychosocial well-being. Mastectomy and reduction mammoplasty services are covered only when medically necessary. Medical necessity for reduction mammoplasty is related to signs and symptoms resulting from macromastia. Medicaid covers surgical reconstruction following breast cancer treatment. Before cosmetic services are performed, they must be prior authorized. Services are authorized on a case-by-case basis. (See the Prior Authorization Information on the Contact Us link on the Provider Information website.)
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services (ARM 37.86.2201–2235) Program
The EPSDT program covers all medically necessary services for children ages 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages. (See the EPSDT Well-Child chapter in the General Information for Providers manual.) Some services are covered for children that are not covered for adults, such as the following:
Nutritionist services
Private duty nursing
Respiratory therapy
Therapeutic family and group home care
Substance dependency inpatient and day treatment services
School-based services

All prior authorization and Passport approval requirements must be followed. See the Prior Authorization chapter in this manual and the Passport to Health  manual.  
Family Planning Services (ARM 37.86.1701)
Family planning services include the following:
Annual visit
Comprehensive history
Initial physical examination
Initial visit
Laboratory services
Medical counseling
Routine visits

Medicaid covers prescription contraceptive supplies, implantation, or removal of subcutaneous contraceptives, and fitting or removal of an IUD and fitting of a diaphragm. Approval by the Passport provider is not required for family planning services. See the Submitting a Claim chapter in this manual for Passport indicators. Specific billing procedures must be followed for family planning services. (See Billing Procedures.)
Home Obstetrics (ARM 37.85.207)
Home deliveries are only covered on an emergency basis by a physician or licensed midwife. Home deliveries are those delivery services not provided in a licensed healthcare facility or nationally accredited birthing center and necessary to protect the health and safety of the woman and fetus from the onset of labor through delivery.
Immunizations
The Vaccines for Children (VFC) program makes selected vaccines available at no cost to providers for eligible children 18 years old and under. Medicaid will therefore pay only for the administration of these vaccines (oral, nasal, or injection) and only the federal mandated rate. VFC covered vaccines may change from year to year. For more information on the VFC program and current VFC covered vaccines, call the Department’s Immunization program at 406-444-5580, or refer to the most recent VFC provider notice.

Medicaid does not cover pneumonia and flu vaccines for members with Medicare Part B insurance because Medicare covers these immunizations. Other vaccines for Medicare patients should be billed through Medicare Part D.
Infertility (ARM 37.85.207)
Medicaid does not cover treatment services for infertility, including sterilization reversals.
Prescriptions (ARM 37.86.1102)
For detailed information about prescription drugs, refer to the Prescription Drug Program manual on the Pharmacy page of the website.

The DUR Board has set monthly limits on certain drugs. Use over these amounts requires prior authorization. Refer to the Prior Authorization chapter of the Prescription Drug Program manual for limits.
Routine Podiatric Care
Medicaid pays for routine podiatric care when a medical condition affecting the legs or feet (such as diabetes or arteriosclerosis obliterans) requires treatment by a physician or podiatrist. Routine podiatric care includes the following:
Cutting or removing of corns and calluses
Trimming of nails
Application of skin creams
Debridement of nails
Other hygienic or preventive maintenance care
Sterilization (ARM 37.86.104)
Elective Sterilization
Elective sterilizations are sterilizations done for the purpose of becoming sterile. Medicaid covers elective sterilization for men and women when all of the following requirements are met:
Member must complete and sign the Informed Consent to Sterilization (MA-38) form at least 30 days, but not more than 180 days, prior to the sterilization procedure. This form is the only form Medicaid accepts for elective sterilizations. If this form is not properly completed, payment will be denied. See the Forms page on the Provider Information website for the form and instructions for completing.

The 30-day waiting period may be waived for either of the following reasons:
Premature Delivery. The Informed Consent to Sterilization must be completed and signed by the member at least 30 days prior to the estimated delivery date and at least 72 hours prior to the sterilization.
Emergency Abdominal Surgery. The Informed Consent to Sterilization form must be completed and signed by the member at least 72 hours prior to the sterilization procedure.
Member must be at least 21 years of age when signing the form.
Member must not have been declared mentally incompetent by a federal, state, or local court, unless the member has been declared competent to specifically consent to sterilization.
Member must not be confined under civil or criminal status in a correctional or rehabilitative facility, including a psychiatric hospital or other correctional facility for the treatment of the mentally ill.
Before performing a sterilization, the following requirements must be met:
The member must have the opportunity to have questions regarding the sterilization procedure answered to his/her satisfaction.
The member must be informed of his/her right to withdraw or withhold consent anytime before the sterilization without being subject to retribution or loss of benefits.
The member must be made aware of available alternatives of birth control and family planning.
The member must understand the sterilization procedure being considered is irreversible.
The member must be made aware of the discomforts and risks which may accompany the sterilization procedure being considered.
The member must be informed of the benefits and advantages of the sterilization procedure.
The member must know that he/she must have at least 30 days to reconsider his/her decision to be sterilized.
An interpreter must be present to translate or sign for those members who are blind, deaf, or do not understand the language to assure the person has been informed.

Informed consent for sterilization may not be obtained under the following circumstances:
If the member is in labor or childbirth.
If the member is seeking or obtaining an abortion.
If the member is under the influence of alcohol or other substance which affects his/her awareness.

Medically Necessary Sterilization
When sterilization results from a procedure performed to address another medical problem, it is considered a medically necessary sterilization. These procedures include hysterectomies, oophorectomies, salpingectomies, and orchiectomies. Every claim submitted to Medicaid for a medically necessary sterilization must be accompanied by one of the following:
A completed Medicaid Hysterectomy Acknowledgement form (MA-39) for each provider submitting a claim. It is the provider’s responsibility to obtain a copy of the form from the primary or attending physician. Complete only one section of this form. When no prior sterility (Section B) or life-threatening emergency (Section C) exists, the member (or representative, if any) and physician must sign and date Section A of this form prior to the procedure. (See 42 CFR 441.250 for the federal policy on hysterectomies and sterilizations.) Also, for Section A, signatures dated after the surgery date require manual review of medical records by the Department. The Department must verify that the member (and representative, if any) was informed orally and in writing, prior to the surgery, that the procedure would render the member permanently incapable of reproducing. The member does not need to sign this form when Sections B or C are used. Refer to the Forms page on the Provider Information website for instructions on completing the form.
For members who have become retroactively eligible for Medicaid, the physician must certify in writing that the surgery was performed for medical reasons and must document one of the following:
The individual was informed prior to the hysterectomy that the operation would render the member permanently incapable of reproducing.
The reason for the hysterectomy was a life-threatening emergency.
The member was already sterile at the time of the hysterectomy and the reason for prior sterility.  

When submitting claims for retroactively eligible members, attach a copy of the Notice of Retroactive Eligibility (Form 160-M) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted.
Surgical Services
The fee schedule shows Medicaid policies code by code on global periods, bilateral procedures, assistants at surgery, co-surgeons, and team surgery. These policies are almost always identical to Medicare policies but in cases of discrepancy, the Medicaid policy applies.
Medicaid only covers assistant at surgery services when provided by physicians or mid-level practitioners who are Medicaid providers.
Medicaid does not cover surgical technician services.
See the Billing Procedures chapter regarding the appropriate use of modifiers for surgical services.
Telemedicine Services
Medicaid covers telemedicine services when the consulting provider is enrolled in Medicaid.
The requesting provider need not be enrolled in Medicaid nor be present during the telemedicine consult.
Medicaid does not cover network use charges.
Transplants
All Medicaid transplant services must be prior authorized. (See the Prior Authorization Information page on the  website.)
All transplants must be medically necessary.
Each case receives individualized review and is evaluated for medical suitability.
Weight Reduction
Physicians and mid-level practitioners who counsel and monitor members on weight reduction programs can be paid for those services. If medical necessity is documented, Medicaid will also cover lab work. Similar services provided by nutritionists are not covered for adults.
Medicaid does not cover the following weight reduction services:
Weight reduction plans/programs (e.g., Jenny Craig, Weight Watchers)
Nutritional supplements
Dietary supplements
Health club memberships
Educational services of nutritionists

Prior Authorization

Prior Authorization

Prior authorization refers to a list of services that require approval from the Medicaid program prior to the service being rendered. If a service requires prior authorization, the requirement exists for all Medicaid members. When prior authorization is granted, a prior authorization number is issued and must be on the claim.  

Different codes are issued for Passport approval and prior authorization; when necessary, both must be on the claim form. Medicaid does not pay for services when prior authorization requirements are not met.

Prior Authorization for Retroactively Eligible Members

When a member is determined retroactively eligible for Medicaid, the member should give the provider a Notice of Retroactive Eligibility (160-M). The provider has 12 months from the date retroactive eligibility was determined to bill for those services. When a member becomes retroactively eligible for Medicaid the provider may:

  • Accept the member as a Medicaid member from the current date.
  • Accept the member as a Medicaid member from the date retroactive eligibility was effective.
  • Require the member to continue as a private-pay member.

Providers may choose whether to accept retroactive eligibility. All prior authorization requirements must be met to receive Medicaid payment. When requesting prior authorization, attach a copy of the 160-M to the prior authorization request.  It is the member’s responsibility to ensure his/her caseworker prepares an 160-M for each provider who participates in the member’s healthcare during this retroactive period. See the Billing Procedures chapter in this manual for retroactive eligibility billing requirements. When seeking prior authorization, keep in mind the following:   

  • The referring provider should initiate all authorization requests.
  • Always refer to the current Medicaid fee schedule to verify if prior authorization is required for specific services.
  • For a list of services that require prior authorization, who to contact, and documentation requirements, see the Contact Us link in the menu on the Provider Information  website.
  • Prior authorization criteria forms for most services are available on the Forms page of the Provider Information website.
  • When prior authorization is granted from Mountain-Pacific Quality Health (MPQH), providers receive notification from both MPQH and Xerox Claims Processing. The Prior Authorization Notice from Claims Processing has a prior authorization number which must be included on the claim.