Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
This edition has three search options.
Prior manuals may be located through the provider website archives.
Updated 03/05/2021
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
This publication supersedes all previous Physician-Related Services handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.
Updated September 2002, January 2003, June 2003, July 2003, August 2003, September 2003, December 2003, June 2004, September 2004, November 2004, January 2005, March 2005, January 2006, April 2006, July 2006, July 2008, July 2014, July 2015, August 2015, September 2016, November 2016, September 2017, and March 2021.
CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.
03/05/2021
Updated the discrimination contact information in the Definitions and Acronyms chapter.
09/29/2017
Physician-Related Services Manual converted to an HTML format and adapted to 508 Accessibility Standards. Language throughout the manual was updated.
11/28/2016
In summary, the Page 5.6 of the Billing Procedures chapter was amended to add information for locum tenens, several links were updated, and two blank pages were removed. The Table of Contents and Index sections were adjusted, several links were updated in the Introduction and Covered Services Chapter, the entire manual was formatted as approved by the September 2016 Manuals Meeting for initial 508 adaptations, and the Cover page was amended with the current date.
09/12/2016
In summary, the entire manual has undergone formatting changes, the Billing Procedures section has had some minor language changes and the Cover reflects the current date.
08/31/2016
In summary, The cost share section was removed from the Billing Procedures Chapter, related entries were removed from the Index Section adjustments were made to the Index Section , and the date was changed on the Cover Page.
07/31/2015
Physician-Related Services, August 2015: Entire Manual, Removed EPSDT Well-Child
07/08/2014
Physician-Related Services, July 2014: Multiple Chapters
07/14/2008
Physician-Related Services, March 2008: Key Contacts, Completing a Claim Form, Prior Authorization, Billing for Immunizations
07/25/2006
Physician-Related Services, July 2006: Well-Child EPSDT Update
04/25/2006
Physician-Related Services, April 2006: Revised Instructions for Completing a Claim, Revised Information on How Cost-Sharing Affects Claim Payment
01/05/2006
Physician-Related Services, September 2005: New EPSDT, Hysterectomy Acknowledgement Form, Revised Information on Imaging Modifiers, Billing for Immunizations, and ER Visits for Clients Under Age 2
03/01/2005
Physician-Related Services, March 2005: Hysterectomy Acknowledgement Update
01/25/2005
Physician-Related Services, January 2005: Rule References Added, Updates to Covered Services, PA and Modifiers
11/16/2004
Physician-Related Services, November 2004: Updated Prescription Drug PA Criteria
09/15/2004
Physician-Related Services, September 2004: Team Care Added
06/16/2004
Physician-Related Services, July 2004: Clarification on Sterilizations, Hysterectomies, Abortions and HIPAA and Drug PA Update
12/23/2003
Physician-Related Services, December 2003: Immunizations, PA Criteria, Family Planning, and Using Modifiers
09/16/2003
Physician-Related Services, September 2003: Hysterectomies and Prescription Drug PA Update
08/20/2003
Physician-Related Services, June 2003: New Emergency Services Policy and Hard Card Information
07/28/2003
Physician-Related Services, Hysterectomy Requirements
06/01/2003
Physician-Related Services, New PA Requirements and Hysterectomy Information
01/02/2003
Physician-Related Services, January 2003: Prior Authorization
09/01/2002
Physician-Related Services, September 2002: Cost Sharing
End of Update Log Chapter
Manual Organization
Manual Maintenance
Rule References
Claim Review (MCA 53-6-111, ARM 37.85.406)
Getting Questions Answered
General Coverage Principles
Coverage of Specific Services
Prior Authorization for Retroactively Eligible Members
When Members Have Other Coverage
Identifying Other Sources of Coverage
When a Member Has Medicare
Submitting Medicare Claims to Medicaid
When a Member Has TPL (ARM 37.85.407)
Other Programs
Claim Forms
Timely Filing Limits (ARM 37.85.406)
When to Bill Medicaid Members (ARM 37.85.406)
Member Cost Sharing (ARM 37.85.204 and ARM 37.85.402)
When Members Have Other Insurance
Billing for Retroactively Eligible Members
Place of Service
Multiple Visits (E/M Codes) on Same Date
Coding
Using the Medicaid Fee Schedule
Using Modifiers
Billing Tips for Specific Provider Types
RHC/FQHC - Professional Services in Hospitals
Billing Tips for Specific Services
Submitting Electronic Claims
Billing Electronically with Paper Attachments
Submitting Paper Claims
Claim Inquiries
The Most Common Billing Errors and How to Avoid Them
CMS-1500 Agreement
Avoiding Claim Errors
Overview
The RBRVS Fee Schedule
Anesthesia Services
Clinical Lab Services (ARM 37.85.212)
Vaccines and Drugs Provided within the Office
How Cost Sharing Is Calculated on Medicaid Claims
How Payment Is Calculated on TPL Claims
How Payment Is Calculated on Medicare Crossover Claims
Other Department Programs
End of Table of Contents Chapter
End of Key Contacts and Websites Chapter
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.
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 There is a list of contacts on the Contact Us page on the Provider Information website. Find the Contact Us and other resources under the Site Index in the left menu.
Manuals must be kept current.
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the home page of the provider website and under Provider Notices on the provider type page of the provider website. Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
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.
NOTE: Providers are responsible for knowing and following current laws and regulations
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:
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).
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). Medicaid manuals, provider notices, fee schedules, forms, and more are available on the Provider Information website.
End of Introduction Chapter
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. Locate the Podiatrist Page and fee schedule on the Provider Website by visiting the Resources by Provider Type page.
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 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 Provided by Independent Diagnostic Testing Facilities (ARM 37.85.220)
Services Provided by Public Health Clinics (ARM 37.86.1401–1406)
Services Provided by Mobile Imaging/Portable X-ray Supplier (ARM 37.85.219 )
Medicaid covers tests provided by a mobile imaging provider when the following requirements are met:
Services Provided by Licensed Direct Entry Midwife (ARM 37.86.1201 )
Medicaid covers services provided by a licensed direct entry midwife when the following requirements are met:
Non-Covered Services (ARM 37.85.207 and ARM 37.86.205)
Some services not covered by Medicaid include the following:
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.
NOTE: Use the current fee schedule for your provider type to verify coverage for specific services.
Fee schedules are available on the Provider Information website listed under each provider type page.
Locate Provider type pages on the Provider Website under "Resources by Provider Type".
Locate Physician Fee Schedules and ATP Tests and Fees Fee Schedules on the Physician Provider Type page.
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:
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:
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 located in the site index in the left menu of the Provider 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:
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:
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 quarterly. 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 page can be located by choosing the Resources by Provider Type link from the home page of the Provider 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:
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:
The 30-day waiting period may be waived for either of the following reasons:
All forms required for sterilizations can be downloaded from the Provider Information website, Locate the Forms page by choosing the Forms link on the home page of the provider website.
Before performing a sterilization, the following requirements must be met:
Informed consent for sterilization may not be obtained under the following circumstances:
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:
NOTE: A notation Not a Sterilization on a claim is not sufficient to fulfill these certification requirements.
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
Telemedicine Services
Please refer to the Telemedicine section of the General Information for Providers Manual.
Transplants
Weight Reduction
End of Covered Services Chapter
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.
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:
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:
End of Prior Authorization Chapter
Medicaid members often have coverage though Medicare, workers’ compensation, employment-based coverage, individually purchased coverage, etc. Coordination of benefits is the process of determining which source of coverage is the primary payer in a particular situation. In general, providers must bill other carriers before billing Medicaid, but there are some exceptions. (See Exceptions to Billing Third Party First later in this chapter.) Medicare coverage is processed differently than other sources of coverage.
The member’s Medicaid eligibility information may list other payers such as Medicare or other third party payers. (See Member Eligibility and Responsibilities in the General Information for Providers manual.) If a member has Medicare, the Medicare ID number is listed on the eligibility verification. If a member has other coverage (excluding Medicare), it will be shown also. Some examples of third party payers include:
*These third party payers (and others) may not be listed on the member’s Medicaid eligibility information.
Providers must use the same procedures for locating third party sources for Medicaid members as for their non-Medicaid members. Providers cannot refuse service because of a third party payer or potential third party payer.
Medicare claims are processed and paid differently than claims involving other payers. The other sources of coverage are referred to as third party liability (TPL), but Medicare is not.
Medicare Part A Claims
Medicare Part A covers inpatient hospital care, skilled nursing care, and other services. Medicare Part A carriers and Medicaid use electronic exchange of institutional claims covering Part A services. Providers must submit these claims first to Medicare. After Medicare processes the claim, an Explanation of Medicare Benefits (EOMB) is sent to the provider. The provider then reviews the EOMB and submits the claim to Medicaid.
Medicare Part B Crossover Claims
Medicare Part B covers outpatient hospital care, physician care and other services. Although outpatient hospital care is covered under Part B, it is processed by Medicare Part A. The Department has an agreement with Medicare Part B carriers for Montana (Noridian) and the Durable Medical Equipment Regional Carrier [DMERC]. Under this agreement, the carriers provide the Department with claims for members who have both Medicare and Medicaid coverage. Providers must tell Medicare that they want their claims sent to Medicaid automatically and must have their Medicare provider number on file with Medicaid.
NOTE: To avoid confusion and paperwork, submit Medicare Part B crossover claims to Medicaid only when necessary.
In these situations, providers need not submit Medicare Part B crossover claims to Medicaid. Medicare will process the claim, submit it to Medicaid, and send the provider an EOMB. Providers must check the EOMB for the statement indicating that the claim has been referred to Medicaid for further processing. It is the provider’s responsibility to follow up on crossover claims and make sure they are correctly billed to Medicaid within the timely filing limit. (See the Billing Procedures chapter.)
When Medicare Pays or Denies a Service
When Medicaid Does Not Respond to Crossover Claims
When Medicaid does not respond within 45 days of the provider receiving the Medicare EOMB, submit a claim and a copy of the Medicare EOMB to Medicaid for processing.
NOTE: When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Billing Procedures chapter in this manual.
When submitting a claim to Medicaid, include the Medicare EOMB and use Medicaid billing instructions and codes. Medicare’s instructions, codes, and modifiers may not be the same as Medicaid’s. The claim must also include the Medicaid provider number and Medicaid member ID number.
When a Medicaid member has additional medical coverage (other than Medicare), the other insurance is often referred to as third party liability (TPL). In most cases,the providers must bill other insurance carriers before billing Medicaid.
Providers are required to notify their members that any funds the member receives from third party payers (when the services were billed to Medicaid) must be turned over to the Department. The following words printed on the member’s statement will fulfill this requirement: When services are covered by Medicaid and another source, any payment the member receives from the other source must be turned over to Medicaid.
Exceptions to Billing Third Party First
In a few cases, providers may bill Medicaid first.
Requesting an Exemption
Providers may request to bill Medicaid first under certain circumstances. In each of these cases, the claim and required information must be sent directly to the Third Party Liability Unit.
When the Third Party Pays or Denies a Service
When a third party payer is involved (excluding Medicare) and the other payer:
When the Third Party Does Not Respond
If another insurance has been billed, and 90 days have passed with no response, bill Medicaid as follows:
The information covered in this chapter also applies to members enrolled in the Mental Health Services Plan (MHSP) and Healthy Montana Kids (HMK) dental and vision providers.
End of Coordination of Benefits
Services provided by the healthcare professionals covered in this manual must be billed either electronically on a professional claim 837P or on a CMS-1500 paper claim form. CMS-1500 forms are available from various publishing companies; they are not available from the Department or Provider Relations.
Providers must submit clean claims to Medicaid within:
Clean claims are claims that can be processed without additional information or action from the provider. The submission date is defined as the date that the claim was received by the Department or the claims processing contractor. All problems with claims must be resolved within this 12-month period.
Tips to Avoid Timely Filing Denials
In most circumstances, providers may not bill Medicaid members for services covered under Medicaid. The main exception is that providers may collect cost sharing from members.
More specifically, providers cannot bill members directly:
Under certain circumstances, providers may need a signed agreement to bill a Medicaid member (see the following table).
Providers may bill a member when:
Patient is Medicaid enrolled and provider accepted them as a Medicaid member
Patient is Medicaid enrolled and provider did not accept them as a Medicaid member
Patient is not Medicaid Enrolled
NOTE: If a provider bills Medicaid and the claim is denied because the member is not eligible, the provider may bill the member directly.
Private-Pay Agreement: This may be a private-pay agreement between the provider and member that states that the member is not accepted as a Medicaid member, and that he/she must pay for the services received.
Custom Agreement: This agreement lists the service the member is receiving and states that the service is not covered by Medicaid and that the member will pay for the service. See the Custom Agreement for Medicaid non-covered service agreement under the Forms button found on the home page of the provider website.
If a Medicaid member is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the member’s healthcare, see the Coordination of Benefits chapter in this manual.
When the provider accepts the member’s retroactive eligibility, the provider has 12 months from the date retroactive eligibility was determined to bill for those services. When submitting claims for retroactively eligible members in which the date of service is more than 12 months earlier than the date the claim is submitted, attach a copy of the Provider Notice of Eligibility (Form 160-M). The provider must request the form from the member’s local Office of Public Assistance. See https://dphhs.mt.gov/hcsd/OfficeofPublicAssistance.
For more information on retroactive eligibility, see the Member Eligibility and Responsibilities chapter in the General Information for Providers manual.
Place of service must be entered correctly on each line. Medicaid typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Medicaid separately for facility charges.
Physician clinics that are affiliated with hospitals should be particularly careful. If the Department has granted a clinic provider-based status then the hospital can bill for facility charges even if the clinic is not on the hospital campus. In these situations the clinic must show outpatient (22) as the place of service.
Medicaid generally covers only one visit (or hospital admission) per member per day. When a member requires additional visits on the same day, use a modifier to describe the reason for multiple visits. When a modifier is not appropriate for the situation, attach documentation of medical necessity to the claim, and submit it to the appropriate Department program officer.
Standard use of medical coding conventions is required when billing Medicaid. Provider Relations or the Department cannot suggest specific codes to be used in billing for services. For coding resources, see the table of Coding Resources section below.
The following suggestions may help reduce coding errors and unnecessary claim denials:
Please note that the Department does not endorse the products of any particular publisher.
Description:
CPT codes and definitions.
Updated each January.
Contact:
American Medical Association
(800) 621-8335
Description:
A newsletter on CPT coding issues.
Contacts:
American Medical Association
(800) 621-8335
Description:
HCPCS codes and definitions.
Updated each January and throughout the year.
Contact:
Description:
ICD diagnosis and procedure code definitions.
Updated each October .
Contact:
Available through various publishers and bookstores.
Description:
Various newsletters and other coding resources.
Contact:
Medicode (Ingenix)
Description:
This manual contains National Correct Coding Initiative (NCCI) policy and edits, which are pairs of CPT or HCPCS codes that are not separately payable except under certain circumstances. The edits are applied to services billed by the same provider for the same member on the same date of service.
Contact:National Technical Information Service
NOTE: Always refer to the long descriptions in coding books.
When billing Medicaid, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the current CPT and HCPCS diagnosis coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers, global periods, if multiple surgery guidelines apply, if the procedure can be done bilaterally, if an assistant, co-surgeon, or team is allowed for the procedure, if the code is separately billable, and more. Department fee schedules are updated each January and July. Fee schedules are available on the Provider Information website under the Resources by Provider Type button.
Mid-Level Practitioner Billing
Mid-level practitioners must bill under their own NPI and taxonomy number rather than under a physician number.
Physician Billing
Medicaid-enrolled providers may bill for locum tenens physician services when the following criteria are met:
Podiatrist Billing
Podiatrists must use appropriate codes and modifiers from their specific fee schedule.
Independent Labs
Independent labs must use appropriate fee schedules, codes, and modifiers for their provider type.
Independent Diagnostic Testing Facilities (IDTF)
IDTF providers must use appropriate fee schedules, codes and modifiers for their provider type. If an IDTF performs laboratory services, they must enroll as an independent lab in addition to IDTF.
Mobile Imaging/Portable X-ray Supplier
RHC and FQHC practitioners (e.g., physicians, mid-level practitioners) performing services in a hospital setting should bill those services using the appropriate manual/rules that apply for that practitioner.
Abortions
A completed Montana Healthcare Programs Physician Certification for Abortion Services (MA-37) form must be attached to every abortion claim or payment will be denied. This is the only form Medicaid accepts for abortions.
Anesthesia
With the exception of moderate conscious sedation, Montana Medicaid does not allow separate reporting of anesthesia for a medical or surgical procedure when it is provided by the practitioner performing the procedure.
When billing for anesthesia services, the date of service on the claim form must match the date of service that anesthesia was administered. If the surgery overlaps days, then bill the anesthesia only with the start date.
CPT states: For continuous services that last beyond midnight, use the date in which the service began and report the total units of time provided continuously.
The following payment method is used for anesthesia services, regardless of whether the service is billed by an anesthesiologist or another professional. Though the method differs from the RBRVS payment method, the two methods are linked and contain similar provisions.
Bundled Services
Certain services with CPT codes (e.g., telephone advice, some pulse oximetry services) are covered by Medicaid but have a fee of zero. This means that the service is typically bundled with an office visit or other service. Since the bundled service is covered by Medicaid, providers may not bill the member separately for it.
Cosmetic Services
Include the prior authorization number on the claim. ( See the Submitting a Claim chapter in this manual.)
EPSDT Well-Child Screens
Family Planning Services
Contraceptive supplies and reproductive health items provided free to family planning clinics cannot be billed to Medicaid. When these supplies are not free to the clinic, providers associated with a family planning clinic can bill Medicaid for the following items:
Code - Item
A4266 - Diaphragm
A4267 - Male Condoms
A4268 - Female Condoms
A4269 - Spermicide
S4993 - Oral Contraceptives
340B drugs may be billed for acquisition costs only. For family planning indicators, see the Submitting a Claim chapter in this manual.
Immunizations
Per CPT, Codes 90460 and 90461 replace deleted Code 90465– Code 90468 for Vaccines for Children (VCF), a program for members ages 0–18.
Code 90460 (non-VFC) is billed for the first component of a vaccine. Code 90461 SL is not allowed by the VFC Program.
VFC codes are reviewed quarterly and updates may be implemented; please consult current provider notices to see if there are any changes.
Follow the CPT coding instructions as outlined in the CPT coding book for the proper use of these codes (i.e., face-to-face physician or qualified healthcare counseling time) member age, and add-on coding rules. Also, a combination of these two sets for the same date of service, member, and provider will result in an NCCI denial, with or without an NCCI modifier, because Codes 90471, 90472, 90473, and 90474 are component codes to Codes 90460 and 90461.
You may only bill for administrative services if performed by or under the direct supervision of a reimbursable professional (i.e., physician, mid-level). All administration of VFC vaccines must be billed on a CMS-1500.
The administration codes should have the appropriate modifier (SL) to be reimbursed for the federally mandated administration rate. Codes for the VFC supplied vaccines must be billed on the same claim with no charge ($0.00). See the fee schedule on the Physician page on the Provider Information website.
Note: If a significant separately identifiable Evaluation and Management (E/M) service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code with the appropriate modifier should be reported in addition to the vaccine and toxoid administrative codes.
Note: Administrative Code 90460 (VFC) may have multiple units per line because the code can be used for all VFCs. Codes 90471, 90473, and 90474 define route of administration.
Note: If a significant separately identifiable E/M service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code with the appropriate modifier should be reported in addition to the vaccine and toxoid administration codes.
Obstetrical Services
If the provider’s care includes prenatal (antepartum) and/or postnatal (postpartum) care in addition to the delivery, the appropriate global OB code must be billed. Antepartum care includes all visits until delivery, and there are different codes for specified numbers of visits. There are also different codes for antepartum and postpartum care when only one or the other is provided. Please review your CPT coding book carefully.
When billing a medical or surgical procedure, the date of service on the claim form must match the date of service that the procedure was performed. If the procedure has a global component and the provider saw the patient before and after the procedure, then the provider must bill the global procedure code on the claim form with the date associated for services rendered. For instance, if a vaginal delivery with antepartum and postpartum care (CPT 59400) is performed, it must be billed using the date of delivery as the from and to dates of service.
Reference Lab Billing
Under federal regulations, all lab services must be billed to Medicaid by the lab that performed the service. Modifier 90, used to indicate reference lab services, is not covered by Medicaid.
Sterilization
For elective sterilizations, a completed Informed Consent to Sterilization (MA-38) form must be attached to the claim for each provider involved or payment will be denied. No fields may be left blank, except for the Interpreter’s Statement. This form must be legible and accurate. If revisions are made, they must be made with a single line through the incorrect information and initialed by the party making the change. patient information may only be changed by the patient and must be initialed by the patient. Documentation must be included explaining why revisions were made. It is the provider’s responsibility to obtain a copy of the form from the primary or attending physician.
For medically necessary sterilizations (including hysterectomies, oophorectomies, salpingectomies, and orchiectomies), one of the following must be attached to the claim, or payment will be denied:
When submitting claims for retroactively eligible members, attach a copy of the MA-160 (eligibility determination letter) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted. For more information on sterilizations, see the Covered Services chapter in this manual.Surgical Services Medicaid does not provide additional payment for the operating room in a physician’s office. Medicaid pays facility expenses only to licensed hospitals and ambulatory surgical centers.
Reporting surgical services
Certain surgical procedures must not be reported together, such as:
Medicaid edits for some surgical services using Medicaid’s National Correct Coding Initiative (NCCI) edits and performs post-payment review on others. See Coding Resources earlier in this chapter for more information on NCCI.
Assistant at Surgery
When billing for an assistant at surgery, refer to the current Medicaid fee schedule to see if an assist is allowed for that procedure.
If an assistant at surgery does not use the appropriate modifier, then either the assistant’s claim or the surgeon’s claim (whichever is received later) will be denied as a duplicate service.
Physicians must bill assistant at surgery services using the appropriate surgical procedure code and Modifier 80, 81, or 82.
Mid-level practitioners must bill assistant at surgery services under their own NPI and taxonomy using the appropriate surgical procedure code and Modifier AS, 80, 81, or 82.
Global surgery periods: Global surgery periods are time spans assigned to surgery codes. During these time spans, services related to the surgery may not be billed. Group practice members that are of the same specialty must bill Medicaid as if a single practitioner provided all related follow-up services for a member. For example, Dr. Armstrong performs orthopedic surgery on a member. The member comes in for a follow-up exam, and Dr. Armstrong is on vacation. Dr. Armstrong’s partner, Dr. Black, performs the follow-up. Dr. Black cannot bill this service to Medicaid because the service was covered in the global period when Dr. Armstrong billed for the surgery.
For major surgeries, this span is 90 days and includes the day prior to the surgery and the following services: post-operative surgery related care and pain management and surgically-related supplies and miscellaneous services.
For minor surgeries and some endoscopies, the spans are either 1 day or 10 days. They include any surgically related follow-up care and supplies on the day of surgery, and for a 10-day period after the surgery.
For a list of global surgery periods by procedure code, see the current Department fee schedule for your provider type.
If the CPT manual lists a procedure as including the surgical procedure only (i.e., a “starred” procedure) but Medicaid lists the code with a global period, the Medicaid global period applies. Almost all Medicaid fees are based on Medicare relative value units (RVUs), and the Medicare relative value units were set using global periods even for starred procedures. Montana Medicaid has accepted these RVUs as the basis for its fee schedule.
In some cases, a physician (or the physician’s partner of the same specialty in the same group practice) provides care within a global period that is unrelated to the surgical procedure. In these circumstances, the unrelated service must be billed with the appropriate modifier to indicate it was not related to the surgery.
Telemedicine Services
When performing a telemedicine consult, use the appropriate CPT E/M consult code. The place of service is the location of the provider providing the telemedicine service. Medicaid does not pay for network use or other infrastructure charges.
Please refer to the Telemedicine section of the General Information for Providers Manual.
Transplants
Include the prior authorization number on the claim. See the Submitting a Claim chapter in this manual. All providers must have their own prior authorization number for the services. For details on obtaining prior authorization, see the Prior Authorization chapter in this manual.
Weight Reduction
Providers who counsel and monitor members on weight reduction programs must bill Medicaid using appropriate E/M codes.
Unlisted Procedures
Unlisted CPT or HCPCS codes are to be sent to the Department at the address below for review.
Claim Review
Physician-Related Services
P.O. Box 202951
Helena, MT 59624
Providers who submit claims electronically experience fewer errors and quicker payment. Claims may be submitted using the methods below. For detailed submission methods, see the electronic submissions manual on the Electronic Billing page of the website.
o Utilizes either a dial-up modem or submissions through the Montana Access to Health (MATH) Web Portal.
o Requires completion of the X12N Transaction Packet to allow for claim submissions.
o Requires completion of the X12N Transactions Packet to allow for claim submissions.
o A request for this must be made through Conduent Provider Relations for established trading partners.
Providers should be familiar with federal rules and regulations related to electronic claims submission.
When submitting claims that require additional supporting documentation, the Attachment Control Number field must be populated with an identifier. Identifier formats can be designed by software vendors or clearinghouses, but the preferred method is the provider’s NPI followed by the member’s ID number and the date of service, each separated by a dash:
The supporting documentation must be submitted with a Paperwork Attachment Cover Sheet under the forms button on the provider website home page. The number in the paper Attachment Control Number field must match the number on the cover sheet.
Electronic claims that have the PWK indicator will pend for 30 days awaiting the appropriate paperwork to be submitted using the above procedure. If the claim has no PWK indicator, claims will proceed through the normal adjudication process.
For instructions on completing a paper claim, see the Submitting a Claim chapter in this manual. Unless otherwise stated, all paper claims must be mailed to:
Claims Processing
P.O. Box 8000
Helena, MT 59604
Contact Provider Relations for general claim questions and questions regarding member eligibility, payments, and denials.
Paper claims are often returned to the provider before they can be processed, and many other claims (both paper and electronic) are denied. To avoid unnecessary returns and denials, double-check each claim to confirm the following items are included and accurate.
Reasons for Return or Denial:
Provider’s NPI and/or taxonomy missing or invalid
Preventing Returned or Denied Claims:
Verify the correct NPI and taxonomy are on the claim.
Reasons for Return or Denial:
Authorized signature missing.
Preventing Returned or Denied Claims:
Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, or handwritten.
Reasons for Return or Denial:
Signature date missing.
Preventing Returned or Denied Claims:
Each claim must have a signature date.
Reasons for Return or Denial:
Incorrect claim form used.
Preventing Returned or Denied Claims:
The claim must be the correct form for the provider type. Services covered in this manual require a CMS-1500 claim form (or electronic professional claim).
Reasons for Return or Denial:
Information on claim form not legible.
Preventing Returned or Denied Claims:
Information on the claim form must be legible. Use dark ink and center the information in the field. Information must not be obscured by lines.
Reasons for Return or Denial:
Recipient number not on file, or recipient was not eligible on date of service.
Preventing Returned or Denied Claims:
Before providing services to the member:
View the member’s eligibility information at each visit. Medicaid eligibility may change monthly.
Verify member eligibility by using one of the methods described in the Member Eligibility and Responsibilities chapter of the General Information for Providers manual.
Reasons for Return or Denial:
Duplicate claim.
Preventing Returned or Denied Claims:
Please check all remittance advices for previously submitted claims before resubmitting.
When making changes to previously paid claims, submit an adjustment form rather than a new claim. (See Remittance Advices and Adjustments in this manual.)
Please allow 45 days for the Medicare/Medicaid Part B crossover claim to appear on the remittance advice before submitting the claim directly to Medicaid.
Reasons for Return or Denial:
Procedure requires Passport provider referral – No Passport provider number on claim.
Preventing Returned or Denied Claims:
A Passport provider number must be on the claim when such a referral is required. See the Passport to Health manual.
Reasons for Return or Denial:
TPL on file and no credit amount on claim.
Preventing Returned or Denied Claims:
If the member has other insurance (or Medicare), bill the other carrier before Medicaid. See Coordination of Benefits in this manual.
If the member’s TPL coverage has changed, providers must notify Conduent TPL unit before submitting a claim.
End of Billing Procedures Chapter
The services described in this manual are billed either electronically on a professional claim or on a CMS-1500 paper claim form. Claims submitted with all of the necessary information are referred to as clean and are usually paid in a timely manner. ( See the Billing Procedures chapter in this manual.)
Claims are completed differently for the different types of coverage a member has. The following are accepted codes for completing box 24h:
Code | Member/Servide | Purpose |
---|---|---|
1 | EPSDT | Used when the member is under age 21. |
2 | Family Planning | Used when providing family planning services. |
3 | EPSDT and family planning | Used when the member is under age 21 and is receiving family planning services. |
4 | Pregnancy (any service provided to a pregnant woman) | Used when providing services to to pregnant women. |
6 | Nursing facility member | Used when providing services to nursing facility residents. |
Unless otherwise stated, all paper claims must be mailed to the following address:
Claims Processing
P.O. Box 8000
Helena, MT 59604
Your signature on the CMS-1500 constitutes your agreement to the terms presented on the back of the form. This form is subject to change by the Centers for Medicare and Medicaid Services (CMS).
Claims are often denied or even returned to the provider before they can be processed. To avoid denials and returns, double-check each claim to confirm the following items are accurate. For more information on returned and denied claims, see the Billing Procedures chapter in this manual.
Claim Errors:
Required field is blank.
Prevention:
If a required field is blank, the claim may either be returned or denied.
Claim Errors:
Member ID number missing or invalid.
Prevention:
This is a required field; verify that the member’s Medicaid ID number is listed as it appears on the member’s eligibility information.
Claim Errors:
Patient name missing.
Prevention:
This is a required field; check that it is correct.
Claim Errors:
Provider NPI and taxonomy missing or invalid.
Prevention:
Verify the correct NPI and taxonomy are on the claim.
Claim Errors:
Referring or Passport provider name and ID number missing.
Prevention:
When a provider refers a member to another provider, include the referring provider’s name and ID number or Passport number. See the Passport to Health manual.
Claim Errors:
Prior authorization number missing.
Prevention:
When prior authorization is required for a service, the prior authorization number must be listed on the claim. See the Prior Authorization chapter in this manual.
Claim Errors:
Not enough information regarding other coverage.
Prevention:
When a member has other coverage, related fields become required.
Claim Errors:
Authorized signature missing.
Prevention:
Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, or hand-written.
Claim Errors:
Signature date missing.
Prevention:
Each claim must have a signature date.
Claim Errors:
Incorrect claim form used.
Prevention:
Services covered in this manual require a CMS-1500 claim form or an electronic professional claim.
Claim Errors:
Information on claim form not legible.
Prevention:
Information on the claim form must be legible. Use dark ink and center the information in the field. Information must not be obscured by lines.
Claim Errors:
Medicare EOMB not attached.
Prevention:
When Medicare is involved in payment on a claim, the Medicare EOMB must be attached to the claim or it will be denied.
This chapter also applies to claims forms completed for Mental Health Services Plan (MHSP) services and Healthy Montana Kids (HMK)/CHIP eyeglass services.
End of Submitting a Claim Chapter
Though providers do not need the information in this chapter in order to submit claims to the Department, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Most services by provider types covered in this manual are reimbursed for using he Department’s RBRVS fee schedule. RBRVS stands for Resource-Based Relative Value Scale. The fee schedule includes CPT codes and HCPCS codes. Within the CPT coding structure, only anesthesia services and clinical lab services are not reimbursed for using the RBRVS fee schedule.
NOTE: Many Medicaid payment methods are based on Medicare, but there are differences. In these cases, the Medicaid method prevails.
RBRVS was developed for the Medicare program. Medicare does a major update annually, with smaller updates performed quarterly. Montana Medicaid’s RBRVS-based fee schedule is based largely on the Medicare model, with a few differences as described below. By adapting the Medicare model to the needs of the Montana Medicaid program, the Department was able to take advantage of the research performed by the federal government and national associations of physicians and other healthcare professionals. RBRVS-based payment methods are widely used across the U.S. by Medicaid programs, workers’ compensation plans and commercial insurers.
Fee Calculation
Each fee is the product of a relative value times a conversion factor.
Basis of Relative Values
For almost all services, Medicaid uses the same relative values as Medicare in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality. For fewer than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the fee.
Composition of Relative Values
For each code, the relative value is the sum of a relative value for the work effort (including time, stress, and difficulty), the associated transitional practice expense, and the associated malpractice expense.
Site of Service Differential
The Medicare program has calculated two sets of relative values for each code: one reflects the practitioner’s practice cost of performing the service in an office and one reflects the practitioner’s practice cost of performing the service in a facility.
Medicaid typically pays a lower fee if the service is provided in a facility because Medicaid typically also pays the facility.
Conversion Factor
The Department sets the conversion factor for the state fiscal year (July through June) and it is listed on the fee schedule.
Policy Adjuster
To encourage access to maternity services and family planning services, the Department increases fees for these codes using a policy adjuster that increases the fee. The fee listed on the fee schedule includes the policy adjuster.
Global Periods
For many surgical services and maternity services, the fee covers both the service and all related care within a specified global period. For almost all such codes, the global periods used by Medicaid are identical to those used by Medicare, but in cases of differences the Medicaid policy applies. See the Billing Procedures chapter in this manual for information on global periods.
Professional and Technical Components
Many imaging services and some diagnostic services are divided into the technical component (performing the test) and the professional component (interpreting the test). A practitioner who only performs the test would bill the service with modifier TC; a practitioner who only interprets the test would bill Modifier 26; and a practitioner who performs both components would bill the code without a modifier. Performance of both components is called the global service. The fee schedule has separate fees for each component and for the global service.
Other Modifiers
Under the RBRVS fee schedule, certain other modifiers also affect payment. Modifiers affecting reimbursement are listed in the table on the next page.
How Modifiers Change Pricing
Modifier: 22 Definition: Increased procedural service
How Payment is Affected: The services is paid at 110% of the fee.
Modifier: 26 Definition: Professional component
How Payment is Affected: For services paid via the RBRVS fee schedule, see the specific service. For other services, payment equals 40% of the fee.
Modifier: 47 Definition: Anesthesia by surgeon
How Payment is Affected: Modifier not allowed.
Modifier: 50 Definition: Bilateral procedure
How Payment is Affected: The procedure is paid at 150% of the fee.
Modifier: 51 Definition: Multiple procedures
How Payment is Affected: Each procedure is paid at 50% of the fee.
Modifier: 52 Definition: Reduced service
How Payment is Affected: The service is paid at 50% of the fee.
Modifier: 53 Definition: Discontinued procedure
How Payment is Affected: The service is paid at 50% of the fee.
Modifier: 54 Definition: Surgical care only
How Payment is Affected: The service is paid at 75% of the fee.
Modifier: 55 Definition: Postoperative management only
How Payment is Affected: The service is paid at 25% of the fee.
Modifier: 56 Definition: Preoperative management only
How Payment is Affected: The service is paid at 25% of the fee.
Modifier: 5 9 Definition: Distinct procedural service
How Payment is Affected: The service is paid at 50% of the fee unless the procedure is identified as ‘modifier 51 exempt’ or ‘add-on’.
Modifier: 62 Definition: Two surgeons
How Payment is Affected: Each surgeon is paid at 62.5% of the fee.
Modifier: 80 Definition: Assistant surgeon
How Payment is Affected: The service is paid at 16% of the fee.
Modifier: 81 Definition: Minimum assistant surgeon
How Payment is Affected: The service is paid at 16% of the fee.
Modifier: 82 Definition: Assistant surgeon; qualified resident surgeon not available
How Payment is Affected: The service is paid at 16% of the fee.
Modifier: 90 Definition: Reference laboratory
How Payment is Affected: Modifier not allowed
Modifier: AD Definition: Medical supervision of more than four concurrent anesthesia procedures
How Payment is Affected: Each service is paid at 52.5% of the fee.
Modifier: AS Definition: Physician assistant, nurse practitioner or clinical nurse specialist as assistant at surgery
How Payment is Affected: The service is paid at 16% of the fee.
Modifier: QK Definition: Medical supervision of 2–4 concurrent anesthesia procedures
How Payment is Affected: Each service is paid at 52.5% of the fee.
Modifier: QX Definition: Certified registered nurse anesthetist service: medically directed by MD
How Payment is Affected: Each service is paid at 52.5% of the fee.
Modifier: QZ Definition: Certified registered nurse anesthetist service without medical direction
How Payment is Affected: The modifier does not reduce the fee, but a professional differential of 90% is applied due to provider type. See Professional Differentials in this chapter.
Modifier: TC Definition: Technical component
How Payment is Affected: For services paid via the RBRVS fee schedule, see the specific service. For other services, payment equals 60% of the fee.
Professional Differentials
Mid-level practitioners generally receive 90% of the fee that a physician would receive for the same service. The exception is that mid-level practitioners receive 100% of the fee for immunizations, family planning, injectables, lab and pathology services, radiology, cardiography and echocardiography, and services to members under age 21 (i.e., well-child EPSDT services).
Charge Cap
For the services covered in this manual, Medicaid pays the lower of the established Medicaid fee or the provider’s charge.
Bundled Codes
A few services are covered by Medicaid but have a fee of zero, meaning that payment for the service is considered bundled into the payment for services that are usually provided with it. Because these services are covered by Medicaid, providers may not bill members for them on a private-pay basis.
Status Codes
The Medicare physician fee schedule includes status codes that show how each services is reimbursed. Medicaid also uses status codes.
With the exception of moderate conscious sedation, Montana Medicaid does not allow separate reporting of anesthesia for a medical or surgical procedure when it is provided by the practitioner performing the procedure.
When billing for anesthesia services, the date of service on the claim form must match the date of service that anesthesia was administered. If the surgery overlaps days, then bill the anesthesia only with the start date.
NOTE: When billing Medicaid for anesthesia services, enter the number of minutes in the Units field of the CMS-1500 claim form.
CPT states: For continuous services that last beyond midnight, use the date in which the service began and report the total units of time provided continuously.
The following payment method is used for anesthesia services, regardless of whether the service is billed by an anesthesiologist or another professional. Though the method differs from the RBRVS payment method, the two methods are linked and contain similar provisions.
Time Units
A unit of time for anesthesia is 15 minutes, though Medicaid does pay for partial units. Providers enter the number of minutes on the claim; the claims processing contractor then converts the minutes to time units.
Base Units
Base units are adopted by Medicaid from the schedule of base units used by Medicare. Base units are calculated by the American Society of Anesthesiologists. Providers do not enter the number of base units on the claim.
Fee Calculation
For a particular service, Medicaid payment is calculated as follows: (Time units + base units) x anesthesia conversion factor = payment
Modifiers
Payment for anesthesia services is affected by the modifier pricing rules shown in this chapter; take note of the modifiers for anesthesia care provided under medical supervision. Medicaid follows Medicare in not paying extra for the patient status Modifiers P1 to P6.
In general, Medicaid pays the same fees for clinical lab services as Medicare pays in Montana. If a Medicare fee is not available for a lab test covered by Medicaid, then payment is calculated by looking at the average charge and the amounts paid by other payers.
Many vaccines are available for free to physician offices through the Vaccines for Children (VFC) program. For information on obtaining these vaccines, call (406) 444-5580. For these vaccines, Medicaid does not pay separately. Medicaid does pay for the administration of the vaccine, however. Medicaid pays for most vaccines not available through the VFC program. (See the Immunizations section of the Billing Procedures chapter in this manual.)
Reimbursement for physician administered drugs (PAD), which are billed using HCPCS codes is made according to the Department’s fee schedule. The Department’s fee schedule is based on the Medicare Average Sale Price (ASP) Fee Schedule if there is an ASP fee, or the RBRVS fee if there is an RBRVS fee. If there is no ASP or RBRVS fee then the fee is calculated by National Drug Code (NDC) using the estimated acquisition cost to set reimbursement. Most must be billed with a HCPCS code and include the NDC, unit type, and number of units.
Member cost sharing fees are a set dollar amount per visit. ( See the Cost Sharing section in Billing Procedures chapter in the General Information for Providers Manual) The member’s cost sharing amount is shown on the remittance advice and deducted from the Medicaid allowed amount.
NOTE: When billing Medicaid for anesthesia services, enter the number of minutes in the Units field of the CMS-1500 claim form.
When a member has coverage from both Medicaid and Medicare, Medicare is the primary payer as described in the Coordination of Benefits chapter of this manual. Medicaid then makes a payment as the secondary payer. For the provider types covered in this manual, Medicaid’s payment is calculated so that the total payment to the provider is either the Medicaid allowed amount less the Medicare paid amount or the sum of the Medicare coinsurance and deductible, whichever is lower. This method is sometimes called “lower of” pricing.
The payment method described in this chapter also applies to services provided under the Mental Health Services Plan (MHSP).
End of How Payment Is Calculated Chapter
End of Appendix A: Forms Chapter
End of Appendix B: Place of Service Codes Chapter
Montana Medicaid adds many codes from the yearly edition of the Current Procedural Terminology and HCPCS manuals. Refer to the fee schedules posted on the Provider Information website. If you are billing unlisted J codes (e.g., J3490), verify that a new J code does not exist before you bill. If one does not exist send the claim with a copy of the invoice directly to the State office.
The Department does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, age, sex, handicap, political beliefs, religion or disability. This includes the admission to, participation in, or receipt of services or benefits of any of its programs, activities or employment, whether carried out by the Department or through a contractor or other entity.
For questions or to file a complaint alleging violations, contact the Montana Human Rights Bureau (800) 542-0807 or (406) 444-2884.
A sports physical is typically a non problem-oriented encounter in which the provider evaluate and certifies a patient’s involvement in organized sports, such as high school football. If a comprehensive history and physical examination are performed, report the age-appropriate code from the preventive medicine series. If less than a comprehensive history and exam, are performed, report the appropriate level office or other outpatient evaluation and management visit code.
Federal law requires written Medicaid prescriptions to be on tamper-resistant pads. The Department, in accordance with CMS guidance, requires that a Medicaid prescription pad contain all of the following.
End of Definitions and Acronyms Chapter
Previous editions of this manual contained an index.
This edition has three search options.
End of Index Chapter
End of Physician-Related Services Manual
This publication supersedes all previous Physician-Related Services handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.
Updated September 2002, January 2003, June 2003, July 2003, August 2003, September 2003, December 2003, June 2004, September 2004, November 2004, January 2005, March 2005, January 2006, April 2006, July 2006, July 2008, July 2014, July 2015, August 2015, September 2016, November 2016, September 2017, and March 2021.
CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.
03/05/2021
Updated the discrimination contact information in the Definitions and Acronyms chapter.
09/29/2017
Physician-Related Services Manual converted to an HTML format and adapted to 508 Accessibility Standards. Language throughout the manual was updated.
11/28/2016
In summary, the Page 5.6 of the Billing Procedures chapter was amended to add information for locum tenens, several links were updated, and two blank pages were removed. The Table of Contents and Index sections were adjusted, several links were updated in the Introduction and Covered Services Chapter, the entire manual was formatted as approved by the September 2016 Manuals Meeting for initial 508 adaptations, and the Cover page was amended with the current date.
09/12/2016
In summary, the entire manual has undergone formatting changes, the Billing Procedures section has had some minor language changes and the Cover reflects the current date.
08/31/2016
In summary, The cost share section was removed from the Billing Procedures Chapter, related entries were removed from the Index Section adjustments were made to the Index Section , and the date was changed on the Cover Page.
07/31/2015
Physician-Related Services, August 2015: Entire Manual, Removed EPSDT Well-Child
07/08/2014
Physician-Related Services, July 2014: Multiple Chapters
07/14/2008
Physician-Related Services, March 2008: Key Contacts, Completing a Claim Form, Prior Authorization, Billing for Immunizations
07/25/2006
Physician-Related Services, July 2006: Well-Child EPSDT Update
04/25/2006
Physician-Related Services, April 2006: Revised Instructions for Completing a Claim, Revised Information on How Cost-Sharing Affects Claim Payment
01/05/2006
Physician-Related Services, September 2005: New EPSDT, Hysterectomy Acknowledgement Form, Revised Information on Imaging Modifiers, Billing for Immunizations, and ER Visits for Clients Under Age 2
03/01/2005
Physician-Related Services, March 2005: Hysterectomy Acknowledgement Update
01/25/2005
Physician-Related Services, January 2005: Rule References Added, Updates to Covered Services, PA and Modifiers
11/16/2004
Physician-Related Services, November 2004: Updated Prescription Drug PA Criteria
09/15/2004
Physician-Related Services, September 2004: Team Care Added
06/16/2004
Physician-Related Services, July 2004: Clarification on Sterilizations, Hysterectomies, Abortions and HIPAA and Drug PA Update
12/23/2003
Physician-Related Services, December 2003: Immunizations, PA Criteria, Family Planning, and Using Modifiers
09/16/2003
Physician-Related Services, September 2003: Hysterectomies and Prescription Drug PA Update
08/20/2003
Physician-Related Services, June 2003: New Emergency Services Policy and Hard Card Information
07/28/2003
Physician-Related Services, Hysterectomy Requirements
06/01/2003
Physician-Related Services, New PA Requirements and Hysterectomy Information
01/02/2003
Physician-Related Services, January 2003: Prior Authorization
09/01/2002
Physician-Related Services, September 2002: Cost Sharing
End of Update Log Chapter
Manual Organization
Manual Maintenance
Rule References
Claim Review (MCA 53-6-111, ARM 37.85.406)
Getting Questions Answered
General Coverage Principles
Coverage of Specific Services
Prior Authorization for Retroactively Eligible Members
When Members Have Other Coverage
Identifying Other Sources of Coverage
When a Member Has Medicare
Submitting Medicare Claims to Medicaid
When a Member Has TPL (ARM 37.85.407)
Other Programs
Claim Forms
Timely Filing Limits (ARM 37.85.406)
When to Bill Medicaid Members (ARM 37.85.406)
Member Cost Sharing (ARM 37.85.204 and ARM 37.85.402)
When Members Have Other Insurance
Billing for Retroactively Eligible Members
Place of Service
Multiple Visits (E/M Codes) on Same Date
Coding
Using the Medicaid Fee Schedule
Using Modifiers
Billing Tips for Specific Provider Types
RHC/FQHC - Professional Services in Hospitals
Billing Tips for Specific Services
Submitting Electronic Claims
Billing Electronically with Paper Attachments
Submitting Paper Claims
Claim Inquiries
The Most Common Billing Errors and How to Avoid Them
CMS-1500 Agreement
Avoiding Claim Errors
Overview
The RBRVS Fee Schedule
Anesthesia Services
Clinical Lab Services (ARM 37.85.212)
Vaccines and Drugs Provided within the Office
How Cost Sharing Is Calculated on Medicaid Claims
How Payment Is Calculated on TPL Claims
How Payment Is Calculated on Medicare Crossover Claims
Other Department Programs
End of Table of Contents Chapter
End of Key Contacts and Websites Chapter
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.
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 There is a list of contacts on the Contact Us page on the Provider Information website. Find the Contact Us and other resources under the Site Index in the left menu.
Manuals must be kept current.
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the home page of the provider website and under Provider Notices on the provider type page of the provider website. Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
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.
NOTE: Providers are responsible for knowing and following current laws and regulations
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:
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).
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). Medicaid manuals, provider notices, fee schedules, forms, and more are available on the Provider Information website.
End of Introduction Chapter
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. Locate the Podiatrist Page and fee schedule on the Provider Website by visiting the Resources by Provider Type page.
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 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 Provided by Independent Diagnostic Testing Facilities (ARM 37.85.220)
Services Provided by Public Health Clinics (ARM 37.86.1401–1406)
Services Provided by Mobile Imaging/Portable X-ray Supplier (ARM 37.85.219 )
Medicaid covers tests provided by a mobile imaging provider when the following requirements are met:
Services Provided by Licensed Direct Entry Midwife (ARM 37.86.1201 )
Medicaid covers services provided by a licensed direct entry midwife when the following requirements are met:
Non-Covered Services (ARM 37.85.207 and ARM 37.86.205)
Some services not covered by Medicaid include the following:
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.
NOTE: Use the current fee schedule for your provider type to verify coverage for specific services.
Fee schedules are available on the Provider Information website listed under each provider type page.
Locate Provider type pages on the Provider Website under "Resources by Provider Type".
Locate Physician Fee Schedules and ATP Tests and Fees Fee Schedules on the Physician Provider Type page.
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:
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:
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 located in the site index in the left menu of the Provider 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:
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:
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 quarterly. 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 page can be located by choosing the Resources by Provider Type link from the home page of the Provider 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:
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:
The 30-day waiting period may be waived for either of the following reasons:
All forms required for sterilizations can be downloaded from the Provider Information website, Locate the Forms page by choosing the Forms link on the home page of the provider website.
Before performing a sterilization, the following requirements must be met:
Informed consent for sterilization may not be obtained under the following circumstances:
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:
NOTE: A notation Not a Sterilization on a claim is not sufficient to fulfill these certification requirements.
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
Telemedicine Services
Please refer to the Telemedicine section of the General Information for Providers Manual.
Transplants
Weight Reduction
End of Covered Services Chapter
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.
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:
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:
End of Prior Authorization Chapter
Medicaid members often have coverage though Medicare, workers’ compensation, employment-based coverage, individually purchased coverage, etc. Coordination of benefits is the process of determining which source of coverage is the primary payer in a particular situation. In general, providers must bill other carriers before billing Medicaid, but there are some exceptions. (See Exceptions to Billing Third Party First later in this chapter.) Medicare coverage is processed differently than other sources of coverage.
The member’s Medicaid eligibility information may list other payers such as Medicare or other third party payers. (See Member Eligibility and Responsibilities in the General Information for Providers manual.) If a member has Medicare, the Medicare ID number is listed on the eligibility verification. If a member has other coverage (excluding Medicare), it will be shown also. Some examples of third party payers include:
*These third party payers (and others) may not be listed on the member’s Medicaid eligibility information.
Providers must use the same procedures for locating third party sources for Medicaid members as for their non-Medicaid members. Providers cannot refuse service because of a third party payer or potential third party payer.
Medicare claims are processed and paid differently than claims involving other payers. The other sources of coverage are referred to as third party liability (TPL), but Medicare is not.
Medicare Part A Claims
Medicare Part A covers inpatient hospital care, skilled nursing care, and other services. Medicare Part A carriers and Medicaid use electronic exchange of institutional claims covering Part A services. Providers must submit these claims first to Medicare. After Medicare processes the claim, an Explanation of Medicare Benefits (EOMB) is sent to the provider. The provider then reviews the EOMB and submits the claim to Medicaid.
Medicare Part B Crossover Claims
Medicare Part B covers outpatient hospital care, physician care and other services. Although outpatient hospital care is covered under Part B, it is processed by Medicare Part A. The Department has an agreement with Medicare Part B carriers for Montana (Noridian) and the Durable Medical Equipment Regional Carrier [DMERC]. Under this agreement, the carriers provide the Department with claims for members who have both Medicare and Medicaid coverage. Providers must tell Medicare that they want their claims sent to Medicaid automatically and must have their Medicare provider number on file with Medicaid.
NOTE: To avoid confusion and paperwork, submit Medicare Part B crossover claims to Medicaid only when necessary.
In these situations, providers need not submit Medicare Part B crossover claims to Medicaid. Medicare will process the claim, submit it to Medicaid, and send the provider an EOMB. Providers must check the EOMB for the statement indicating that the claim has been referred to Medicaid for further processing. It is the provider’s responsibility to follow up on crossover claims and make sure they are correctly billed to Medicaid within the timely filing limit. (See the Billing Procedures chapter.)
When Medicare Pays or Denies a Service
When Medicaid Does Not Respond to Crossover Claims
When Medicaid does not respond within 45 days of the provider receiving the Medicare EOMB, submit a claim and a copy of the Medicare EOMB to Medicaid for processing.
NOTE: When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Billing Procedures chapter in this manual.
When submitting a claim to Medicaid, include the Medicare EOMB and use Medicaid billing instructions and codes. Medicare’s instructions, codes, and modifiers may not be the same as Medicaid’s. The claim must also include the Medicaid provider number and Medicaid member ID number.
When a Medicaid member has additional medical coverage (other than Medicare), the other insurance is often referred to as third party liability (TPL). In most cases,the providers must bill other insurance carriers before billing Medicaid.
Providers are required to notify their members that any funds the member receives from third party payers (when the services were billed to Medicaid) must be turned over to the Department. The following words printed on the member’s statement will fulfill this requirement: When services are covered by Medicaid and another source, any payment the member receives from the other source must be turned over to Medicaid.
Exceptions to Billing Third Party First
In a few cases, providers may bill Medicaid first.
Requesting an Exemption
Providers may request to bill Medicaid first under certain circumstances. In each of these cases, the claim and required information must be sent directly to the Third Party Liability Unit.
When the Third Party Pays or Denies a Service
When a third party payer is involved (excluding Medicare) and the other payer:
When the Third Party Does Not Respond
If another insurance has been billed, and 90 days have passed with no response, bill Medicaid as follows:
The information covered in this chapter also applies to members enrolled in the Mental Health Services Plan (MHSP) and Healthy Montana Kids (HMK) dental and vision providers.
End of Coordination of Benefits
Services provided by the healthcare professionals covered in this manual must be billed either electronically on a professional claim 837P or on a CMS-1500 paper claim form. CMS-1500 forms are available from various publishing companies; they are not available from the Department or Provider Relations.
Providers must submit clean claims to Medicaid within:
Clean claims are claims that can be processed without additional information or action from the provider. The submission date is defined as the date that the claim was received by the Department or the claims processing contractor. All problems with claims must be resolved within this 12-month period.
Tips to Avoid Timely Filing Denials
In most circumstances, providers may not bill Medicaid members for services covered under Medicaid. The main exception is that providers may collect cost sharing from members.
More specifically, providers cannot bill members directly:
Under certain circumstances, providers may need a signed agreement to bill a Medicaid member (see the following table).
Providers may bill a member when:
Patient is Medicaid enrolled and provider accepted them as a Medicaid member
Patient is Medicaid enrolled and provider did not accept them as a Medicaid member
Patient is not Medicaid Enrolled
NOTE: If a provider bills Medicaid and the claim is denied because the member is not eligible, the provider may bill the member directly.
Private-Pay Agreement: This may be a private-pay agreement between the provider and member that states that the member is not accepted as a Medicaid member, and that he/she must pay for the services received.
Custom Agreement: This agreement lists the service the member is receiving and states that the service is not covered by Medicaid and that the member will pay for the service. See the Custom Agreement for Medicaid non-covered service agreement under the Forms button found on the home page of the provider website.
If a Medicaid member is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the member’s healthcare, see the Coordination of Benefits chapter in this manual.
When the provider accepts the member’s retroactive eligibility, the provider has 12 months from the date retroactive eligibility was determined to bill for those services. When submitting claims for retroactively eligible members in which the date of service is more than 12 months earlier than the date the claim is submitted, attach a copy of the Provider Notice of Eligibility (Form 160-M). The provider must request the form from the member’s local Office of Public Assistance. See https://dphhs.mt.gov/hcsd/OfficeofPublicAssistance.
For more information on retroactive eligibility, see the Member Eligibility and Responsibilities chapter in the General Information for Providers manual.
Place of service must be entered correctly on each line. Medicaid typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Medicaid separately for facility charges.
Physician clinics that are affiliated with hospitals should be particularly careful. If the Department has granted a clinic provider-based status then the hospital can bill for facility charges even if the clinic is not on the hospital campus. In these situations the clinic must show outpatient (22) as the place of service.
Medicaid generally covers only one visit (or hospital admission) per member per day. When a member requires additional visits on the same day, use a modifier to describe the reason for multiple visits. When a modifier is not appropriate for the situation, attach documentation of medical necessity to the claim, and submit it to the appropriate Department program officer.
Standard use of medical coding conventions is required when billing Medicaid. Provider Relations or the Department cannot suggest specific codes to be used in billing for services. For coding resources, see the table of Coding Resources section below.
The following suggestions may help reduce coding errors and unnecessary claim denials:
Please note that the Department does not endorse the products of any particular publisher.
Description:
CPT codes and definitions.
Updated each January.
Contact:
American Medical Association
(800) 621-8335
Description:
A newsletter on CPT coding issues.
Contacts:
American Medical Association
(800) 621-8335
Description:
HCPCS codes and definitions.
Updated each January and throughout the year.
Contact:
Description:
ICD diagnosis and procedure code definitions.
Updated each October.
Contact:
Available through various publishers and bookstores.
Description:
Various newsletters and other coding resources.
Contact:
Medicode (Ingenix)
Description:
This manual contains National Correct Coding Initiative (NCCI) policy and edits, which are pairs of CPT or HCPCS codes that are not separately payable except under certain circumstances. The edits are applied to services billed by the same provider for the same member on the same date of service.
Contact:National Technical Information Service
NOTE: Always refer to the long descriptions in coding books.
When billing Medicaid, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the current CPT and HCPCS diagnosis coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers, global periods, if multiple surgery guidelines apply, if the procedure can be done bilaterally, if an assistant, co-surgeon, or team is allowed for the procedure, if the code is separately billable, and more. Department fee schedules are updated each January and July. Fee schedules are available on the Provider Information website under the Resources by Provider Type button.
Mid-Level Practitioner Billing
Mid-level practitioners must bill under their own NPI and taxonomy number rather than under a physician number.
Physician Billing
Medicaid-enrolled providers may bill for locum tenens physician services when the following criteria are met:
Podiatrist Billing
Podiatrists must use appropriate codes and modifiers from their specific fee schedule.
Independent Labs
Independent labs must use appropriate fee schedules, codes, and modifiers for their provider type.
Independent Diagnostic Testing Facilities (IDTF)
IDTF providers must use appropriate fee schedules, codes and modifiers for their provider type. If an IDTF performs laboratory services, they must enroll as an independent lab in addition to IDTF.
Mobile Imaging/Portable X-ray Supplier
RHC and FQHC practitioners (e.g., physicians, mid-level practitioners) performing services in a hospital setting should bill those services using the appropriate manual/rules that apply for that practitioner.
Abortions
A completed Montana Healthcare Programs Physician Certification for Abortion Services (MA-37) form must be attached to every abortion claim or payment will be denied. This is the only form Medicaid accepts for abortions.
Anesthesia
With the exception of moderate conscious sedation, Montana Medicaid does not allow separate reporting of anesthesia for a medical or surgical procedure when it is provided by the practitioner performing the procedure.
When billing for anesthesia services, the date of service on the claim form must match the date of service that anesthesia was administered. If the surgery overlaps days, then bill the anesthesia only with the start date.
CPT states: For continuous services that last beyond midnight, use the date in which the service began and report the total units of time provided continuously.
The following payment method is used for anesthesia services, regardless of whether the service is billed by an anesthesiologist or another professional. Though the method differs from the RBRVS payment method, the two methods are linked and contain similar provisions.
Bundled Services
Certain services with CPT codes (e.g., telephone advice, some pulse oximetry services) are covered by Medicaid but have a fee of zero. This means that the service is typically bundled with an office visit or other service. Since the bundled service is covered by Medicaid, providers may not bill the member separately for it.
Cosmetic Services
Include the prior authorization number on the claim. (See the Submitting a Claim chapter in this manual.)
EPSDT Well-Child Screens
Family Planning Services
Contraceptive supplies and reproductive health items provided free to family planning clinics cannot be billed to Medicaid. When these supplies are not free to the clinic, providers associated with a family planning clinic can bill Medicaid for the following items:
Code - Item
A4266 - Diaphragm
A4267 - Male Condoms
A4268 - Female Condoms
A4269 - Spermicide
S4993 - Oral Contraceptives
340B drugs may be billed for acquisition costs only. For family planning indicators, see the Submitting a Claim chapter in this manual.
Immunizations
Per CPT, Codes 90460 and 90461 replace deleted Code 90465– Code 90468 for Vaccines for Children (VCF), a program for members ages 0–18.
Code 90460 (non-VFC) is billed for the first component of a vaccine. Code 90461 SL is not allowed by the VFC Program.
VFC codes are reviewed quarterly and updates may be implemented; please consult current provider notices to see if there are any changes.
Follow the CPT coding instructions as outlined in the CPT coding book for the proper use of these codes (i.e., face-to-face physician or qualified healthcare counseling time) member age, and add-on coding rules. Also, a combination of these two sets for the same date of service, member, and provider will result in an NCCI denial, with or without an NCCI modifier, because Codes 90471, 90472, 90473, and 90474 are component codes to Codes 90460 and 90461.
You may only bill for administrative services if performed by or under the direct supervision of a reimbursable professional (i.e., physician, mid-level). All administration of VFC vaccines must be billed on a CMS-1500.
The administration codes should have the appropriate modifier (SL) to be reimbursed for the federally mandated administration rate. Codes for the VFC supplied vaccines must be billed on the same claim with no charge ($0.00). See the fee schedule on the Physician page on the Provider Information website.
Note: If a significant separately identifiable Evaluation and Management (E/M) service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code with the appropriate modifier should be reported in addition to the vaccine and toxoid administrative codes.
Note: Administrative Code 90460 (VFC) may have multiple units per line because the code can be used for all VFCs. Codes 90471, 90473, and 90474 define route of administration.
Note: If a significant separately identifiable E/M service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code with the appropriate modifier should be reported in addition to the vaccine and toxoid administration codes.
Obstetrical Services
If the provider’s care includes prenatal (antepartum) and/or postnatal (postpartum) care in addition to the delivery, the appropriate global OB code must be billed. Antepartum care includes all visits until delivery, and there are different codes for specified numbers of visits. There are also different codes for antepartum and postpartum care when only one or the other is provided. Please review your CPT coding book carefully.
When billing a medical or surgical procedure, the date of service on the claim form must match the date of service that the procedure was performed. If the procedure has a global component and the provider saw the patient before and after the procedure, then the provider must bill the global procedure code on the claim form with the date associated for services rendered. For instance, if a vaginal delivery with antepartum and postpartum care (CPT 59400) is performed, it must be billed using the date of delivery as the from and to dates of service.
Reference Lab Billing
Under federal regulations, all lab services must be billed to Medicaid by the lab that performed the service. Modifier 90, used to indicate reference lab services, is not covered by Medicaid.
Sterilization
For elective sterilizations, a completed Informed Consent to Sterilization (MA-38) form must be attached to the claim for each provider involved or payment will be denied. No fields may be left blank, except for the Interpreter’s Statement. This form must be legible and accurate. If revisions are made, they must be made with a single line through the incorrect information and initialed by the party making the change. patient information may only be changed by the patient and must be initialed by the patient. Documentation must be included explaining why revisions were made. It is the provider’s responsibility to obtain a copy of the form from the primary or attending physician.
For medically necessary sterilizations (including hysterectomies, oophorectomies, salpingectomies, and orchiectomies), one of the following must be attached to the claim, or payment will be denied:
When submitting claims for retroactively eligible members, attach a copy of the MA-160 (eligibility determination letter) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted. For more information on sterilizations, see the Covered Services chapter in this manual.Surgical Services Medicaid does not provide additional payment for the operating room in a physician’s office. Medicaid pays facility expenses only to licensed hospitals and ambulatory surgical centers.
Reporting surgical services
Certain surgical procedures must not be reported together, such as:
Medicaid edits for some surgical services using Medicaid’s National Correct Coding Initiative (NCCI) edits and performs post-payment review on others. See Coding Resources earlier in this chapter for more information on NCCI.
Assistant at Surgery
When billing for an assistant at surgery, refer to the current Medicaid fee schedule to see if an assist is allowed for that procedure.
If an assistant at surgery does not use the appropriate modifier, then either the assistant’s claim or the surgeon’s claim (whichever is received later) will be denied as a duplicate service.
Physicians must bill assistant at surgery services using the appropriate surgical procedure code and Modifier 80, 81, or 82.
Mid-level practitioners must bill assistant at surgery services under their own NPI and taxonomy using the appropriate surgical procedure code and Modifier AS, 80, 81, or 82.
Global surgery periods: Global surgery periods are time spans assigned to surgery codes. During these time spans, services related to the surgery may not be billed. Group practice members that are of the same specialty must bill Medicaid as if a single practitioner provided all related follow-up services for a member. For example, Dr. Armstrong performs orthopedic surgery on a member. The member comes in for a follow-up exam, and Dr. Armstrong is on vacation. Dr. Armstrong’s partner, Dr. Black, performs the follow-up. Dr. Black cannot bill this service to Medicaid because the service was covered in the global period when Dr. Armstrong billed for the surgery.
For major surgeries, this span is 90 days and includes the day prior to the surgery and the following services: post-operative surgery related care and pain management and surgically-related supplies and miscellaneous services.
For minor surgeries and some endoscopies, the spans are either 1 day or 10 days. They include any surgically related follow-up care and supplies on the day of surgery, and for a 10-day period after the surgery.
For a list of global surgery periods by procedure code, see the current Department fee schedule for your provider type.
If the CPT manual lists a procedure as including the surgical procedure only (i.e., a “starred” procedure) but Medicaid lists the code with a global period, the Medicaid global period applies. Almost all Medicaid fees are based on Medicare relative value units (RVUs), and the Medicare relative value units were set using global periods even for starred procedures. Montana Medicaid has accepted these RVUs as the basis for its fee schedule.
In some cases, a physician (or the physician’s partner of the same specialty in the same group practice) provides care within a global period that is unrelated to the surgical procedure. In these circumstances, the unrelated service must be billed with the appropriate modifier to indicate it was not related to the surgery.
Telemedicine Services
When performing a telemedicine consult, use the appropriate CPT E/M consult code. The place of service is the location of the provider providing the telemedicine service. Medicaid does not pay for network use or other infrastructure charges.
Please refer to the Telemedicine section of the General Information for Providers Manual.
Transplants
Include the prior authorization number on the claim. See the Submitting a Claim chapter in this manual. All providers must have their own prior authorization number for the services. For details on obtaining prior authorization, see the Prior Authorization chapter in this manual.
Weight Reduction
Providers who counsel and monitor members on weight reduction programs must bill Medicaid using appropriate E/M codes.
Unlisted Procedures
Unlisted CPT or HCPCS codes and supporting documentation are to be sent to the Department at the address below for review. If the claim is submitted electronically, the documentation must be sent as a paperwork attachment. (See Paperwork Attachment instruction section below.)
Claim Review
Physician-Related Services
P.O. Box 202951
Helena, MT 59624
Providers who submit claims electronically experience fewer errors and quicker payment. Claims may be submitted using the methods below. For detailed submission methods, see the electronic submissions manual on the Electronic Billing page of the website.
o Utilizes either a dial-up modem or submissions through the Montana Access to Health (MATH) Web Portal.
o Requires completion of the X12N Transaction Packet to allow for claim submissions.
o Requires completion of the X12N Transactions Packet to allow for claim submissions.
o A request for this must be made through Conduent Provider Relations for established trading partners.
Providers should be familiar with federal rules and regulations related to electronic claims submission.
When submitting claims that require additional supporting documentation, the Attachment Control Number field must be populated with an identifier. Identifier formats can be designed by software vendors or clearinghouses, but the preferred method is the provider’s NPI followed by the member’s ID number and the date of service, each separated by a dash:
The supporting documentation must be submitted with a Paperwork Attachment Cover Sheet under the forms button on the provider website home page. The number in the paper Attachment Control Number field must match the number on the cover sheet.
Electronic claims that have the PWK indicator will pend for 30 days awaiting the appropriate paperwork to be submitted using the above procedure. If the claim has no PWK indicator, claims will proceed through the normal adjudication process.
For instructions on completing a paper claim, see the Submitting a Claim chapter in this manual. Unless otherwise stated, all paper claims must be mailed to:
Claims Processing
P.O. Box 8000
Helena, MT 59604
Contact Provider Relations for general claim questions and questions regarding member eligibility, payments, and denials.
Paper claims are often returned to the provider before they can be processed, and many other claims (both paper and electronic) are denied. To avoid unnecessary returns and denials, double-check each claim to confirm the following items are included and accurate.
Reasons for Return or Denial:
Provider’s NPI and/or taxonomy missing or invalid
Preventing Returned or Denied Claims:
Verify the correct NPI and taxonomy are on the claim.
Reasons for Return or Denial:
Authorized signature missing.
Preventing Returned or Denied Claims:
Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, or handwritten.
Reasons for Return or Denial:
Signature date missing.
Preventing Returned or Denied Claims:
Each claim must have a signature date.
Reasons for Return or Denial:
Incorrect claim form used.
Preventing Returned or Denied Claims:
The claim must be the correct form for the provider type. Services covered in this manual require a CMS-1500 claim form (or electronic professional claim).
Reasons for Return or Denial:
Information on claim form not legible.
Preventing Returned or Denied Claims:
Information on the claim form must be legible. Use dark ink and center the information in the field. Information must not be obscured by lines.
Reasons for Return or Denial:
Recipient number not on file, or recipient was not eligible on date of service.
Preventing Returned or Denied Claims:
Before providing services to the member:
View the member’s eligibility information at each visit. Medicaid eligibility may change monthly.
Verify member eligibility by using one of the methods described in the Member Eligibility and Responsibilities chapter of the General Information for Providers manual.
Reasons for Return or Denial:
Duplicate claim.
Preventing Returned or Denied Claims:
Please check all remittance advices for previously submitted claims before resubmitting.
When making changes to previously paid claims, submit an adjustment form rather than a new claim. (See Remittance Advices and Adjustments in this manual.)
Please allow 45 days for the Medicare/Medicaid Part B crossover claim to appear on the remittance advice before submitting the claim directly to Medicaid.
Reasons for Return or Denial:
Procedure requires Passport provider referral – No Passport provider number on claim.
Preventing Returned or Denied Claims:
A Passport provider number must be on the claim when such a referral is required. See the Passport to Health manual.
Reasons for Return or Denial:
TPL on file and no credit amount on claim.
Preventing Returned or Denied Claims:
If the member has other insurance (or Medicare), bill the other carrier before Medicaid. See Coordination of Benefits in this manual.
If the member’s TPL coverage has changed, providers must notify Conduent TPL unit before submitting a claim.
End of Billing Procedures Chapter
The services described in this manual are billed either electronically on a professional claim or on a CMS-1500 paper claim form. Claims submitted with all of the necessary information are referred to as clean and are usually paid in a timely manner. (See the Billing Procedures chapter in this manual.)
Claims are completed differently for the different types of coverage a member has. The following are accepted codes for completing box 24h:
Code | Member/Servide | Purpose |
---|---|---|
1 | EPSDT | Used when the member is under age 21. |
2 | Family Planning | Used when providing family planning services. |
3 | EPSDT and family planning | Used when the member is under age 21 and is receiving family planning services. |
4 | Pregnancy (any service provided to a pregnant woman) | Used when providing services to to pregnant women. |
6 | Nursing facility member | Used when providing services to nursing facility residents. |
Unless otherwise stated, all paper claims must be mailed to the following address:
Claims Processing
P.O. Box 8000
Helena, MT 59604
Your signature on the CMS-1500 constitutes your agreement to the terms presented on the back of the form. This form is subject to change by the Centers for Medicare and Medicaid Services (CMS).
Claims are often denied or even returned to the provider before they can be processed. To avoid denials and returns, double-check each claim to confirm the following items are accurate. For more information on returned and denied claims, see the Billing Procedures chapter in this manual.
Claim Errors:
Required field is blank.
Prevention:
If a required field is blank, the claim may either be returned or denied.
Claim Errors:
Member ID number missing or invalid.
Prevention:
This is a required field; verify that the member’s Medicaid ID number is listed as it appears on the member’s eligibility information.
Claim Errors:
Patient name missing.
Prevention:
This is a required field; check that it is correct.
Claim Errors:
Provider NPI and taxonomy missing or invalid.
Prevention:
Verify the correct NPI and taxonomy are on the claim.
Claim Errors:
Referring or Passport provider name and ID number missing.
Prevention:
When a provider refers a member to another provider, include the referring provider’s name and ID number or Passport number. See the Passport to Health manual.
Claim Errors:
Prior authorization number missing.
Prevention:
When prior authorization is required for a service, the prior authorization number must be listed on the claim. See the Prior Authorization chapter in this manual.
Claim Errors:
Not enough information regarding other coverage.
Prevention:
When a member has other coverage, related fields become required.
Claim Errors:
Authorized signature missing.
Prevention:
Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, or hand-written.
Claim Errors:
Signature date missing.
Prevention:
Each claim must have a signature date.
Claim Errors:
Incorrect claim form used.
Prevention:
Services covered in this manual require a CMS-1500 claim form or an electronic professional claim.
Claim Errors:
Information on claim form not legible.
Prevention:
Information on the claim form must be legible. Use dark ink and center the information in the field. Information must not be obscured by lines.
Claim Errors:
Medicare EOMB not attached.
Prevention:
When Medicare is involved in payment on a claim, the Medicare EOMB must be attached to the claim or it will be denied.
This chapter also applies to claims forms completed for Mental Health Services Plan (MHSP) services and Healthy Montana Kids (HMK)/CHIP eyeglass services.
End of Submitting a Claim Chapter
Though providers do not need the information in this chapter in order to submit claims to the Department, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Most services by provider types covered in this manual are reimbursed for using he Department’s RBRVS fee schedule. RBRVS stands for Resource-Based Relative Value Scale. The fee schedule includes CPT codes and HCPCS codes. Within the CPT coding structure, only anesthesia services and clinical lab services are not reimbursed for using the RBRVS fee schedule.
NOTE: Many Medicaid payment methods are based on Medicare, but there are differences. In these cases, the Medicaid method prevails.
RBRVS was developed for the Medicare program. Medicare does a major update annually, with smaller updates performed quarterly. Montana Medicaid’s RBRVS-based fee schedule is based largely on the Medicare model, with a few differences as described below. By adapting the Medicare model to the needs of the Montana Medicaid program, the Department was able to take advantage of the research performed by the federal government and national associations of physicians and other healthcare professionals. RBRVS-based payment methods are widely used across the U.S. by Medicaid programs, workers’ compensation plans and commercial insurers.
Fee Calculation
Each fee is the product of a relative value times a conversion factor.
Basis of Relative Values
For almost all services, Medicaid uses the same relative values as Medicare in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality. For fewer than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the fee.
Composition of Relative Values
For each code, the relative value is the sum of a relative value for the work effort (including time, stress, and difficulty), the associated transitional practice expense, and the associated malpractice expense.
Site of Service Differential
The Medicare program has calculated two sets of relative values for each code: one reflects the practitioner’s practice cost of performing the service in an office and one reflects the practitioner’s practice cost of performing the service in a facility.
Medicaid typically pays a lower fee if the service is provided in a facility because Medicaid typically also pays the facility.
Conversion Factor
The Department sets the conversion factor for the state fiscal year (July through June) and it is listed on the fee schedule.
Policy Adjuster
To encourage access to maternity services and family planning services, the Department increases fees for these codes using a policy adjuster that increases the fee. The fee listed on the fee schedule includes the policy adjuster.
Global Periods
For many surgical services and maternity services, the fee covers both the service and all related care within a specified global period. For almost all such codes, the global periods used by Medicaid are identical to those used by Medicare, but in cases of differences the Medicaid policy applies. See the Billing Procedures chapter in this manual for information on global periods.
Professional and Technical Components
Many imaging services and some diagnostic services are divided into the technical component (performing the test) and the professional component (interpreting the test). A practitioner who only performs the test would bill the service with modifier TC; a practitioner who only interprets the test would bill Modifier 26; and a practitioner who performs both components would bill the code without a modifier. Performance of both components is called the global service. The fee schedule has separate fees for each component and for the global service.
Other Modifiers
Under the RBRVS fee schedule, certain other modifiers also affect payment. Modifiers affecting reimbursement are listed in the table on the next page.
How Modifiers Change Pricing
Modifier: 22 Definition: Increased procedural service
How Payment is Affected: The services is paid at 110% of the fee.
Modifier: 26 Definition: Professional component
How Payment is Affected: For services paid via the RBRVS fee schedule, see the specific service. For other services, payment equals 40% of the fee.
Modifier: 47 Definition: Anesthesia by surgeon
How Payment is Affected: Modifier not allowed.
Modifier: 50 Definition: Bilateral procedure
How Payment is Affected: The procedure is paid at 150% of the fee.
Modifier: 51 Definition: Multiple procedures
How Payment is Affected: Each procedure is paid at 50% of the fee.
Modifier: 52 Definition: Reduced service
How Payment is Affected: The service is paid at 50% of the fee.
Modifier: 53 Definition: Discontinued procedure
How Payment is Affected: The service is paid at 50% of the fee.
Modifier: 54 Definition: Surgical care only
How Payment is Affected: The service is paid at 75% of the fee.
Modifier: 55 Definition: Postoperative management only
How Payment is Affected: The service is paid at 25% of the fee.
Modifier: 56 Definition: Preoperative management only
How Payment is Affected: The service is paid at 25% of the fee.
Modifier: 59 Definition: Distinct procedural service
How Payment is Affected: The service is paid at 50% of the fee unless the procedure is identified as ‘modifier 51 exempt’ or ‘add-on’.
Modifier: 62 Definition: Two surgeons
How Payment is Affected: Each surgeon is paid at 62.5% of the fee.
Modifier: 80 Definition: Assistant surgeon
How Payment is Affected: The service is paid at 16% of the fee.
Modifier: 81 Definition: Minimum assistant surgeon
How Payment is Affected: The service is paid at 16% of the fee.
Modifier: 82 Definition: Assistant surgeon; qualified resident surgeon not available
How Payment is Affected: The service is paid at 16% of the fee.
Modifier: 90 Definition: Reference laboratory
How Payment is Affected: Modifier not allowed
Modifier: AD Definition: Medical supervision of more than four concurrent anesthesia procedures
How Payment is Affected: Each service is paid at 52.5% of the fee.
Modifier: AS Definition: Physician assistant, nurse practitioner or clinical nurse specialist as assistant at surgery
How Payment is Affected: The service is paid at 16% of the fee.
Modifier: QK Definition: Medical supervision of 2–4 concurrent anesthesia procedures
How Payment is Affected: Each service is paid at 52.5% of the fee.
Modifier: QX Definition: Certified registered nurse anesthetist service: medically directed by MD
How Payment is Affected: Each service is paid at 52.5% of the fee.
Modifier: QZ Definition: Certified registered nurse anesthetist service without medical direction
How Payment is Affected: The modifier does not reduce the fee, but a professional differential of 90% is applied due to provider type. See Professional Differentials in this chapter.
Modifier: TC Definition: Technical component
How Payment is Affected: For services paid via the RBRVS fee schedule, see the specific service. For other services, payment equals 60% of the fee.
Professional Differentials
Mid-level practitioners generally receive 90% of the fee that a physician would receive for the same service. The exception is that mid-level practitioners receive 100% of the fee for immunizations, family planning, injectables, lab and pathology services, radiology, cardiography and echocardiography, and services to members under age 21 (i.e., well-child EPSDT services).
Charge Cap
For the services covered in this manual, Medicaid pays the lower of the established Medicaid fee or the provider’s charge.
Bundled Codes
A few services are covered by Medicaid but have a fee of zero, meaning that payment for the service is considered bundled into the payment for services that are usually provided with it. Because these services are covered by Medicaid, providers may not bill members for them on a private-pay basis.
Status Codes
The Medicare physician fee schedule includes status codes that show how each services is reimbursed. Medicaid also uses status codes.
With the exception of moderate conscious sedation, Montana Medicaid does not allow separate reporting of anesthesia for a medical or surgical procedure when it is provided by the practitioner performing the procedure.
When billing for anesthesia services, the date of service on the claim form must match the date of service that anesthesia was administered. If the surgery overlaps days, then bill the anesthesia only with the start date.
NOTE: When billing Medicaid for anesthesia services, enter the number of minutes in the Units field of the CMS-1500 claim form.
CPT states: For continuous services that last beyond midnight, use the date in which the service began and report the total units of time provided continuously.
The following payment method is used for anesthesia services, regardless of whether the service is billed by an anesthesiologist or another professional. Though the method differs from the RBRVS payment method, the two methods are linked and contain similar provisions.
Time Units
A unit of time for anesthesia is 15 minutes, though Medicaid does pay for partial units. Providers enter the number of minutes on the claim; the claims processing contractor then converts the minutes to time units.
Base Units
Base units are adopted by Medicaid from the schedule of base units used by Medicare. Base units are calculated by the American Society of Anesthesiologists. Providers do not enter the number of base units on the claim.
Fee Calculation
For a particular service, Medicaid payment is calculated as follows: (Time units + base units) x anesthesia conversion factor = payment
Modifiers
Payment for anesthesia services is affected by the modifier pricing rules shown in this chapter; take note of the modifiers for anesthesia care provided under medical supervision. Medicaid follows Medicare in not paying extra for the patient status Modifiers P1 to P6.
In general, Medicaid pays the same fees for clinical lab services as Medicare pays in Montana. If a Medicare fee is not available for a lab test covered by Medicaid, then payment is calculated by looking at the average charge and the amounts paid by other payers.
Many vaccines are available for free to physician offices through the Vaccines for Children (VFC) program. For information on obtaining these vaccines, call (406) 444-5580. For these vaccines, Medicaid does not pay separately. Medicaid does pay for the administration of the vaccine, however. Medicaid pays for most vaccines not available through the VFC program. (See the Immunizations section of the Billing Procedures chapter in this manual.)
Reimbursement for physician administered drugs (PAD), which are billed using HCPCS codes is made according to the Department’s fee schedule. The Department’s fee schedule is based on the Medicare Average Sale Price (ASP) Fee Schedule if there is an ASP fee, or the RBRVS fee if there is an RBRVS fee. If there is no ASP or RBRVS fee then the fee is calculated by National Drug Code (NDC) using the estimated acquisition cost to set reimbursement. Most must be billed with a HCPCS code and include the NDC, unit type, and number of units.
Member cost sharing fees are a set dollar amount per visit. (See the Cost Sharing section in the Billing Procedures chapter in the General Information for Providers Manual) The member’s cost sharing amount is shown on the remittance advice and deducted from the Medicaid allowed amount.
When a member has coverage from both Medicaid and Medicare, Medicare is the primary payer as described in the Coordination of Benefits chapter of this manual. Medicaid then makes a payment as the secondary payer. For the provider types covered in this manual, Medicaid’s payment is calculated so that the total payment to the provider is either the Medicaid allowed amount less the Medicare paid amount or the sum of the Medicare coinsurance and deductible, whichever is lower. This method is sometimes called “lower of” pricing.
The payment method described in this chapter also applies to services provided under the Mental Health Services Plan (MHSP).
End of How Payment Is Calculated Chapter
End of Appendix A: Forms Chapter
End of Appendix B: Place of Service Codes Chapter
Montana Medicaid adds many codes from the yearly edition of the Current Procedural Terminology and HCPCS manuals. Refer to the fee schedules posted on the Provider Information website. If you are billing unlisted J codes (e.g., J3490), verify that a new J code does not exist before you bill. If one does not exist send the claim with a copy of the invoice directly to the State office.
The Department does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, age, sex, handicap, political beliefs, religion or disability. This includes the admission to, participation in, or receipt of services or benefits of any of its programs, activities or employment, whether carried out by the Department or through a contractor or other entity.
For questions or to file a complaint alleging violations, contact the Montana Human Rights Bureau (800) 542-0807 or (406) 444-2884.
A sports physical is typically a non problem-oriented encounter in which the provider evaluate and certifies a patient’s involvement in organized sports, such as high school football. If a comprehensive history and physical examination are performed, report the age-appropriate code from the preventive medicine series. If less than a comprehensive history and exam, are performed, report the appropriate level office or other outpatient evaluation and management visit code.
Federal law requires written Medicaid prescriptions to be on tamper-resistant pads. The Department, in accordance with CMS guidance, requires that a Medicaid prescription pad contain all of the following.
End of Definitions and Acronyms Chapter
Previous editions of this manual contained an index.
This edition has three search options.
End of Index Chapter
End of Physician-Related Services Manual