Mont. Admin. r. 37.85.212 - RESOURCE BASED RELATIVE VALUE SCALE (RBRVS) REIMBURSEMENT FOR SPECIFIED PROVIDER TYPES
(1) For purposes of
this rule, the following definitions apply:
(a) "Anesthesia units" means time and base
units used to compute reimbursement under RBRVS for anesthesia services. Base
units are those units as defined by the Medicare program. Time units are
15-minute intervals during which anesthesia is provided.
(b) "Conversion factor" means a dollar amount
by which the relative value units, or the anesthesia units for anesthesia
services, are multiplied in order to establish the RBRVS fee for a service. The
effective date and conversion factor amounts are adopted at ARM
37.85.105(2).
There are four conversion factor categories:
(i) physician services, which applies to the
following health care professionals listed in (2): physicians, mid-level
practitioners, podiatrists, public health clinics, independent diagnostic
testing facilities (IDTF), mobile imaging/portable X-ray providers, qualified
Medicare beneficiary (QMB) and early and periodic screening, diagnostic and
treatment (EPSDT) chiropractors, laboratory and x-ray services, family planning
clinics, and dentists providing medical services;
(ii) allied services, which applies to the
following health care professionals listed in (2): physical therapists,
occupational therapists, speech therapists, optometrists, opticians,
audiologists, school-based services, licensed direct-entry midwives, and EPSDT
orientation and mobility specialists;
(iii) mental health services, which applies
to the following health care professionals listed in (2): licensed
psychologists, licensed clinical social workers, and licensed professional
counselors; and
(iv) anesthesia
services, which applies to anesthesia services.
(c) "Conversion factor category" means the
four categories of providers for purposes of calculating Medicaid fees. The
categories are physician services, allied services, mental health services, and
anesthesia services.
(d) "Policy
adjustor" means a factor by which the product of the relative value units and
the conversion factor is multiplied to increase or decrease the fees paid by
Medicaid for certain categories of services.
(e) "Provider rate of reimbursement
adjustment" means the change to the RBRVS fee calculated for a procedure based
on the health care professional delivering the service.
(f) "Rate variable" means a multiplier in the
rate equation, such as a policy adjustor, a provider rate of reimbursement, or
pricing modifier, that changes the RBRVS rate for a procedure or
service.
(g) "RBRVS fee" for a
covered procedure means the amount calculated by multiplying the relative value
units (or the anesthesia units for anesthesia services) for the procedure by
the appropriate conversion factor. If applicable, a rate variable may be
applied to the RBRVS fee to calculate the Montana Medicaid fee for the
procedure.
(h) "Relative value unit
(RVU)" means a numerical value assigned in the resource based relative value
scale to each procedure code used to bill for services provided by a health
care provider. The relative value unit assigned to a particular code expresses
the relative effort and expense expended by a provider in providing one service
as compared with another service.
(i) "Resource-based relative value scale
(RBRVS)" means the Medicare resource-based relative value scale contained in
the Medicare Physician Fee Schedule adopted by the Centers for Medicare &
Medicaid Services (CMS) of the U.S. Department of Health and Human Services.
The effective date and citation for the RBRVS is adopted at ARM
37.85.105(2).
(2) Services provided by the following health
care professionals will be reimbursed in accordance with the RBRVS methodology
set forth in (3):
(a) physicians;
(b) mid-level practitioners;
(c) podiatrists;
(d) physical therapists;
(e) occupational therapists;
(f) speech therapists;
(g) audiologists;
(h) optometrists;
(i) opticians;
(j) public health clinics;
(k) licensed psychologists;
(l) licensed clinical social workers;
(m) licensed professional
counselors;
(n) dentists providing
medical services;
(o) laboratory
and x-ray services;
(p) independent
diagnostic testing facilities (IDTF);
(q) school-based services;
(r) QMB and EPSDT chiropractors;
(s) family planning clinics;
(t) anesthesia services;
(u) licensed direct-entry midwives;
(v) EPSDT orientation and mobility
specialists;
(w) mobile
imaging/portable x-ray providers; and
(x) BCBA/BCBA-D.
(3) The RBRVS fee for a covered service is
calculated by multiplying the RVUs determined in accordance with (7) by the
conversion factor. The RBRVS fee may also be multiplied by a rate variable to
calculate the fee paid by Medicaid.
(4) The conversion factor for physician
services is calculated as stated in
53-6-124 and
53-6-125, MCA. The conversion
factor for allied services, mental health services, and anesthesia services is
calculated as follows:
(a) The total RVUs for
the prior period is calculated as the sum of the product of the RVUs for a
procedure code multiplied by the number of times the procedure code was paid in
a prior period.
(b) The total RVUs
for the prior period is multiplied by the projected change in utilization to
estimate utilization during the appropriation period.
(c) The Montana Legislature's appropriation
for the period is divided by the estimated utilization for the period to
calculate the conversion factor.
(d) The RVU assigned to each procedure code
is multiplied by the appropriate conversion factor to calculate the RBRVS fee
for a particular procedure code.
(5) Policy adjustors will be used to
accomplish targeted funding allocations. The effective date and amounts are as
provided in ARM
37.85.105(2).
(6) All conversion factors may be adjusted,
pursuant to
17-7-140, MCA, to ensure that the
expenditure of appropriations does not exceed available revenue.
(7) The RVUs for services are adopted from
the Medicare Physician Fee Schedule described in (1).
(8) Subject to the provisions of (8)(a), when
billed with a modifier, payment for procedures established under the provisions
of (7) is a percentage of the rate established for the procedures.
(a) The methodology to determine the specific
percent for each modifier is as follows:
(i)
The department obtains information from Medicare and other third party payers
regarding the comparative value utilized for payment of procedures billed with
modifiers.
(ii) The department
establishes a specific percentage for each modifier based upon the purpose of
the modifier, the comparative value of the modified service and the medical
insurance industry trend of reimbursement for the modifier.
(iii) The department's list of the specific
percents for the modifiers used by Medicaid is adopted and incorporated by
reference. A copy of the list is available on the department's web site at:
https://medicaidprovider.mt.gov/manuals/physicianrelatedservicesmanual.
The effective date and amounts are as provided in ARM
37.85.105(2).
(9) In applying the
RBRVS methodology set forth in this rule, Medicaid reimburses in accordance
with Medicare's policy on the bundling of services, as set forth in the
Medicare Physician Fee Schedule adopted by CMS and published in the Federal
Register annually, whereby payment for certain services constitutes payment for
certain other services which are considered to be included in those services.
(10) Providers must bill for
services using the procedure codes and modifiers set forth, and according to
the definitions contained in the Federal Health Care Administration's Common
Procedure Coding System (HCPCS). Information regarding billing codes,
modifiers, and HCPCS is available in provider manuals located on the
department's web site at: https://medicaidprovider.mt.gov/.
Notes
AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-125, MCA
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