Administrative Rules of Montana › Department 24 - LABOR AND INDUSTRY › Chapter 24.29 - WORKERS' COMPENSATION AND OCCUPATIONAL DISEASE › Subchapter 24.29.14 - General Medical Rules and Facility Service Rules › Rule 24.29.1401A - DEFINITIONS

Current through Register Vol. 13, July 5, 2024
As used in subchapters 14 and 15, the following definitions
				  apply:
(1) "Acute care hospital" or
				"hospital" means a health care facility appropriately licensed by the
				Department of Public Health and Human Services that provides inpatient and
				outpatient medical services to injured workers experiencing acute illness or
				trauma. Acute care hospitals are sometimes referred to as regulated
				hospitals.
(2) "Ambulatory Payment
				Classification (APC)" means the reimbursement system adopted by the department
				for outpatient services.
(3)
				"Ambulatory surgery center (ASC)" means a health care facility that operates
				primarily for the purpose of furnishing outpatient surgical services to
				patients.
(4) "Base rate" means the
				dollar value which is multiplied by the relative weight of the MS-DRG or APC to
				determine payment.
(5) "Bundling"
				means the practice of grouping multiple services, procedures, and supplies into
				one charge item instead of billing each separately.
(6) "CCR," formerly known as "RCC," means the
				cost-to-charge ratio computed by using the hospital's Medicare cost report and
				charges.
(7) "CMS" means the
				Centers for Medicare and Medicaid Services.
(8) "Correct Coding Initiative (CCI)" means
				the code edits adopted by the department that are used to correct contradictory
				billing information.
(9) "Current
				Procedural Terminology (CPT)" codes means codes and descriptors of procedures
				owned, copyrighted, and published by the American Medical
				Association.
(10) "Designated
				Treating Physician" means a provider who is designated or formally approved by
				the insurer as the physician who will be coordinating the injured worker's
				care, according to the criteria in
				39-71-1101, MCA.
(11) "Documentation" means written
				information that is complete, clear, and legible, which describes the service
				provided and substantiates the charge for the service.
(12) "Durable medical equipment (DME)" means
				durable medical appliances or devices used in the treatment or management of a
				condition or complaint, along with associated nondurable materials and supplies
				required for use in conjunction with the appliance or device. The term does not
				include an implantable object or device.
(13) "Evidence-based" means use of the best
				evidence available in making decisions about the care of the individual
				patient, gained from the scientific method of medical decision-making and
				includes use of techniques from science, engineering, and statistics, such as
				randomized controlled trials (RCTs), meta-analysis of medical literature,
				integration of individual clinical expertise with the best available external
				clinical evidence from systematic research, and a risk-benefit analysis of
				treatment (including lack of treatment).
(14) "Facility" or "health care facility"
				means all or a portion of an institution, building, or agency, private or
				public, excluding federal facilities, whether organized for profit or not, that
				is used, operated, or designed to provide health services, medical treatment,
				or nursing, rehabilitative, or preventive care to any individual. The term
				includes chemical dependency facilities, critical access hospitals, end-stage
				renal dialysis facilities, home health agencies, home infusion therapy
				agencies, hospices, hospitals, long-term care facilities, intermediate care
				facilities for the developmentally disabled, medical assistance facilities,
				mental health centers, outpatient centers for surgical services, rehabilitation
				facilities, residential care facilities, and residential treatment facilities.
				The above facilities are defined in
				50-5-101, MCA. The term does not
				include outpatient centers for primary care, infirmaries, provider-based
				clinics, offices of private physicians, dentists or other physical or mental
				health care workers, including licensed addiction counselors.
(15) "Functional status" means written
				information that is complete, clear, and legible, that identifies objective
				findings indicating the claimant's physical capabilities and provides
				information about the change in the status as a result of treatment.
(16) "Healthcare Common Procedure Coding
				System (HCPCS)" means the identification system for health care matters
				developed by the federal government, and includes level one codes, known as CPT
				codes, and level two codes that were developed to use for supplies, procedures,
				or services that do not have a CPT code. These codes also include successor
				codes for CPT and HCPCS established by the American Medical Association and
				CMS.
(17) "Implantable" means a
				system of objects or devices that is made either to replace and act as a
				missing biological structure, to repair or support a biological structure, or
				to manage chronic disease processes and that is surgically implanted, embedded,
				inserted, or otherwise applied. The term also includes any related equipment
				necessary to install, operate, program, and recharge the implantable.
(18) "Improvement status" means written
				information that is complete, clear, and legible, which identifies objective
				medical findings of the claimant's medical status with respect to the treatment
				plan.
(19) "Inpatient services"
				means services rendered to a person who has been admitted to a hospital for bed
				occupancy for purposes of receiving inpatient hospital services. Generally, a
				patient is considered an inpatient if formally admitted as inpatient with the
				expectation that the patient will remain at least overnight and occupy a bed
				even though it later develops that the patient can be discharged or transferred
				to another hospital and not actually use the hospital bed overnight. The
				physician or other practitioner responsible for a patient's care at the
				hospital is also responsible for deciding whether the patient should be
				admitted as an inpatient.
(20)
				"Interested party" means:
(a) the "physician"
				or "provider" as defined by this rule;
(b) the "claimant" or "injured worker";
				or
(c) the representative of the
				injured worker.