Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.2 - Miscellaneous › Rule 37.85.212 - RESOURCE BASED RELATIVE VALUE SCALE (RBRVS) REIMBURSEMENT FOR SPECIFIED PROVIDER TYPES

Current through Register Vol. 13, July 5, 2024
(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 and 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).