Current through Register Vol. 18, September 20, 2024
(1) In
addition to the amount payable under the provisions of ARM
37.40.307(1) or
(4), the department will reimburse nursing
facilities located in the state of Montana for the following separately
billable items. Refer to the department's nursing facility fee schedule for
specific codes and refer to healthcare common procedure coding system (HCPCS)
coding manuals for complete descriptions of codes:
(a) ostomy surgical tray;
(b) ostomy face plate;
(c) ostomy skin barriers;
(d) ostomy filter;
(e) ostomy bags (pouches);
(f) ostomy belt;
(g) adhesive;
(h) adhesive remover;
(i) ostomy irrigation set and
supplies;
(j) ostomy
lubricant;
(k) ostomy
rings;
(l) ostomy irrigation
supply, cone/catheter, including brush;
(m) catheter care kit;
(n) urine test or reagent strips or
tablets;
(o) blood tubing, arterial
or venous;
(p) blood glucose test
strips for dialysis;
(q) blood
glucose test or reagent strips for home blood glucose monitor;
(r) implantable access catheter (venous,
arterial, epidural, subarachnoid, peritoneal, etc.) external access;
(s) gastrostomy/jejunostomy tube, any
material, any type;
(t)
oropharyngeal suction catheter;
(u)
implanted pleural catheter;
(v)
external urethral clamp or compression device;
(w) urinary catheters;
(x) urinary insertion trays (sets);
(y) urinary collection bags;
(z) tracheostomy care kit for established
tracheostomy;
(aa) tracheostomy,
inner cannula (replacement only);
(ab) oxygen contents, portable,
liquid;
(ac) oxygen contents,
portable, gas;
(ad) oxygen
contents, stationary, liquid;
(ae)
oxygen contents, stationary, gas;
(af) cannula, nasal;
(ag) oxygen tubing;
(ah) regulator;
(ai) mouth piece;
(aj) stand/rack;
(ak) face tent;
(al) humidifier;
(am) breathing circuits;
(an) respiratory suction pump, home model,
portable, or stationary;
(ao)
nebulizer, with compressor;
(ap)
feeding syringe;
(aq) nasal
interface (mask or cannula type) used with positive airway device;
(ar) stomach tube - levine type;
(as) nasogastric tubing (with or without
stylet);
(at) nutrition
administration kits;
(au) feeding
supply kits;
(av) nutrient
solutions for parenteral and enteral nutrition therapy when such solutions are
the only source of nutrition for residents who, because of chronic illness or
trauma, cannot be sustained through oral feeding. Payment for these solutions
will be allowed only where the department determines they are medically
necessary and appropriate, and authorizes payment before the items are provided
to the resident;
(aw) routine
nursing supplies used in extraordinary amounts and prior authorized by the
department;
(ax) oxygen
concentrators and portable oxygen units (cart, E tank and regulators), if prior
authorized by the department.
(i) The
department will prior authorize oxygen concentrators and portable oxygen units
(cart, E tank and regulators) only if:
(A)
The provider submits to the department documentation of the cost and useful
life of the concentrator or portable oxygen unit, and a copy of the purchase
invoice.
(B) The provider
maintains a certificate of medical necessity indicating the PO2 level or oxygen
saturation level. This certificate of medical necessity must meet or exceed
Medicare criteria and must be signed and dated by the patient's physician. If
this certificate is not available on request of the department or during audit,
the department may collect the corresponding payment from the provider as an
overpayment in accordance with ARM
37.40.347.
(ii) The provider must
attach to its billing claim a copy of the prior authorization form.
(iii) The department's maximum monthly
payment rate for oxygen concentrators and portable oxygen units (cart, E tank
and regulators) will be the invoice cost of the unit divided by its estimated
useful life as determined by the department. The provider is responsible for
maintenance costs and operation of the equipment and will not be reimbursed for
such costs by the department. Such costs are considered to be covered by the
provider's per diem rate.
(2) The department may, in its discretion,
pay as a separately billable item, a per diem nursing services increment for
services provided to a ventilator dependent resident, trach dependent resident,
behavior related needs resident, wound care resident, bariatric care resident,
and residents with traumatic brain injury (TBI) diagnoses if the department
determines that extraordinary staffing by the facility is medically necessary
based upon the resident's needs.
(a) Payment
of a per diem nursing services increment under (2) for services provided to a
ventilator dependent resident shall be available only if, prior to the
provision of services, the increment has been authorized in writing by the
department's senior and long term care division. Approvals will be effective
for one month intervals and reapproval must be obtained monthly.
(b) The department may require the provider
to submit any appropriate medical and other documentation to support a request
for authorization of the increment. Each calendar month, the provider must
submit to the department, together with reporting forms and according to
instructions supplied by the department, time records of nursing services
provided to the resident during a period of five consecutive days. The
submitted time records must identify the amount of time care is provided by
each type of nursing staff, i.e., licensed and nonlicensed.
(c) The increment amount shall be determined
by the department as follows. The department shall subtract the facility's
current average Medicaid case mix index (CMI) used for rate setting determined
in accordance with ARM
37.40.320
from the CMI computed for the ventilator dependent resident, determined based
upon the current minimum data set (MDS) information for the resident in order
to determine the difference in case mix for this resident from the average case
mix for all Medicaid residents in the facility. The increment shall be
determined by the department by multiplying the provider's direct resident care
component by the ratio of the resident's CMI to the facility's average Medicaid
CMI to compute the adjusted rate for the resident. The department will
determine the increment for each resident monthly after review of case mix
information and five consecutive day nursing time documentation
review.
(3) The
department will reimburse for all Montana Medicaid covered services delivered
via telemedicine/telehealth originating site fees as long as such services are
medically necessary and clinically appropriate for delivery via
telemedicine/telehealth, comply with the guidelines set forth in the applicable
Montana Medicaid provider manual, and are not a service specifically required
to be face-to-face.
(4) The
department will reimburse for separately billable items at direct cost, with no
indirect charges or mark-up added. For purposes of combined facilities
providing these items through the hospital portion of the facility, direct cost
will mean invoice price to the hospital with no indirect cost added.
(a) If the items listed in (1)(a) through
(1)(ax) are also covered by the Medicare program and provided to a Medicaid
recipient who is also a Medicare recipient, reimbursement will be limited to
the lower of the Medicare prevailing charge or the amount allowed under (3).
Such items may not be billed to the Medicaid program for days of service for
which Medicare Part A coverage is in effect.
(b) The department will reimburse for
separately billable items only for a particular resident, where such items are
medically necessary for the resident and have been prescribed by a physician.
(5) Physical,
occupational, and speech therapies which are not nursing facility services may
be billed separately by the licensed therapist providing the service, subject
to department rules applicable to physical therapy, occupational therapy, and
speech therapy services.
(a) Maintenance
therapy and rehabilitation services within the definition of nursing facility
services in ARM
37.40.302
are reimbursed under the per diem rate and may not be billed separately by
either the therapist or the provider.
(b) If the therapist is employed by or under
contract with the provider, the provider must bill for services which are not
nursing facility services under a separate therapy provider number.
(6) Durable medical equipment and
medical supplies which are not nursing facility services in ARM
37.40.302
and which are intended to treat a condition of the recipient which cannot be
met by nursing care, may be billed separately .
(a) Powered wheelchairs are not
covered.
(b) The department may
reimburse a nursing facility for a specialized (non-powered) wheelchair for a
nursing facility resident if the nursing facility demonstrates that the
specialized wheelchair:
(i) is necessary to
treat a condition of the recipient which cannot be met by nursing
care;
(ii) cannot reasonably be
used by another nursing facility resident;
(iii) is the least costly option;
(iv) is necessary to meet the recipient's
mobility-related activities of daily living; and
(v) is not intended for the recipient's
independence or the convenience of the recipient, the recipient's caretaker, or
the provider.
(c) The
department will reimburse for medically necessary custom-molded wheelchair
positioning equipment for a nursing home resident.
(7) All prescribed medication may be billed
separately by the pharmacy providing the medication, subject to department
rules applicable to outpatient drugs. The nursing facility will bill Medicare
directly for reimbursement of Medicare Part B covered drugs and vaccines and
their administration when they are provided to an eligible Medicare Part B
recipient. Medicaid reimbursement is not available for Medicare Part B covered
drugs and vaccines and related administration costs for residents that are
eligible for Medicare Part B.
(8)
Nonemergency routine transportation for activities other than those described
in ARM
37.40.302(11),
may be billed separately in accordance with department rules applicable to such
services. Emergency transportation may be billed separately by an ambulance
service in accordance with department rules applicable to such
services.
(9) The provider of any
other medical services or supplies, which are not nursing facility services,
provided to a nursing facility resident may be billed by the provider of such
services or supplies to the extent allowed under and subject to the provisions
of applicable department rules.
(10) The provisions of (3) through (7) apply
to all nursing facilities, including intermediate care facilities for
individuals with intellectual disabilities, whether or not located in the state
of Montana.
(11) Providers may
contract with any qualified person or agency, including home health agencies,
to provide nursing facility services. However, except as specifically allowed
in these rules, the department will not reimburse the provider for such
contracted services in addition to the amounts payable under ARM
37.40.307.
AUTH:
53-2-201,
53-6-113,
MCA; IMP:
53-2-201,
53-6-101,
53-6-111,
53-6-113,
MCA
