Rule 18-6 Division Established Codes and Values

 

(A)             Face-to-face or telephonic meeting by a treating physician with the employer, claim representatives, or any attorney, and with or without the injured worker. Claim representatives may include physicians or qualified medical personnel performing payer-initiated medical treatment reviews, but this code does not apply to requests initiated by a provider for prior authorization for payment (see Rule 16-9 and 16-10).
Before the meeting is separately payable, the following must be met:
(1)        Each meeting shall be at a minimum 15 minutes. 
(2)        A report or written record signed by the physician is required and shall include the following:
(a)        Who was present at the meeting and their role at the meeting;
(b)        Purpose of the meeting;
(c)        A brief statement of recommendations and actions at the conclusion of the meeting;
(d)        Documented time (both start and end times); and
(e)        Billing code DoWC Z0701.
$75.00 per 15 minutes for time attending the meeting and preparing the report (no travel time or mileage is separately payable). The fee includes the cost of the report for all parties, including the injured worker.
(B)             Cancellation Fees for Payer Made Appointments
(1)        A cancellation fee is payable only when a payer schedules an appointment the injured worker fails to keep, and the payer has not canceled three (3) business days prior to the appointment. The payer shall pay:
One-half of the usual fee for the scheduled services, or $150.00, whichever is less.
Cancellation Fee Billing Code:     DoWC Z0720
(2)        Missed Appointments:
When claimants fail to keep scheduled appointments, the provider should contact the payer within two (2) business days. Upon reporting the missed appointment, the provider may request whether the payer wishes to reschedule the appointment for the claimant. If the claimant fails to keep the payer’s rescheduled appointment, the provider may bill for a cancellation fee according to 18-6(B).
(C) Copying Fees
The payer, payer's representative, injured worker and injured worker's representative shall pay a reasonable fee for the reproduction of the injured worker's medical record. Reasonable cost for paper copies shall not exceed $14.00 for the first 10 or fewer pages, $0.50 per page for pages 11-40, and $0.33 per page thereafter. Actual postage or shipping costs and applicable sales tax, if any, may also be charged. The per-page fee for records copied from microfilm shall be $1.50 per page.
If the requester and provider agree, the copy may be provided on a disc. The fee will not exceed $14.00 per disc. 
If the requester and provider agree and appropriate security is in place, including, but not limited to, compatible encryption, the copies may be submitted electronically. Requester and provider should attempt to agree on a reasonable fee. Absent an agreement to the contrary, the fee shall be $0.10 per page.
Copying charges do not apply for the initial submission of records that are part of the required documentation for billing.
Copying Fee Billing Code:           DoWC Z0721
(D)       Deposition and Testimony Fees
(1)        When requesting deposition or testimony from physicians or any other type of provider, guidance should be obtained from the Interprofessional Code, as prepared by the Colorado Bar Association, the Denver Bar Association, the Colorado Medical Society and the Denver Medical Society. If the parties cannot agree upon lesser fees for the deposition or testimony services, or cancellation time frames and/or fees, the following deposition and testimony rules and fees shall be used.
If, in an individual case, a party can show good cause to an Administrative Law Judge (ALJ) for exceeding the fee schedule, that ALJ may allow a greater fee than listed in 18-6(D) for that case.
(2)        By prior agreement, the provider may charge for preparation time for a deposition, for reviewing and signing the deposition or for preparation time for testimony.
Preparation Time:
Treating or Non-treating Provider:
DoWC Z0730                                                    $325.00 per hour
(3)        Deposition:
Payment for a treating or non-treating provider’s testimony at a deposition shall not exceed $325.00 per hour billed in half-hour increments. Calculation of the provider’s time shall be "portal to portal."
If requested, the provider is entitled to a full hour deposit in advance in order to schedule the deposition.
If the provider is notified of the cancellation of the deposition at least seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours s/he has reasonably spent in preparation and shall refund to the deposing party any portion of an advance payment in excess of time actually spent preparing and/or testifying. Bill using code DoWC Z0731.
If the provider is notified of the cancellation of the deposition at least five (5) business days but less than seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours s/he has reasonably spent in preparation and one-half the time scheduled for the deposition. Bill using code DoWC Z0732.
If the provider is notified less than five (5) business days in advance of a cancellation, or the deposition is shorter than the time scheduled, the provider shall be paid the number of hours s/he has reasonably spent in preparation and has scheduled for the deposition. Bill using code DoWC Z0733.
Deposition:
Treating or Non-treating provider: DoWC Z0734              $325.00 per hr.
Billed in half-hour increments
(4)        Testimony:
Calculation of the provider’s time shall be "portal to portal” (includes travel time and mileage in both directions).
For testifying at a hearing, if requested the provider is entitled to a four (4) hour deposit in advance in order to schedule the testimony.
If the provider is notified of the cancellation of the testimony at least seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours s/he has reasonably spent in preparation and shall refund any portion of an advance payment in excess of time actually spent preparing and/or testifying. Bill using code DoWC Z0735.
If the provider is notified of the cancellation of the testimony at least five (5) business days but less than seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours s/he has reasonably spent in preparation and one-half the time scheduled for the testimony. Bill using code DoWC Z0736.
If the provider is notified of a cancellation less than five (5) business days prior to the date of the testimony or the testimony is shorter than the time scheduled, the provider shall be paid the number of hours s/he has reasonably spent in preparation and has scheduled for the testimony. Bill using code DoWC Z0737.
Testimony:                   
Treating or Non-treating provider:    DoWC Z0738 
                                    Maximum Rate of $450.00 per hour
(E)       Injured Worker Travel Expenses
The payer shall pay an injured worker for reasonable and necessary expenses for travel to and from medical appointments and reasonable mileage to obtain prescribed medications. The rate for mileage shall be 53 cents per mile. The injured worker shall submit a request to the payer showing the date(s) of travel and mileage, with an explanation for any other reasonable and necessary travel expenses incurred or anticipated.
Mileage Expense Billing Code:    DoWC Z0723
Other Travel Expenses Billing Code: DoWC Z0724
(F)        Permanent Impairment Rating
(1)        The payer is only required to pay for one (1) combined whole-person permanent impairment rating per claim, except as otherwise provided in the Workers' Compensation Rules of Procedures. Exceptions that may require payment for an additional impairment rating include, but are not limited to, reopened cases, as ordered by the Director or an administrative law judge, or a subsequent request to review apportionment. The authorized treating provider is required to submit in writing all permanent restrictions and future maintenance care related to the injury or occupational disease.
(2)        Provider Restrictions
The permanent impairment rating shall be determined by the Level II Accredited Authorized Treating Physician (see Rule 5-5(D)).
(3)        Maximum Medical Improvement (MMI) Determined Without any Permanent Impairment
When physicians determine the injured worker is at MMI and has no permanent impairment, the physicians should be reimbursed an appropriate level of E&M service. The authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient should complete the Physician’s Report of Workers’ Compensation Injury (Closing Report), WC164 (see 18-6(G)(2)). Reimbursement for the appropriate level of E&M service is only applicable if the physician examines the injured worker and meets the criteria as defined in the RVP©.
(4)        MMI Determined with a Calculated Permanent Impairment Rating
(a)        Calculated Impairment: The total fee includes the office visit, a complete physical examination, complete history, review of all medical records except when the amount of medical records is extensive (see below), determining MMI, completing all required measurements, referencing all tables used to determine the rating, using all report forms from the AMA's Guide to the Evaluation of Permanent Impairment, Third Edition (Revised), (AMA Guides), and completing the Division form, titled Physician's Report of Workers’ Compensation Injury (Closing Report) WC164.
Extensive medical records take longer than one (1) hour to review and a separate report is created. The separate report must document each record reviewed, specific details of the record reviewed and the dates represented by the record(s) reviewed. The separate record review can be billed under special reports for written reports only and requires prior authorization and agreement from the payer for the separate record review fees.
(b)        Use the appropriate DoWC code:
(1)        Fee for the Level II Accredited Authorized Treating Physician Providing Primary Care:
Bill DoWC Z0759 $355.00.
(2)        Fee for the Referral, Level II Accredited Authorized Physician:
Bill DoWC Z0760 $575.00.
(3)        A return visit for a range of motion (ROM) validation shall be reimbursed using the appropriate separate procedure CPT® code in the medicine section of the RVP©.
(4)        Fee for a Multiple Impairment Evaluation Requiring More Than One (1) Level II Accredited Physician:
All physicians providing consulting services for the completion of a whole person impairment rating shall bill using the appropriate E&M consultation code and shall forward their portion of the rating to the authorized physician determining the combined whole person rating.
(G)       Report Preparation
(1)        Routine Reports
Routine reports or records are incorporated in all fees for service. They include:
Diagnostic testing
Procedure reports
Progress notes
Office notes
Operative reports
Supply invoices, if requested by the payer
Providers shall submit routine reports free of charge as directed in Rule 16-7(E) and by statute. Requests for additional copies of routine reports and for reports not in Rule 16-7(E) or in statute are reimbursable under the copying fee section of this Rule.
(2)        Completion of the Physician’s Report of Workers’ Compensation Injury (WC164)
(a)        Initial Report
The authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient completes the initial WC164 and submits it to the payer and to the injured worker after the first visit with the injured worker. When applicable, the emergency room or urgent care authorized treating physician for this workers’ compensation injury may also create a WC164 initial report. Unless requested or prior authorized by the payer in a specific workers’ compensation claim, no other authorized physician should complete and bill for the initial WC164 form. This form shall include completion of items 1-7 and 10. Note that certain information in Item 2 (such as Insurer Claim #) may be omitted if not known by the provider.
(b)        Closing Report
The WC164 closing report is required from the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient when the injured worker is at maximum medical improvement for all injuries or diseases covered under this workers’ compensation claim, with or without a permanent impairment. The form requires the completion of items 1-5, 6 b-c, 7, 8 and 10. If the injured worker has sustained a permanent impairment, then Item 9 must be completed and the following additional information shall be attached to the bill at the time MMI is determined:
(1)        All necessary permanent impairment rating reports when the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is Level II Accredited, or
(2)        The name of the Level II Accredited Physician requested to perform the permanent impairment rating when a rating is necessary and the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is not determining the permanent impairment rating.
(c)        Payer Requested WC164 Report
If the payer requests a provider complete the WC164 report, the payer shall pay the provider for the completion and submission of the completed WC164 report.
(d)        Provider Initiated WC164 Report
If a provider wants to use the WC164 report as a progress report or for any purpose other than those designated in 18-6(G)(2)(a), (b) or (c), and seeks reimbursement for completion of the form, the provider shall get prior approval from the payer.
(e)        Billing Codes and Maximum Allowance for completion and submission of WC164 report
Maximum allowance for the completion and submission of the WC164 report is:
DoWC Z0750  $42.00 Initial Report
DoWC Z0751    $42.00 Progress Report (Payer Requested or Provider Initiated)
DoWC Z0752    $42.00 Closing Report
DoWC Z0753    $42.00 Initial and Closing Reports are completed on the
                        same form for the same date of service
(3)        Request for physicians to complete additional forms sent to them by a payer or employer shall be paid by the requesting party. A form requiring 15 minutes or less of a physician’s time shall be billed pursuant to (a) and (b) below. Forms requiring more than 15 minutes shall be paid as a special report.
(a)        Billing Code Z0754
(b)        Maximum fee is $42.00 per form completion
(4)        Special Reports
Description: The term special reports includes reports not otherwise addressed under Rule 16, Utilization Standards, Rule 17, Medical Treatment Guidelines and Rule 18, including any form, questionnaire or letter with variable content. This includes, but is not limited to, independent medical evaluations (Z0756) or reviews when the physician is requested to review files and examine the patient to provide an opinion for the requesting party, performed outside C.R.S. §8-42-107.2 (the Division IME process) and treating or non-treating medical reviewers or evaluators producing written reports pertaining to injured workers not otherwise addressed. Special reports also include payment for meeting, reviewing another’s written record, and amending or signing that record (see 18-5(I)(7)). Reimbursement for preparation of special reports or records shall require prior agreement with the requesting party. 
Billable Hours: Because narrative reports may have variable content, the content and total payment shall be agreed upon by the provider and the report's requester before the provider begins the report.
Advance Payment: If requested, the provider is entitled to a two (2) hour deposit in advance in order to schedule any patient exam associated with a special report.   
Cancellation:
Written Reports Only: In cases of cancellation for those special reports not requiring a scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation up to the date of cancellation. Bill the cancellation using code DoWC Z0761.
IME/report with patient exam: In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation at least seven (7) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and shall refund to the party requesting the special report any portion of an advance payment in excess of time actually spent preparing. Bill the cancellation using code DoWC Z0762.
In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation at least five (5) business days but less than seven (7) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and one-half the time scheduled for the patient exam. Any portion of a deposit in excess of this amount shall be refunded. Bill the cancellation using code DoWC Z0763.
In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation less than five (5) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and has scheduled for the patient exam. Bill the cancellation using code DoWC Z0764.
Billing Codes:
Written Report Only                   DoWC Code:    Z0755
IME/Report with patient exam      DoWC Code:    Z0756
Lengthy Form Completion           DoWC Code:    Z0757
18-5(I)(7) meeting and report
with Non-treating Physician        DoWC Code:    Z0758
Special Report Maximum Fees:  $325.00 per hour billed in 15- minute increments.
CRS 8-43-404 IME Audio Recording       DoWC Code:    Z0766
                                                            $30.00 per exam
CRS 8-43-404 IME Audio copying fee     DoWC Code:    Z0767
                                                            $20.00 per copy
(5)        Chronic Opioid Management Report
(a)        When the authorized treating physician prescribes long-term opioid treatment, s/he shall use the Division of Workers’ Compensation Chronic Pain Disorder Medical Treatment Guidelines and also review the Colorado State Board of Medical Examiners’ Policy # 10-14, “Guidelines for the Use of Controlled Substances for the Treatment of Pain.” Urine drug tests for chronic opioid management shall employ testing methodologies that meet or exceed industry standards for sensitivity, specificity and accuracy. The test methodology must be capable of identifying and quantifying the parent compound and relevant metabolites of the opioid prescribed. In-office screening tests designed to screen for drugs of abuse are not appropriate for chronic opioid compliance monitoring.
(1)        Drug testing shall be done prior to the initial long-term drug prescription being implemented and randomly repeated at least annually.
(2)        When drug screen tests are ordered, the authorized treating physician shall utilize the Colorado Prescription Drug Monitoring Program (PDMP).
(3)        While the injured worker is receiving chronic opioid management, additional drug screens with documented justification may be conducted. Examples of documented justification include the following:
 (i)        Concern regarding the functional status of the patient
(ii)        Abnormal results on previous testing
(iii)       Change in management of dosage or pain
(iv)       Chronic daily opioid dosage above 150 mg of morphine or equivalent
(4)        The opioids prescribed for long-term treatment shall be provided through a pharmacy.
(5)        The prescribing authorized treating physician shall review and integrate the screening results, PDMP, and the injured worker’s past and current functional status on the prescribed levels of medications. A written report will document the treating physician’s assessment of the patient’s past and current functional status of work, leisure activities and activities of daily living competencies.
(b)        Codes and maximum fees for the authorized treating physician for a written report with all the following review services completed and documented:
(1)        Ordering and reviewing drug tests
(2)        Ordering and reviewing PDMP results
(3)        Reviewing the medical records
(4)        Reviewing the injured workers’ current functional status
(5)        Determining what actions, if any, need to be taken
(6)        Appropriate chronic pain diagnostic code (ICD)
Bill using code DoWC Z0765      $75.00 per 15 minutes
– maximum of 30 minutes per report
NOTE: This code is not to be used for acute or subacute pain management.
(H)       Supplies, Durable Medical Equipment (DME), Orthotics and Prostheses
(1)        Unless other limitations exist in this Rule, medical professionals may bill supplies, including “Supply et al.,” orthotics, prostheses, DME or drugs, including injectables, using Medicare’s HCPCS Level II codes, when one exists, as established in the most recent January Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) schedule.  Otherwise, the billing provider is responsible for identifying their cost for the items, if they wish to be paid at their cost plus 20% instead of Medicare’s Colorado HCPCS Level II maximum fee. This may be done using an advance agreement between the payer and provider or may be done by furnishing an invoice with their bill.
(2)        Payers may pay medical professionals using Medicare’s most recent January DMEPOS Colorado HCPCS Level II maximum fee values listed for the codes billed unless the provider has indicated that the item(s) is to be paid at cost plus 20%. If no code exists, the payer shall pay 120% of the cost for the item as indicated on the provider’s invoice.
(3)        Reimbursement of supplies to facilities shall be in compliance with Rule 18-6 (I) – (K). If the provider failed to indicate that an item was to be paid at cost plus 20%, and their cost plus 20% is more than the Medicare Colorado HCPCS Level II value, the provider may submit cost information within 60 days following receipt of the Explanation of Benefits (EOB) and is entitled to at least their cost plus 20%.
(4)        Payment for professional services associated with the fabrication and/or modification of orthotics, custom splints, adaptive equipment, and/or adaptation and programming of communication systems and devices shall be paid in accordance with the Colorado Medicare HCPCS Level II values.
(I)         Inpatient Hospital Facility Fees
(1)        Provider Restrictions
All non-emergency, inpatient admissions require prior authorization for payment (see Rule 16-9 and 16-10).
(2)        Bills for Services
(a)        Inpatient hospital facility fees shall be billed on the UB-04 and require summary level billing by revenue code. The provider must submit itemized bills along with the UB-04.
(b)        The maximum inpatient facility fee is determined by applying the Center for Medicare and Medicaid Services (CMS) “Medicare Severity Diagnosis Related Groups” (MS-DRGs) classification system in effect at the time of discharge. Exhibit #1 to Rule 18 shows the relative weights per MS-DRGs that are used in calculating the maximum allowance.
The hospital shall indicate the MS-DRG code number FL 71 of the UB-04 billing form and maintain documentation on file showing how the MS-DRG was determined. The hospital shall determine the MS-DRG using the MS-DRGs Definitions Manual in effect at the time of discharge. The attending physician shall not be required to certify this documentation unless a dispute arises between the hospital and the payer regarding MS-DRG assignment. The payer may deny payment for services until the appropriate MS-DRG code is supplied.
(c)        Exhibit #1 to this Rule establishes the maximum length of stay (LOS) using the “arithmetic mean LOS”. However, no additional allowance for exceeding this LOS, other than through the cost outlier criteria under 18-6(I)(3)(d) is allowed.
(d)        Any inpatient admission requiring the use of both an acute care hospital (admission/discharge) and its Medicare certified rehabilitation facility (admission/discharge) is considered as one (1) admission and MS-DRG. This does not apply to long term care and licensed rehabilitation facilities.
(3)        Inpatient Facility Reimbursement:
(a)        The following types of inpatient facilities are reimbursed at 100% of billed inpatient charges:
(1)        Children’s hospitals
(2)        Veterans’ Administration hospitals
(3)        State psychiatric hospitals
(b)        The following types of inpatient facilities are reimbursed at 80% of billed inpatient charges:
(1)        Medicare certified Critical Access Hospitals (CAH) (listed in Exhibit #3 of this Rule)
(2)        Medicare certified long-term care hospitals
(3)        Colorado Department of Public Health and Environment (CDPHE) licensed rehabilitation facilities,
(4)        CDPHE licensed psychiatric facilities that are privately owned.
(5)        CDPHE licensed skilled nursing facilities (SNF).
(c)        All other inpatient facilities are reimbursed as follows:
Retrieve the relative weights for the assigned MS-DRG from the MS-DRG table in effect at the time of discharge in Exhibit #1 of this Rule and locate the hospital’s base rate in Exhibit #2 of this Rule.
The “Maximum Fee Allowance” is determined by calculating:
(1)        (MS-DRG Relative Wt x Specific hospital base rate x 185%) + (trauma center activation allowance) + (organ acquisition, when appropriate).
2)         For trauma center activation allowance, (revenue codes 680-685) see 18-6(J)(6)(b)(5).
(3)        For organ acquisition allowance, (revenue codes 811-812) see 18-6(I)(3)(h).
(d)        Outliers are admissions with extraordinary cost warranting additional reimbursement beyond the maximum allowance under 18-6(I)(3)(c). To calculate the additional reimbursement, if any:
(1)        Determine the “Hospital’s Cost”:
Total billed charges (excluding any trauma center activation or organ acquisition billed charges) multiplied by the hospital’s cost-to-charge ratio.
(2)        Each hospital’s cost-to-charge ratio is given in Exhibit #2 of this Rule.
(3)        The “Difference” = “Hospital’s Cost” – “Maximum Fee Allowance” excluding any trauma center activation or organ acquisition allowance (see (c) above).
(4)        If the “Difference” is greater than $24,104.00, additional reimbursement is warranted. The additional reimbursement is determined by the following equation:
“Difference” x .80 = additional fee allowance
(e)        Inpatient combined with ERD, Trauma Center or organ acquisition reimbursement
(1)        If an injured worker is admitted to the hospital, the ERD reimbursement is included in the inpatient reimbursement under 18-6 (I)(3),
(2)        Trauma Center activation fees (see 18-6(J)(6)(b)(5)) and organ acquisition allowance (see 18-6(I)(3)(h)) are paid in addition to inpatient fees (18-6(I)(3)(c-d)).
(f)         If an injured worker is admitted to one hospital and is subsequently transferred to another hospital, the payment to the transferring hospital will be based upon a per diem value of the MS-DRG maximum value. The per diem value is calculated based upon the transferring hospital’s MS-DRG relative weight multiplied by the hospital’s specific base rate (Exhibit #2 of this Rule) divided by the MS-DRG geometric mean length of stay (Exhibit #1 of this Rule). This per diem amount is multiplied by the actual LOS. If the patient is admitted and transferred on the same day, the actual LOS equals one (1). The receiving hospital shall receive the appropriate MS-DRG maximum value.
(g)        To comply with Rule 16-6(B), the payer shall compare each billed charge type:
•           The MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier allowance);
•           The trauma center activation billed charge to the trauma center activation allowance; and 
•           The organ acquisition charges to the organ acquisition maximum fees under 18-6(I)(3)(h).
The MS-DRG adjusted billed charges are determined by subtracting the trauma center activation billed charges and the organ acquisition billed charges from the total billed charges. The final payment is the sum of the lesser of each of these comparisons.
(h)        The organ acquisition allowance will be calculated using the most recent filed computation of organ acquisition costs and charges for hospitals which are certified transplant centers (CMS Worksheet D-4 or subsequent form) plus 20%.
(J)        Outpatient Hospital Facility Fees
(1)        Provider Restrictions
(a)        All non-emergency outpatient surgeries require prior authorization for payment (see Rule 16-9 and 16-10).
(b)        A separate facility fee is only payable if the facility is licensed as a hospital by the Colorado Department of Public Health and Environment (CDPHE) or applicable out of state governing agency and statute.
(2)        Types of Bills for Service
(a)        Outpatient facility fees shall be billed on the UB-04 and require summary level billing by revenue code. The provider must submit itemized bills along with the UB-04.
(b)        All professional charges are subject to the RVP© and Dental Fee Schedules as incorporated by this Rule and applicable to all facilities regardless of whether the facility fees are based upon Exhibit #4 or a percentage of billed charges.
(c)        Outpatient hospital facility bills include all outpatient surgery, Emergency Room Department (ERD), Clinics, Urgent Care (UC) and diagnostic testing.
(3)        Outpatient Facility Reimbursement:
(a)        The following types of outpatient facilities are reimbursed at 100% of billed outpatient charges, except for any associated professional fees:
(1)        Children’s hospitals
(2)        Veterans’ Administration hospitals
(3)        State psychiatric hospitals
(b)        The following types of outpatient facilities are reimbursed at 80% of billed outpatient clinic facility charges only, except for any associated professional fees:
(1)        CAH facilities listed in Exhibit #3 of this Rule.
(2)        Primary Rural Health clinics, listed in Exhibit # 5 of this Rule.
(c)        Exhibit #4 to this Rule
Hospital reimbursement is based upon Medicare’s 2013 Outpatient Prospective Payment System (OPPS) as modified in Exhibit #4 of this Rule. Exhibit #4 lists Medicare’s Outpatient Hospital Ambulatory Prospective Payment (APC) Codes and the Division’s established rates for hospitals and other types of providers as follows:
•           Column 1 lists the APC code number.
•           Column 2 lists APC code description.
•           Column 3 is used to determine maximum fees for all Outpatient Hospital Emergency Room Departments (ERDs).
•           Column 4 is used to determine maximum fees for all hospital facilities not listed under 18-6(J)(3)(a) and (b).
•           Column 5 is used to determine maximum fees for all Ambulatory Surgery Centers (ASC) when outpatient surgery is performed in an ASC.
To identify which APC grouper is aligned with an Exhibit #4 APC code # and dollar value, use Medicare’s 2013 Addendum B. Grouper code 210 in Exhibit #4 was created by the Division to reimburse RVP© spinal fusion codes not listed in Medicare’s Hospital Outpatient Prospective Payment System, Addendum B.
(4)        The APC Exhibit #4 values include the following packaged revenue codes inclusive of the following services (all surgical implants are separately payable at cost to the facility):  
            (a)        nursing, technician, and related services;
            (b)        use of the facility where the surgical procedure(s) was performed;
            (c)        drugs and biologicals for which separate payment is not allowed;
            (d)        medical and surgical supplies, durable medical equipment and orthotics not listed as a “pass through”;
            (e)        surgical dressings;
            (f)         equipment;
            (g)        splints, casts and related devices;
            (h)        radiology services when not allowed under Exhibit #4;
            (i)         administrative, record keeping and housekeeping items and services;
            (j)         materials, including supplies and equipment for the administration and monitoring of anesthesia;
            (k)        supervision of the services of an anesthetist by the operating surgeon; and
            (l)         post-operative pain blocks.
 

Packaged Services
Revenue Code
Description
0250
Pharmacy; General Classification
0251
Pharmacy; Generic Drugs
0252
Pharmacy; Non-Generic Drugs
0254
Pharmacy; Drugs Incident to Other Diagnostic Services
0255
Pharmacy; Drugs Incident to Radiology
0257
Pharmacy; Non-Prescription
0258
Pharmacy; IV Solutions
0259
Pharmacy; Other Pharmacy
0260
IV Therapy; General Classification
0261
IV Therapy; Infusion Pump
0262
IV Therapy; IV Therapy/Pharmacy Services
0263
IV Therapy; IV Therapy/Drug/Supply Delivery
0264
IV Therapy; IV Therapy/Supplies
0269
IV Therapy; Other IV Therapy
0270
Medical/Surgical Supplies and Devices; General Classification
0271
Medical/Surgical Supplies and Devices; Non-sterile Supply
0272
Medical/Surgical Supplies and Devices; Sterile Supply
0275
Medical/Surgical Supplies and Devices; Pacemaker
0276
Medical/Surgical Supplies and Devices; Intraocular Lens
0278
Medical/Surgical Supplies and Devices; except surgically implanted devices
0279
Medical/Surgical Supplies and Devices; except surgically implanted devices
0280
Oncology; General Classification
0289
Oncology; Other Oncology
0343
Nuclear Medicine; Diagnostic Radiopharmaceuticals
0344
Nuclear Medicine; Therapeutic Radiopharmaceuticals
0370
Anesthesia; General Classification
0371
Anesthesia; Anesthesia Incident to Radiology
0372
Anesthesia; Anesthesia Incident to Other DX Services
0379
Anesthesia; Other Anesthesia
0390
Administration, Processing and Storage for Blood and Blood Components; General Classification
0392
Administration, Processing and Storage for Blood and Blood Components; Processing and Storage
0399
Administration, Processing and Storage for Blood and Blood Components; Other Blood Handling
0621
Medical Surgical Supplies - Extension of 027X; Supplies Incident to Radiology
0622
Medical Surgical Supplies - Extension of 027X; Supplies Incident to Other DX Services
0623
Medical Supplies - Extension of 027X, Surgical Dressings
0624
Medical Surgical Supplies - Extension of 027X; FDA Investigational Devices
0630
Pharmacy - Extension of 025X; Reserved
0631
Pharmacy - Extension of 025X; Single Source Drug
0632
Pharmacy - Extension of 025X; Multiple Source Drug
0633
Pharmacy - Extension of 025X; Restrictive Prescription
0700
Cast Room; General Classification
0710
Recovery Room; General Classification
0720
Labor Room/Delivery; General Classification
0721
Labor Room/Delivery; Labor
0732
EKG/ECG (Electrocardiogram); Telemetry
0801
Inpatient Renal Dialysis; Inpatient Hemodialysis
0802
Inpatient Renal Dialysis; Inpatient Peritoneal Dialysis (Non-CAPD)
0803
Inpatient Renal Dialysis; Inpatient Continuous Ambulatory Peritoneal Dialysis (CAPD)
0804
Inpatient Renal Dialysis; Inpatient Continuous Cycling Peritoneal Dialysis (CCPD)
0809
Inpatient Renal Dialysis; Other Inpatient Dialysis
0810
Acquisition of Body Components; General Classification
0819
Inpatient Renal Dialysis; Other Donor
0821
Hemodialysis-Outpatient or Home; Hemodialysis Composite or Other Rate
0824
Hemodialysis-Outpatient or Home; Maintenance - 100%
0825
Hemodialysis-Outpatient or Home; Support Services
0829
Hemodialysis-Outpatient or Home; Other OP Hemodialysis
0942
Other Therapeutic Services (also see 095X, an extension of 094x); Education/Training
0943
Other Therapeutic Services (also see 095X, an extension of 094X), Cardiac Rehabilitation
0948
Other Therapeutic Services (also see 095X, an extension of 094X), Pulmonary Rehabilitation

(5)        Recognized Status Indicators from Medicare’s Addendum “B” and are applied as follows:
(a)        “A” means use another fee schedule instead of Exhibit #4, i.e., 18-4 Conversion Factors or 18-6(Q) Ambulance Fee Schedule.
(b)        “B” means it is not recognized by Medicare for Outpatient Hospital services Part B bill type (12x and 130x) and therefore is not separately payable unless separate fees are applicable under another section of this Rule 18, such as home health.
(c)        “C” means recognized by Medicare as inpatient only procedures; however, the DWC does recognize these procedures can be done outpatient if prior authorization is obtained per Rule 16-6(C).
(d)        “G” means it is a separate “Pass-Through Drugs and Biologicals” that is separately payable under Exhibit #4.
(e)        “H” means it is a separate “Pass-Through Device” that is separately payable under Exhibit #4.
(f)         “K” means it is not a separately payable “Pass-Through Drug or Biological or Device,” with this code.
(g)        “L” represents Influenza Vaccine and therefore, is generally not considered workers compensation related.
(h)        Any “Packaged Codes” with Q1, Q2, Q3, or STVX combinations are not recognized unless the payer and provider make a prior agreement.
(i)         “M” means not separately payable unless separate fees are applicable under another section of this Rule 18, such as home health.
(j)         “N” means the service is bundled and is not separately payable.
(k)        “R” means separate payment for blood and blood products.
(l)         “S” and “T” means there are multiple procedures, the highest valued code allowed at 100% of the Exhibit #4 value and up to three (3) additional codes allowed at 50% of the Exhibit #4 value, per episode of care.
(m)       “U” means Brachytherapy is separately payable.
(n)        “V” represents a clinic or Emergency Department Visit and is separately payable for hospitals.
(o)        “X” represents Ancillary Services and is separately payable.
(p)        “Y” represents non-implantable Durable Medical Equipment and is paid according to Medicare’s Durable Medical Equipment Regional Carrier (DMERC) fee schedule for Colorado.
(6)        Total maximum facility value for an outpatient hospital episode of care includes:
(a)        The highest valued CPT® code aligned to APC code per Exhibit #4 plus 50% of any lesser-valued CPT® code aligned APC code values.
Facility fee reimbursement is limited to a maximum of four (4) CPT® procedure codes per episode with a maximum of only one (1) procedure reimbursed at 100% of the allowed Exhibit #4 value for the type of facility:
•           Hospital Outpatient ERD bills are reimbursed based upon Column 3;
•           Hospitals are reimbursed based upon Column 4.
•           ASCs are reimbursed for their services under Column 5.
(b)        Fees in addition to section 18-6(J)(6) and requirements necessary to be reimbursed under Column 3 from Exhibit #4 for an Outpatient Hospital ERD Column:
(1)        Outpatient ERDs within Colorado must be physically located within a hospital licensed by the CDPHE as a general hospital; or
(2)        Free-standing ERD, must have equivalent operations as a licensed ERD; or
(3)        Meet the out-of-state facility’s state’s licensure requirements.
(4)        The ERD “Level of Care” is identified based upon one (1) of five (5) levels of care. The level of care is defined by CPT® E&M definitions and internal level of care guidelines developed by the hospital in compliance with Medicare regulations. The hospital’s guidelines should establish an appropriate graduation of hospital resources (ERD staff and other resources) as the level of service increases. Upon request the provider shall supply a copy of their level of care guidelines to the payer. (Only the higher one (1) of any ERD Levels or critical care codes shall be paid).
(5)        Trauma Center fees are not paid for alerts. Trauma activation fees are as follows:
•           Revenue Code 681                    $3,000.00
•           Revenue Code 682                    $2,500.00
•           Revenue Code 683                    $1,000.00
•           Revenue Code 684                                $0
(a)        These fees are in addition to ERD and inpatient fees.
(b)        Activation fees mean a trauma team has been activated, not just alerted.
(c)        The level of trauma activation shall be determined by CDPHE’s assigned hospital trauma level designation.
(6)        The hospital shall be paid an outlier threshold payment if the hospital’s cost is greater than its maximum fee per billed line by $500.00. The outlier calculation is as follows:
•           “Cost” is calculated by taking the individual hospital’s “CCR” rate listed in Exhibit #2 of this Rule and multiplying it by the hospital’s line charge.
•           “Difference” is equal to the Hospital’s line cost subtracted from the line maximum fee.
•           If the line “difference” is greater than $500.00, then the maximum outlier dollar is 80% of the difference. If the difference is equal to or less than $500.00 then no additional outlier dollars are warranted
(7)        For the purposes of Rule 16-6 (B), the sum of all outpatient ERD fees charged, less any amounts charged for professional fees found on the same bill, is to be compared to the maximum reimbursement allowed by the calculated value of 18-6(J)(6)(b). The lesser of the two (2) amounts shall be the maximum facility allowance for the ERD episode of care. A line by line comparison is not appropriate.
(8)        If an injured worker is admitted to the hospital through that hospital’s ERD, the ERD reimbursement is included in the inpatient reimbursement under 18-6(I)(3).
(c)        Multiple APCs identified by multiple CPT® codes are to be indicated by the use of modifiers –51 and –50, respectively. The 50% reduction applies to all lower valued procedures, even if they are identified in the RVP© as modifier -51 exempt. The reduction also applies to the second "primary" procedure of bilateral procedures.
(1)        All surgical procedures performed in one operating room, regardless of the number of surgeons, are considered one outpatient surgical episode of care for purposes of facility fee reimbursement
(2)        If an arthroscopic procedure is converted to an open procedure on the same joint, only the open procedure is payable. If an arthroscopic procedure and open procedure are performed on different joints, the two (2) procedures may be separately payable with anatomic modifiers. 
(3)        When reported in conjunction with other knee arthroscopy codes, any combination of surgical knee arthroscopies for removal of loose body, foreign body, and/or debridement/shaving of articular cartilage shall be paid only if performed in a different compartment of the knee using G0289.
(4)        Discontinued surgeries require the use of modifier -73 (discontinued prior to administration of anesthesia) or modifier -74 (discontinued after administration of anesthesia). Modifier -73 results in a reimbursement of 50% of the APC value for the primary procedure only. Modifier -74 allows reimbursement of 100% of the primary procedure value only.
(5)        In compliance with Rule 16-6(B), the sum of 18-6(J)(3)(c) Columns 1-5 is compared to the total facility fee billed charges. The lesser of the two amounts shall be the maximum facility allowance for the surgical episode of care. A line by line comparison of billed charges to the calculated maximum fee schedule allowance of 18-6(J)(3)(c) is not appropriate.
(d)        Any diagnostic testing clinical labs or therapies with a status indicator (SI) of “A” may be reimbursed using the appropriate CF to the unit values for the specific CPT® code as listed in the RVP©.
(e)        Observation room maximum allowance is limited to six (6) hours without prior authorization for payment (see Rule 16-9 and 16-10). Documentation should support the medical necessity for observation or convalescent care. Observation time begins when the patient is placed in a bed for the purpose of initiating observation care in accordance with the physician’s order. Observation or daily outpatient convalescence time ends when the patient is actually discharged from the hospital or ASC or admitted into a licensed facility for an inpatient stay. Observation time would not include the time patients remain in the observation area after treatment is finished for reasons such as waiting for transportation home. Hospital or convalescence licensure is required for billing observation or convalescence time beyond 23 hours.
Billing Codes:
G0378 Observation/Convalescence rate: $45.00 per hour
round to the nearest hour.
(f)         Professional fees are reimbursed according to the fee schedule times the appropriate conversion factor regardless of the facility type. Additional reimbursement is payable for the following services not included in the values found in Exhibit #4 of this Rule:
•           ambulance services (Revenue Code 540), See 18-6(Q)
•           blood, blood plasma, platelets (Revenue Codes 380X)
•           Physician or physician assistant services
•           Nurse practitioner services
•           Licensed clinical psychologist
•           Licensed social workers
•           Rehabilitation services (PT, OT, Respiratory or Speech/Language, Revenue Codes 420, 430,440) are paid based upon the RVP unit value multiplied by the applicable conversion factor.
(g)        Any prescription for a drug supply to be used longer than a 24 hour period, filled at any clinic, shall fall under the requirements of and be reimbursed as, a pharmacy fee. See 18-6(M).
(h)        All the clinics revenue codes are reimbursed in accordance with Exhibit #4 to this Rule.
(K)       Freestanding (Not Affiliated with a Hospital) Outpatient Diagnostic Testing or Treatment Facilities
(1)        Types of facilities
(a)        Ambulatory Surgery Centers licensed by the CDPHE
(b)        Physician offices
(c)        Freestanding Radiology Imaging Cardiovascular Testing and procedure Centers
(d)        Freestanding Clinical Laboratory Centers
(e)        Urgent Care facility fees are only payable if the facility qualifies as an Urgent Care facility. Facilities licensed by the CDPHE as a Community Clinic (CC) or a Community Clinic and Emergency Center (CCEC) under 6 CCR 1011-1, Chapter IX should still provide evidence of these qualifications to be reimbursed as an Urgent Care facility. The facility shall meet all of the following criteria to be eligible for a separate Urgent Care facility fee:
(1)        Separate facility dedicated to providing initial walk-in urgent care;
(2)        Access without appointment during all operating hours;
(3)        State licensed physician on-site at all times exclusively to evaluate walk-in patients;
(4)        Support staff dedicated to urgent walk-in visits with certifications in Basic Life Support (BLS);
(5)        Advanced Cardiac Life Support (ACLS) certified life support capabilities to stabilize emergencies including, but not limited to, EKG, defibrillator, oxygen and respiratory support equipment (full crash cart), etc.;
(6)        Ambulance access;
(7)        Professional staff on-site at the facility certified in ACLS;
(8)        Extended hours including evening and some weekend hours;
(9)        Basic x-ray availability on-site during all operating hours;
(10)      Clinical Laboratory Improvement Amendments (CLIA) certified laboratory on-site for basic diagnostic labs or ability to obtain basic laboratory results within 1 hour;
(11)      Capabilities include, but are not limited to, suturing, minor procedures, splinting, IV medications and hydration; and
(12)      Written procedures exist for the facility’s stabilization and transport processes.
(2)        Billing and Maximum Fees
(a)        ASCs are reimbursed in accordance with 18-6(J) and Column 5 from Exhibit #4.
(b)        Maximum reimbursement for physicians performing diagnostic testing in their offices during the course of their care shall be based upon the appropriate RVP© unit value multiplied by the applicable 18-4 conversion factor.
(c)        Maximum Fees for all Freestanding Diagnostic Testing Facilities:
(1)        All providers should indicate whether they are billing for the total component (00 modifier), professional component only (26 modifier) or technical component only (TC modifier) for any diagnostic test or procedure by listing the appropriate RVP© modifier on the required billing form CMS-1500.
(2)        Shall be based upon the appropriate RVP© unit value multiplied by the applicable 18-4 conversion factor.
(3)        All radiology and cardiovascular codes are reimbursed at 90% of the modified or not modified RVP© unit value multiplied by the radiology 18-4 conversion factor. A maximum of four (4) radiology codes may be used in one (1) episode of outpatient diagnostic testing. The highest valued radiology code is allowed at 100% of the maximum value and the remaining three lower valued codes are allowed at 50% of the maximum radiology value.
 (4)       Diagnostic testing dyes, contrasts, supplies and drugs are not separately payable.
(5)        Fluoroscopy is generally considered incidental when used for guidance when performing a higher valued radiology tests. Refer to CPT® for specific billing instructions.
(6)        The maximum fees for all clinical laboratory testing shall be reimbursed according the fees as outlined under the Pathology section in 18-5(F).
(7)        All observation services must be prior approved by the payer if time is greater than 3 hours.
            G0378 Observation rate: $45.00 per hour
(d)        Urgent Care Facility Reimbursement
(1)        The total maximum value for an urgent care episode of care includes:
(a)        An Urgent Care facility fee maximum allowance of $75.00; and
(b)        Prior agreement or authorization is recommended for all facilities billing a separate Urgent Care fee. Facilities must provide documentation of the required Urgent Care facility criteria as listed in this Rule 18-6(K) if requested by the payer.
(c)        All other services/procedures provided in an Urgent Care are reimbursed according the appropriate CPT® code relative weight from RVP© multiplied by the appropriate 18-4 conversion factor.
(d)        The Observation Room allowance shall not exceed a rate of $45.00 per hour and is limited to a maximum of three (3) hours without prior authorization for payment (see Rule 16-9 and 16-10).
            G0378 Observation rate: $45.00 per hour
(e)        All supplies are included in the facility fee for Urgent Care facilities.
(g)        Any prescription for a drug supply to be used longer than a 24 hour period, filled at any clinic, shall fall under the requirements of and be reimbursed as a pharmacy fee. See 18-6(M).
(2)        No separate facility fees are allowed for follow-up care. Subsequent care for an initial diagnosis does not qualify for a separate facility fee. To receive another facility fee any subsequent diagnosis shall be a new acute care situation entirely different from the initial diagnosis.
(3)        No facility fee is appropriate when the injured worker is sent to the employer's designated provider for a non-urgent episode of care during regular business hours of 8 am to 5 pm, Monday through Friday.
(L)        Home Therapy
Prior authorization for payment (see Rule 16-9 and 16-10) is required for all home therapy. The payer and the home health entity should agree in writing on the type of care, skill level of provider, frequency of care and duration of care at each visit, and any financial arrangements to prevent disputes.
(1)        Home Infusion Therapy
The per diem rates for home infusion therapy shall include the initial patient evaluation, education, coordination of care, products, equipment, IV administration sets, supplies, supply management, and delivery services. Nursing fees should be billed as indicated in 18-6(L)(2).
(a)        Parenteral Nutrition:
S9364 <1 Liter                         $160.00/day
S9365 1 liter                             $174.00/day
S9366 1.1 - 2.0 liter                  $200.00/day
S9367 2.1 - 3.0 liter                  $227.00/day
S9368 > 3.0 liter                       $254.00/day
The per diem rates include the standard total parenteral nutrition (TPN) formula. Lipids, specialty amino acid formulas, and drugs other than in standard formula are separately payable under 18-6(M).
(b)        Antibiotic Therapy Dosage Rate:
(See 18-6(M)(3))
S9494 hourly                                         $158.00/day
S9497 once every 3 hours                     $152.00/day
S9500 every 24 hours                            $ 97.00/day
S9501 once every 12 hours                    $110.00/day
S9502 once every 8 hours                     $122.00/day
S9503 once every 6 hours                     $134.00/day
S9504 once every 4 hours                     $146.00/day
(c)        Chemotherapy Dosage Rate:
Per diem + AWP (See 18-6(M)(3))
S9329   Administrative Services                                      $ 0.00/day
S9330   Continuous (24 hrs. or more) chemotherapy        $91.00/day
S9331   Intermittent (less than 24 hrs.)                             $103.00/day
(d)        Enteral nutrition (enteral formula and nursing services separately billable):
S9341   Via Gravity                                $44.09/day
S9342   Via Pump                                  $24.23/day
S9343   Via Bolus                                  $24.23/day
(e)        Pain Management:         Per diem + AWP (See 18-6(M)(3))
S9326   Continuous (24 hrs. or more)                              $ 79.00/day
S9327   Intermittent (less than 24 hrs.)                             $103.00/day
S9328   Implanted pump                                                 $116.00/day
(f)         Fluid Replacement:        Per diem + AWP (See 18-6(M)(3))
S9373 < 1 liter per day                         $61.00/day
S9374   1 liter per day                           $85.00/day
S9375 >1 but <2 liters per day               $85.00/day
S9376 >2 liters but <3 liters                   $85.00/day
S9377 >3 liters per day                         $85.00/day
(g)        Multiple Therapies:
Rate per day for highest cost therapy only + AWP (see 18-6(M)(3)) for all drugs
Medication/Drug Restrictions - the payment for drugs may be based upon the AWP (see 18-6(M)) of the drug as determined through the use of industry publications such as the monthly Price Alert, First Databank, Inc.
(2)        Nursing Services
(a)        Skilled Nursing (LPN & RN)
S9123 RN                     $111.00/hr.
S9124 LPN                   $   89.00/hr.
There is a limit of two (2) hours without prior authorization for payment (see Rule 16-9 and 16-10).
(b)        Certified Nurse Assistant (CNA):
S9122 CNA                   $ 25.00/hr.
The amount of time spent with the injured worker must be specified in the medical records and on the bill.
(3)        Physical Medicine
Physical medicine procedures are payable at the same rate as provided in the physical medicine and rehabilitation services section (see 18-5(H)).
(4)        Mileage
Travel allowances should be agreed upon with the payer and the mileage rate should not exceed $0.53 per mile, portal to portal.
DoWC code:     Z0772
(5)        Travel Time
Travel is typically included in the fees listed. Travel time greater than one (1) hour one-way shall be reimbursed. The fee shall be agreed upon at the time of prior authorization for payment (see Rule 16-9 and 16-10) and shall not exceed $30.00 per hour.
DoWC code:     Z0773
(M)       Drugs and Medications 
(1)        Drugs (brand name or generic) shall be reported on bills using the applicable identifier from the National Drug Code (NDC) Directory as published by the Food and Drug Administration (FDA)
(2)        Average Wholesale Price (AWP)
(a)        AWP for brand name and generic pharmaceuticals may be determined through the use of such monthly publications as Price Alert, Red Book, or Medispan. In case of a dispute on AWP values, the parties should take the average of their referenced published values.
(b)        If published AWP data becomes unavailable, substitute Wholesale Acquisition Cost (WAC) + 20% for AWP everywhere it is found in this Rule.
(3)        Reimbursement for Drugs & Medications (Except Compounded Drugs)
(a)        For prescriptions written within 30 days from the date of injury, reimbursement shall be AWP + $4.00.
(b)        For prescriptions written after 30 days from the date of injury, reimbursement shall be AWP + $4.00. If drugs have been repackaged, use the original AWP and NDC that was assigned by the source of the repackaged drugs to determine reimbursement.
(c)        Drugs administered in the course of the provider’s direct care shall be reimbursed at the provider’s actual cost incurred.
(d)        Over-the-counter medications, drugs that are safe and effective for use by the general public without a prescription, are reimbursed at NDC/AWP and are not eligible for dispensing fees.
(4)        Compounded Drugs
All prescriptions shall be billed using the DoWC Z code corresponding with the applicable category for compounded topical products as follows:
Category I         Z0790   Fee $ 75.00      per 30 day supply
Any anti-inflammatory medication or any local anesthetic single agent.
Category II        Z0791   Fee $150.00      per 30 day supply
Any anti-inflammatory agent or agents in combination with any local anesthetic agent or agents.
Category III       Z0792   Fee $250.00      per 30 day supply
Any single agent other than anti-inflammatory agent or local anesthetic, either alone, or in combination with anti-inflammatory or local anesthetic agents.
Category IV      Z0793   Fee $350.00      per 30 day supply
Two (2) or more agents that are not anti-inflammatory or local anesthetic agents, either alone or in combination with other anti-inflammatory or local anesthetic agents.
All ingredient materials must be listed by quantity used per prescription. Category fees include materials, shipping and handling and time. Regardless of how many ingredients or what type, compounded drugs cannot be reimbursed higher than the Category IV fee.
(5)        Injured Worker Reimbursement
In the event the injured worker has directly paid for authorized prescriptions, the payer shall reimburse the injured worker for the amounts actually paid for authorized prescriptions or authorized over-the-counter drugs within 30 days after receipt of the injured worker’s receipt. See Rule 16-11(G).
(6)        Dietary Supplements, Vitamins and Herbal Medicines
Reimbursement for outpatient dietary supplements, vitamins and herbal medicines dispensed in conjunction with acupuncture and complementary alternative medicine are authorized only by prior agreement of the payer, except if specifically provided for in Rule 17, Medical Treatment Guidelines.
(7)        Prescription Writing
(a)        Physicians shall indicate on the prescription form that the medication is related to a workers’ compensation claim.
(b)        All prescriptions shall be filled with bio-equivalent generic drugs unless the physician indicates "Dispense As Written" (DAW) on the prescription.
(c)        The provider shall prescribe no more than a 60-day supply per prescription.
(8)        Required Billing Forms
(a)        All parties shall use one (1) of the following forms:
(1)        CMS-1500 – the dispensing provider shall bill by using the metric quantity and NDC number of the drug being dispensed; or, if one does not exist, the RVP© supply code; or
(2)        WC-M4 form or equivalent – each item on the form shall be completed; or
(3)        With the agreement of the payer, the National Council for Prescription Drug Programs (NCPDP) or ANSI ASC 837 (American National Standards Institute Accredited Standards Committee) electronic billing transaction containing the same information as in (1) or (2) in this sub-section may be used for billing.
            NCPDP Workers’ Compensation/Property and Casualty (P&C) Universal Claim Form, version 1.1, for prescription drugs billed on paper shall be used by dispensing pharmacies and pharmacy benefit managers (PBMs). Physicians may use the CMS- 1500 billing form as described in Rule 16-7(B)(1).
(b)        Items prescribed for the work-related injury that do not have an NDC code shall be billed as a supply, using the RVP© supply code (see 18-6(H)).
(c)        The payer may return any prescription billing form if the information is incomplete.
(d)        A signature shall be kept on file indicating that the patient or his/her authorized representative has received the prescription.
(9)        A line-by-line itemization of each drug billed and the payment for that drug shall be made on the payment voucher by the payer.
(N)       Complementary Alternative Medicine (CAM)
CAM is a term used to describe a broad range of treatment modalities, some of which are generally accepted in the medical community and others that remain outside the accepted practice of conventional western medicine. Non-physician providers of CAM may be both licensed and non-licensed health practitioners with training in one (1) or more forms of therapy and certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in acupuncture and/or Chinese herbology. CAM requires prior authorization for payment (see Rule 16-9 and 16-10). Refer to Rule 17, Medical Treatment Guidelines for the specific types of CAM modalities.
(O)       Acupuncture
Acupuncture is an accepted procedure for the relief of pain and tissue inflammation. While commonly used for treatment of pain, it may also be used as an adjunct to physical rehabilitation and/or surgery to hasten return of functional recovery. Acupuncture may be performed with or without the use of electrical current on the needles at the acupuncture site.
(1)        Provider Restrictions
All non-physician providers must be a Licensed Acupuncturist (LAc) by the Colorado Department of Regulatory Agencies as provided in Rule 16, Utilization Standards. All physician and non-physician providers must provide evidence of training, and licensure upon request of the payer.
(2)        Billing Restrictions
(a)        For treatment frequencies exceeding the maximum allowed in Rule 17, Medical Treatment Guidelines, the provider must obtain prior authorization for payment (see Rule 16-9 and 16-10).
(b)        Unless the provider’s medical records reflect medical necessity and the provider obtains prior authorization for payment (see Rule 16-9 and 16-10), the maximum amount of time allowed for acupuncture and procedures is one (1) hour of procedures, per day, per discipline.
(3)        Billing Codes:
(a)        Reimburse acupuncture, including or not including electrical stimulation, as listed in the RVP©.
(b)        Non-Physician evaluation services
(1)        New or established patient services are reimbursable only if the medical record specifies the appropriate history, physical examination, treatment plan or evaluation of the treatment plan. Payers are only required to pay for evaluation services directly performed by an LAc. All evaluation notes or reports must be written and signed by the LAc. Without appropriate supporting documentation, the payer may deny payment. (See Rule 16-11)
(2)        LAc new patient visit:                 DOWC Z0800
                                                            Maximum value $98.72
(3)        LAc established patient visit:       DOWC Z0801   
                                                            Maximum value $66.64
(c)        Herbs require prior authorization for payment (see Rule 16-9 and 16-10) and fee agreements as in 18-6(M)(6).
(d)        See the appropriate physical medicine and rehabilitation section of the RVP© for other billing codes and limitations (18-5(H)).
(e)        Acupuncture supplies are reimbursed in accordance with 18-6(H).
(P)       Use of an Interpreter
Rates and terms shall be negotiated. Prior authorization for payment (see Rule 16-9 and 16-10) is required except for emergency treatment. Use DoWC Z0722 to bill.
(Q)       Ambulance Fee Schedule
(1)        Billing Requirements:
Payment under the fee schedule for ambulance services is comprised of a base rate payment plus a payment for mileage. Both the transport of the injured worker to the nearest facility and all items and services associated with such transport are considered inclusive with the base rate and mileage rate.
(2)        General Claims Submission:
(a)        All hospitals billing for ground or air ambulance services shall bill on the UB-04 and all other ambulance providers shall bill on the CMS-1500.
(b)        Use the appropriate HCPCS code plus the HCPCS origin/destination modifier.
(c)        The transporting supplier’s name, complete address and provider number should be listed in Item 33 (CMS-1500).
(d)        The zip code for the origin (point of pickup) must be in Item 23 (CMS-1500). If billing on the UB-04 use FL 39-41 with an “AO” and the point of pick up zip code. If billing for multiple trips and the zip code for each origin is the same, services can be submitted on the same claim. If the zip codes are different, a separate claim must be submitted for each trip.
(3)        Ground and Air Ambulance Vehicle and Crew Requirements
As required by the Colorado Department of Public Health and Environment.
(4)        HCPCS Procedure Codes and Maximum Allowances for Ambulance Services:
(a)        Ground (both water and land) Ambulance Base Rates and Mileage
The selection of the base code is based upon the condition of the injured worker at the time of transport, not the vehicle used and includes services and supplies used during the transport.
 

 
 
Urban
Rural (R = Zip Code) First 17 miles or > if not a Super Rural
Super Rural (B =Zip code)
Ground Ambulance
HCPCS Code Description
Medicare Rate *250%
Medicare Rate *250%
Medicare Rate *250%
A0425
Ground mileage, per statue mile
$  17.72
$  17.90
No change
A0426
Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1- Non-Emergency)
$ 663.40
$ 669.90
$ 821.30
A0427
Ambulance service, advanced life support, emergency transport, level 1 (ALS1-Emergency)
$1,050.38
$1,060.68
$1,300.38
A0428
Ambulance service, basic life support, non-emergency transport (BLS)
$  552.83
$  558.25
$  684.40
A0429
Ambulance service, basic life support, emergency transport (BLS-Emergency)
$  884.53
$  893.20
$1,095.05
A0433
Advanced life support, level 2 (ALS2)
$1,520.28
$1,535.18
$1,882.13
A0434
Specialty care transport (SCT)
$1,796.70
$1,814.30
$2,224.35
A0432
Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers.
$  967.45
$  976.93
No change

The “urban” base rate(s) and mileage rate(s) as indicated in 18-6(Q) shall be applied to all relevant/applicable ambulance services unless the zip code range area is “Rural” or “Super Rural.” Medicare MSA zip code grouping is listed on Medicare’s webpage with an “R” indicator for “Rural” and “B” indicator for “Super Rural.” Zip Code to Carrier Locality File- Updated 5/22/12 [ZIP,3MB]
(5)        Modifiers
Modifiers identify place of origin and destination of the ambulance trip. The modifier is to be placed next to the HCPCS code billed. The following is a list of current ambulance modifiers. Each of the modifiers may be utilized to make up the first and/or second half of a two-letter modifier. The first letter must describe the origin of the transport, and the second letter must describe the destination (Example: if a patient is picked up at his/her home and transported to the hospital, the modifier to describe the origin and destination would be – RH).
Code    Description
D          Diagnostic or therapeutic site other than “P” or “H”
E          Residential, domiciliary, custodial facility, nursing home other than SNF (other than 1819 facility)
G          Hospital-based dialysis facility (hospital or hospital-related) which includes:
                        - Hospital administered/Hospital located
                        - Non-Hospital administered/Hospital located
H          Hospital
I           Site of transfer (e.g., airport, ferry, or helicopter pad) between modes of ambulance transport
J          Non-hospital-based dialysis facility
                        - Non-Hospital administered/Non-Hospital located
                        - Hospital administered/Non-Hospital located
N          Skilled Nursing Facility (SNF) (1819 Facility)
P          Physician’s Office (includes HMO non-hospital facility, clinic, etc.)
R          Residence
S          Scene of Accident or Acute Event
X          Destination Code Only (Intermediate stop at physician’s office enroute to the hospital, includes HMO non-hospital facility, clinic, etc.)
(6)        Mileage

Charges for mileage must be based on loaded mileage only, i.e., from the pickup of a patient to his/her arrival at the destination. Payment is allowed for all medically necessary mileage. If mileage is billed, the miles must be in whole numbers. If a trip has a fraction of a mile, round up to the nearest whole number. Use code “1” as the mileage for trips of less than a mile.