Rule 18 MEDICAL FEE SCHEDULE
Pursuant to § 8-42-101(3)(a)(I) C.R.S. and Section 8-47-107, C.R.S., the Director promulgates this medical fee schedule to review and establish maximum allowable fees for health care services falling within the purview of the Act. The Director adopts and hereby incorporates by reference as modified herein the 2007 edition of the Relative Values for Physicians (RVP©), developed by Relative Value Studies, Inc., published by Ingenixâ St. Anthony Publishing, and Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 25.0 (DRGs Definitions Manual) developed and published by 3M Health Information Systems using MS-DRGs effective after October 1, 2007. The incorporation is limited to the specific editions named and does not include later revisions or additions. For information about inspecting or obtaining copies of the incorporated materials, contact the Medical Fee Schedule Administrator, 633 17th Street, Suite 400, Denver, Colorado 80202-3660. These materials may be examined at any state publications depository library. All guidelines and instructions are adopted as set forth in the RVP© or MS-DRGs: Definitions Manual, unless otherwise specified in this rule.
This rule applies to all services rendered on or after January 1, 2008. All other bills shall be reimbursed in accordance with the fee schedule in effect at the time service was rendered.
18-2 STANDARD TERMINOLOGY FOR THIS RULE
(B) DoWC – Colorado Division of Workers’ Compensation created codes
(C) MS-DRGs Definitions Manual – version 25.0 incorporated by reference in Rule 18-1.
(D) RVP© – the 2007 edition incorporated by reference in Rule 18-1.
(E) For other terms, see Rule 16, Utilization Standards.
All users are responsible for the timely purchase and use of Rule 18 and its supporting documentation as referenced herein. The Division shall make available for public review and inspection copies of all materials incorporated by reference in Rule 18. Copies of the RVP© may be purchased from Ingenixâ St. Anthony Publishing, the MS-DRGs Definitions Manual may be purchased from 3M Health Information Systems, and the Colorado Workers' Compensation Rules of Procedures with Treatment Guidelines, 7 CCR 1101-3, may be purchased from LexisNexis Matthew Bender & Co., Inc., Albany, NY. Interpretive Bulletins and unofficial copies of all rules, including Rule 18, are available on the Colorado Department of Labor and Employment web site at www.coworkforce.com/DWC/ . An official copy of the rules is available on the Secretary of State’s webpage http://www.sos.state.co.us/CCR/Welcom.do .
The following CFs shall be used to determine the maximum allowed fee. The maximum fee is determined by multiplying the following section CFs by the established relative value unit(s) (RVU) found in the corresponding RVP© sections:
RVP© SECTION CF
Anesthesia $ 48.89/RVU
Surgery $ 90.97/RVU
Surgery X Procedures $ 37.69/RVU
(see Rule 18-5(D)(1)( d))
Radiology $ 17.26/RVU
Pathology $ 12.99/RVU
Medicine $ 7.56/RVU
Physical Medicine $ 5.57/RVU
Physical Medicine and Rehabilitation, Medical Nutrition Therapy and Acupuncture
Evaluation & Management (E&M) $ 8.47/RVU
18-5 INSTRUCTIONS AND/OR MODIFICATIONS TO THE RVP©
(B) Interim relative value procedures (marked by an “I” in the left-hand margin of the RVP©) are accepted as a basis of payment for services; however deleted CPT® codes (marked by an “M” in the RVP©) are not, unless otherwise advised by this rule. The CPT® 2007 may be referenced for further clarification of descriptions and billing, but if conflicts arise between the RVP© and the CPT® 2007, the RVP© should control.
(a) All anesthesia base values shall be established by the use of the codes as set forth in the RVP©, Anesthesia Section. Anesthesia services are only reimbursable if the anesthesia is administered by a physician or Certified Registered Nurse Anesthetist (CRNA) who remains in constant attendance during the procedure for the sole purpose of rendering anesthesia.
When anesthesia is administered by a CRNA:
(2) Under the medical direction of an anesthesiologist, reimbursement shall be 50% of the maximum anesthesia value. The other 50% is payable to the anesthesiologist providing the medical direction to the CRNA,
(3) Medical direction for administering the anesthesia includes performing the following activities:
· Performs a pre-anesthesia examination and evaluation,
· Prescribes the anesthesia plan,
· Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence,
· Ensures that any procedure in the anesthesia plan that s/he does not perform is performed by a qualified anesthetist,
· Monitors the course of anesthesia administration at frequent intervals,
· Remains physically present and available for immediate diagnosis and treatment of emergencies, and
· Provides indicated post-anesthesia care.
(b) Anesthesia add-on codes are reimbursed using the anesthesia CF and unit values found in the RVP©, Anesthesia section’s Guidelines XII, “Qualifying Circumstances.” (Not under the Medicine section.)
(c) The following modifiers are to be used when billing for anesthesia services:
AA – anesthesia services performed personally by the anesthesiologist
QX – CRNA service; with medical direction by a physician
QZ – CRNA service; without medical direction by a physician
QY – Medical direction of one CRNA by an anesthesiologist
(1) The surgery X procedures are limited to those listed below and found in the table under the RVP©, Anesthesia section’s Guidelines XIII, “Anesthesia Services Where Time Units Are Not Allowed”:
· Providing local anesthetic or other medications through a regional IV
· Daily drug management
· Endotracheal intubation
· Venipuncture, including cutdowns
· Arterial punctures
· Epidural or subarachnoid spine injections
· Somatic and Sympathetic Nerve Injections
· Paravertebral facet joint injections and rhizotomies
In addition, lumbar plexus spine anesthetic injection, posterior approach with daily administration = 7 RVUs.
(2) The maximum reimbursement for these procedures shall be based upon the anesthesia value listed in the table in the RVP©, Anesthesia section’s Guideline XIII multiplied by $37.69 CF. No additional unit values are added for time when calculating the maximum values for reimbursement.
(3) When performing more than one surgery X procedure in a single surgical setting, multiple surgery guidelines shall apply (100% of the listed value for the primary procedure and 50% of the listed value for additional procedures). Use modifier -51 to indicate multiple surgery X procedures performed on the same day during a single operative setting. The 50% reduction does not apply to procedures that are identified in the RVP© as “Add-on” procedures.
(4) Bilateral injections: see 18-5(D)(2)(g).
(5) Other procedures from Table XIII not described above may be found in another section of the RVP© (e.g., surgery). Any procedures found in the table under the RVP©, Anesthesia section’s Guidelines XIII, “Anesthesia Services Where Time Units Are Not Allowed” but not contained in this list (Rule 18-5(D)(1)(d)(1)) are reimbursed in accordance with the assigned units from their respective sections multiplied by their respective CF.
(a) The use of assistant surgeons shall be limited according to the American College Of Surgeons' Physicians as Assistants at Surgery: 2007 Study (January 2007), available from the American College of Surgeons, Chicago, IL, or from their web page at http://www.facs.org/ahp/pubs/2007physasstsurg.pdf (accessed August 29, 2007). The incorporation is limited to the edition named and does not include later revisions or additions. Copies of the material incorporated by reference may be inspected at any State publications depository library. For information about inspecting or obtaining copies of the incorporated material, contact the Medical Fee Schedule Administrator, 633 17th Street, Suite 400, Denver, Colorado, 80202-3660.
Where the publication restricts use of such assistants to "almost never" or a procedure is not referenced in the publication, prior authorization for payment shall be obtained from the payer.
(c) No payment shall be made for more than one assistant surgeon or minimum assistant surgeon without prior authorization unless a trauma team was activated due to the emergency nature of the injury(ies).
(d) The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate modifier should be used on the bill. To modify a billed code refer to Rule 16-11(B)(4).
¨ E&M services unrelated to the primary surgical procedure,
¨ Services necessary to stabilize the patient for the primary surgical procedure,
¨ Services not usually part of the surgical procedure, including an E&M visit by an authorized treating physician (ATP) for disability management,
¨ Unusual circumstances, complications, exacerbations, or recurrences, or
¨ Unrelated diseases or injuries.
(a) The cost of dyes and contrast shall be reimbursed at 80 % of billed charges.
(b) Copying charges for X-Rays and MRIs shall be $15.00/film regardless of the size of the film.
(c) The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate RVP© modifier should have been used on the bill. To modify a billed code, refer to Rule 16-11(B)(4).
(a) The physician supervising and interpreting the thermographic evaluation shall be board certified by the examining board of one of the following national organizations and follow their recognized protocols:
American Academy of Thermology;
American Chiropractic College of Infrared Imaging.
(b) Indications for thermographic evaluation must be one of the following:
Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy (CRPS/RSD);
Sympathetically Maintained Pain (SMP);
Autonomic neuropathy;
Chronic Neuropathic Pain (involving small caliber sensory fiber neuropathy).
(c) Protocol for stress testing is outlined in the Medical Treatment Guidelines found in Rule 17.
(d) Thermography Billing Codes:
DoWC 79993 Upper body w/ Autonomic Stress Testing $856.80
DoWC 79995 Lower body w/Autonomic Stress Testing $856.80
(e) Prior authorization for payment is required for thermography services only if the requested study does not meet the indicators for thermography as outlined in this radiology section. The billing shall include a report supplying the thermographic evaluation and reflecting compliance with Rule 18-5(E)(2).
(F) Pathology Section: The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate modifier should have been used on the bill. To modify a billed code refer to Rule 16-11(B)(4).
(2) Anesthesia add-on values are reimbursed in accordance with the anesthesia section of Rule 18.
Prior authorization for payment shall be required from the payer after 12 visits. A licensed physician or psychologist shall prescribe all services and include the number of sessions. Session notes shall be periodically reviewed by the prescribing physician to determine the continued need for the service. All services shall be provided or supervised by an appropriate recognized provider as listed under Rule 16-5. Supervision shall be as defined in an applicable Rule 17 medical treatment guidelines. Persons providing biofeedback shall be certified by the Biofeedback Certification Institution of America, or be a licensed physician or psychologist, as listed under Rule 16-5(A)(1)(a) and (b) with evidence of equivalent biofeedback training.
(5) Manipulation -- Chiropractic (DC), Medical (MD) and Osteopathic (DO):
(a) Prior authorization from the payer shall be obtained before billing for more than four body regions in one visit. Manipulative therapy is limited to the maximum allowed in the relevant Rule 17 medical treatment guidelines. The provider's medical records shall reflect medical necessity and prior authorization for payment if treatment exceeds these limitations.
(6) Psychiatric/Psychological CNS Tests and Assessment Services:
(a) A licensed clinical psychologist is reimbursed a maximum of 90 % of the medical fee listed in the RVP©. Other non-physician providers performing psychological/psychiatric services shall be paid at 75 % of the fee allowed for physicians.
Evaluation Procedures limit: 4 hours
Testing Procedures limit: 6 hours
(c) Psychotherapy services limit: 50 mins per visit
Prior authorization for payment is required any time the 50 minute/visit limitation is exceeded.
Psychotherapy for work-related conditions requiring more than 20 visits or continuing for more than three (3) months after the initiation of therapy, whichever comes first, requires prior authorization from the payer.
(d) Central nervous system assessments and tests (psychological testing, neurobehavioral status exams and neuropsychological testing) interim values in the 2007 edition of the RVP© are not adopted. Reimburse these procedures as established under the Division’s 2007 fee schedule.
(7) Hyperbaric Oxygen Therapy Services
The maximum unit value shall be 24 units, instead of 14 units as listed in the RVP©.
(H) Physical Medicine and Rehabilitation:
Restorative services are an integral part of the healing process for a variety of injured workers.
(1) Prior authorization is required for medical nutrition therapy. See Rule 18-6(O)(10).
(3) Special Note to All Physical Medicine and Rehabilitation Providers:
Prior authorization shall be obtained from the payer for any physical medicine treatment exceeding the recommendations of the Medical Treatment Guidelines as set forth in Rule 17.
The injured worker shall be re-evaluated by the prescribing physician within thirty (30) calendar days from the initiation of the prescribed treatment and at least once every month while that treatment continues. Prior authorization for payment shall be required for treatment of a condition not covered under the medical treatment guidelines and exceeding sixty (60) days from the initiation of treatment.
(4) Interdisciplinary Rehabilitation Programs – (Requires Prior Authorization)
Billing Restrictions: The billing provider shall detail to the payer the services, frequency of services, duration of the program and their proposed fees for the entire program, inclusive for all professionals. The billing provider and payer shall attempt to mutually agree upon billing code(s) and fee(s) for each interdisciplinary rehabilitation program.
(5) Procedures (therapeutic exercises, neuromuscular re-education, aquatic therapy, gait training, massage, acupuncture, manual therapy techniques, therapeutic activities, cognitive development, sensory integrative techniques and any unlisted physical medicine procedures)
Unless the provider’s medical records reflect medical necessity and the provider obtains prior authorization for payment from the payer, the maximum amount of time allowed is one hour of procedures per day, per discipline.
RVP© Timed and Non-timed Modalities
Billing Restrictions: There is a total limit of two (2) modalities (whether timed or non-timed), including one DoWC code 99915 or 99917, per visit, per discipline, per day.
NOTE: Instruction and application of a TENS unit for the patient's independent use shall be billed using the timed e-stim RVP© code.
Dry Needling of Trigger Points DoWC Codes:
DoWC 99915 Single or multiple needles, one or two muscles,
5.4 RVUs
DoWC 99917 three or more muscles,
5.8 RVUs
(a) All evaluation services must be supported by the appropriate history, physical examination documentation, treatment goals and treatment plan or re-evaluation of the treatment plan. The provider shall clearly state the reason for the evaluation, the nature and results of the physical examination of the patient, and the reasoning for recommending the continuation or adjustment of the treatment protocol. Without appropriate supporting documentation, the payer may deny payment. These codes shall not be billed for pre-treatment patient assessment.
If a new problem or abnormality is encountered that requires a new evaluation and treatment plan, the professional may perform and bill for another initial evaluation. A new problem or abnormality may be caused by a surgical procedure being performed after the initial evaluation has been completed.
(b) Payers are only required to pay for evaluation services directly performed by a PT, OT, or athletic trainer as defined in §12-36-106 C.R.S. All evaluation notes or reports must be written and signed by the PT or OT. Physicians shall bill the appropriate E&M code from the E&M section of the RVP©.
(d) Reimbursement to PTs, OTs, speech language pathologists and audiologists for coordination of care with professionals shall be based upon RVP© telephone case management codes. Coordination of care reimbursement is limited to telephone calls made to professionals outside of the therapist’s/pathologist’s/audiologist’s employment facility(ies) and/or to the injured worker or their family and the prescribing physician.
(e) All interdisciplinary team conferences shall be billed in compliance with Rule 18-5(I)(4).
The following respective tests are considered special tests:
· Job Site Evaluation
· Computer- Enhanced Evaluation
Functional Capacity Evaluation
Work Tolerance Screening
· Assistive technology assessment
· Speech
(1) Job Site Evaluations require prior authorization if exceeding 2 hours. Computer-Enhanced Evaluations, Functional Capacity Evaluations and Work Tolerance Screenings require prior authorization for payment for more than 4 hours.
(2) The provider shall specify the time required to perform the test in 15-minute increments.
(3) The value for the analysis and the written report is included in the code’s value.
(b) Provider Restrictions: all special tests must be fully supervised by a physician, a PT, an OT, a speech language pathologist/therapist or audiologist. Final reports must be written and signed by the physician, the PT, the OT, the speech language pathologist/therapist or the audiologist.
(9) Speech Therapy/Evaluation and Treatment
Reimbursement shall be according to the unit values as listed in the RVP© multiplied by their section’s respective CF.
Physical medicine supplies are reimbursed in accordance with Rule 18-6(H).
When a patient uses a facility or its equipment but is performing unattended procedures, in either an individual or group setting, bill:
DoWC 97152 fixed fee per day 1.5 RVU
Fees, such as gyms, pools, etc., and training or supervision by non-medical providers require prior authorization from the payer and a written negotiated fee.
(13) Unlisted Service Physical Medicine
All unlisted services or procedures require a report.
(14) Work Conditioning, Work Hardening, Work Simulation
(a) Work conditioning is a non-interdisciplinary program that is focused on the individual needs of the patient to return to work. Usually one discipline oversees the patient in meeting goals to return to work. Refer to Rule 17, Medical Treatment Guidelines.
Restriction: Maximum daily time is two (2) hours per day without additional prior authorization.
(b) Work Hardening is an interdisciplinary program that uses a team of disciplines to meet the goal of employability and return to work. This type of program entails a progressive increase in the number of hours a day that an individual completes work tasks until they can tolerate a full workday. In order to do this, the program must address the medical, psychological, behavioral, physical, functional and vocational components of employability and return to work. Refer to Rule 17, Medical Treatment Guidelines.
Restriction: Maximum daily time is six (6) hours per day without additional prior authorization.
(c) Work Simulation is a program where an individual completes specific work-related tasks for a particular job and return to work. Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision. The need for work simulation should be based upon the results of a functional capacity evaluation and/or job analysis. Refer to Rule 17, Medical Treatment Guidelines.
(d) For Work Conditioning, Work Hardening, or Work Simulation, the following apply.
(1) Prior authorization is required.
(I) Evaluation and Management Section (E&M)
(1) Medical record documentation shall encompass the RVP© “E&M Guideline” criteria to justify the billed E&M service. If 50% of the time spent with an injured worker during an E&M visit is disability counseling, then time can determine the level of E&M service.
Disability counseling should be an integral part of managing workers’ compensation injuries. The counseling shall be completely documented in the medical records, including, but not limited to, the amount of time spent with the injured worker. Disability counseling shall include, but not be limited to, return to work, temporary and permanent work restrictions, self management of symptoms while working, correct posture/mechanics to perform work functions, job task exercises for muscle strengthening and stretching, and appropriate tool and equipment use to prevent re-injury and/or worsening of the existing injury.
(2) New or Established Patients
All providers, as defined in Rule 16-5 (A-C), are limited to one office visit per patient, per day, per workers’ compensation claim unless prior authorization is obtained from the payer. The E&M Guideline criteria as specified in the RVP© E&M Section shall be used in all office visits to determine the appropriate level.
(1) the amount of time and date;
(2) the person or person(s) talked to; and
(3) the discussion and/or decision made during the call to coordinate care for the injured worker.
(1) Prepare the billing statement in accordance with Rule 16, Utilization Standards,
¨ One conference charge per facility, per patient, per day.
¨ Reimbursement for each interdisciplinary team conference shall be billed in 15-minute increments. The 30 minute code found in the RVP© should be reimbursed at one half, one, or one and one-half, multiplied times its RVUs to reimburse 15, 30 or 45 minute conferences, respectively.
¨ Patient's identifying information;
¨ Diagnosis;
¨ Medical professionals attending the conference;
¨ A brief statement of conference recommendations and actions (no additional allowance shall be made for this statement); and
¨ Length of time of meeting.
18-6 DIVISION ESTABLISHED CODES AND VALUES
(A) Conferences Held at the Request of a Party
Telephonic or face-to-face conferences shall be related to the injured worker's treatment. All parties shall receive actual notification from the requesting party in advance and within 24 hours of scheduling.
DoWC 99901 Maximum $300.00 per hour;
billed at $75.00 per 15-minute increments.
(B) Cancellation Fees For Payer Made Appointments
One-half of the usual fee for the scheduled services, or
$150.00, whichever is less.
Cancellation Fee Billing Code: DoWC 99910
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 this Rule 18-6(B).
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/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 99911
(D) Deposition and Testimony Fees
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 Rule 18-6(D) in that case.
Preparation Time:
Treating or Non-treating Physician:
DoWC 99985 $325.00 per hour
Payment for a treating or non-treating physician's testimony at a deposition shall not exceed $325.00 per hour billed in half-hour increments. Calculation of the physician's time shall be "portal to portal."
If requested, the physician is entitled to a full hour deposit in advance in order to schedule the deposition.
If the physician 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.
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 he or she has reasonably spent in preparation and one-half the time scheduled for the deposition.
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 he or she has reasonably spent in preparation and has scheduled for the deposition.
Deposition:
Treating or Non-treating physician:
DoWC 99975 $325.00 per hr.
Billed in half-hour increments
Calculation of the physician's time shall be "portal to portal."
For testifying at a hearing, if requested the physician is entitled to a four (4) hour deposit in advance in order to schedule the testimony.
If the physician 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.
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 he or she has reasonably spent in preparation and one-half the time scheduled for the testimony.
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.
Testimony:
Treating or Non-treating physician:
DoWC 99085
Maximum Rate of $450.00 per hour
The payer shall reimburse an injured worker for reasonable and necessary mileage expenses for travel to and from medical appointments and reasonable mileage to obtain prescribed medications. The reimbursement rate shall be 40 cents per mile. The injured worker shall submit a statement to the payer showing the date(s) of travel and number of miles traveled, with receipts for any other reasonable and necessary travel expenses incurred.
Mileage Expense Billing Code: DoWC 99912
(F) Permanent Impairment Rating
(1) The payer is only required to pay for one combined whole-person permanent impairment rating per claim, except as otherwise provided in these 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.
The permanent impairment rating shall be determined by the authorized treating physician, if Level II accredited, or by a Level II accredited physician selected by the authorized treating provider.
(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 and the fee for completing the Physician’s Report of Workers’ Compensation Injury (Closing Report), WC164 (See Rule 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, 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.
(b) Use the appropriate RVP© code:
(1) Fee for the Level II Accredited Authorized Treating Physician Providing Primary Care:
Reimbursed for 1.5 hours with a maximum not to exceed $330.33.
(2) Fee for the Referral, Level II Accredited Authorized Physician:
Reimbursed for 2.5 hours with a maximum not to exceed $635.25.
(4) Fee for a Multiple Impairment Evaluation Requiring More Than One 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.
Completion of routine reports or records are incorporated in all fees for service and 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 Rule 18.
(2) Completion of the Physician’s Report of Workers’ Compensation Injury (WC164)
The completed WC164 initial report is submitted to the payer after the first visit with the injured worker. 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.
The WC164 closing report is required from the authorized treating physician when an injured worker is at maximum medical improvement with or without a permanent impairment. A physician may bill for the completion of the WC164 if neither impairment rating code (see Rule 18-6(F)(4)) has been billed. 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 is Level II Accredited, or
(2) The name of the Level II Accredited physician designated to perform the permanent impairment rating when a rating is necessary and the authorized treating physician is not determining the permanent impairment rating.
(c) Payer Requested WC164 Report
If the payer requests the 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 the provider wants to use the WC164 report as a progress report or for any purpose other than those designated here in Rule 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 99960 $42.00 Initial Report
DoWC 99961 $42.00 Progress Report (Payer Requested or
Provider Initiated)
DoWC 99962 $42.00 Closing Report
DoWC 99963 $42.00 Initial and Closing Reports are completed on the same form for the same date of service
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 or reviews 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. Reimbursement for preparation of special reports or records shall require prior agreement with the requesting party. In special circumstances (e.g., when reviewing and/or editing is necessary) and when prior agreement is made with the requesting party, institutions, clinics or physicians’ offices may charge additional time. Use the appropriate RVP© code.
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.
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.
If requested, the provider is entitled to a two hour deposit in advance in order to schedule any patient exam associated with a special report.
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.
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.
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.
Special Report Preparation: not to exceed $325.00 per hour.
Billed in half hour increments.
(H) Supplies, Durable Medical Equipment (DME), Orthotics and Prosthesis
(2) “Supply et al.” is defined in Rule 16-2. Reimbursement shall be the provider’s cost plus 20%. The provider shall furnish an invoice or their supplier’s published rate, either with their bill for services or by previous agreement, to substantiate their cost. The billing provider is responsible for identifying and itemizing all “Supply et al.” items.
(3) 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 RVP©.
(I) Inpatient Hospital Facility Fees
All non-emergency, inpatient admissions require prior authorization for payment.
(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. 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-DRGs code number in the remarks section (form locator 80) of the UB-04 billing form and maintain documentation on file showing how the MS-DRGs was determined. The hospital shall determine the MS-DRGs using the MS-DRGs Definitions Manual. The attending physician shall not be required to certify this documentation unless a dispute arises between the hospital and the payer regarding MS-DRGs assignment. The payer may deny payment for services until the appropriate MS-DRGs code is supplied.
(c) Exhibit 1 to Rule 18 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 Rule 18-6(I)(3)(d) is allowed.
(d) Any inpatient admission requiring the use of both an acute care hospital and its Medicare certified rehabilitation facility is considered as one 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:
(2) Veterans’ Administration hospital
(3) State psychiatric hospital
(b) The following types of inpatient facilities are reimbursed at 80% of billed inpatient charges:
(1) Medicare certified Critical Access Hospital (CAH) (listed in Exhibit 3 of Rule 18)
(2) Medicare certified long-term care hospital
(4) CDPHE licensed psychiatric facilities that are privately owned.
(c) All other inpatient facilities are reimbursed as follows:
Retrieve the relative weights for the assigned MS-DRG from the MS-DRG table in Exhibit 1 to Rule 18 and locate the hospital’s base rate in Exhibit 2 to Rule 18.
The “Maximum Fee Allowance” is determined by calculating:
(3) For trauma Center activation allowance, see Rule 18-6(M)(3)(g).
(d) Outliers are admissions with extraordinary cost warranting additional reimbursement beyond the maximum allowance under (3) (c) of Rule 18-6(I). To calculate the additional reimbursement, if any:
(1) Determine the “Hospital’s Cost”:
total billed charges (excluding any “Supply et al.” billed charges and trauma center activation 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 Rule 18.
“Difference” x .80 = additional fee allowance
(e) Inpatient combined with ERD or Trauma Center reimbursement
(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 to Rule 18) divided by the MS-DRG geometric mean length of stay. 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:
o The MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier allowance),
o "Supply et al." billed charges to the "Supply et al." allowance [cost + 20%], and
o the trauma center activation billed charge to the trauma center activation allowance.
The MS-DRG adjusted billed charges are determined by subtracting the "Supply et al." billed charges and the trauma center activation billed charges from the total billed charges. The final payment is the sum of the lesser of each of these comparisons.
(J) Scheduled Outpatient Surgery Facility Fees
(a) All non-emergency outpatient surgeries require prior authorization from the payer.
(2) an Ambulatory Surgery Center (ASC).
(3) Outpatient Surgery Facility Reimbursement:
(2) Veterans’ Administration hospital
(3) State psychiatric hospital
(b) CAHs, listed in Exhibit 3 of Rule 18, are to be reimbursed at 80% of billed charges.
(c) All other outpatient surgery facilities are reimbursed based on Exhibit 4 of this Rule 18. Exhibit 4 lists Medicare’s Outpatient Hospital Ambulatory Prospective Payment Codes (APC) with the Division’s values for each APC code. Grouper code 210, found in Exhibit 4, was DoWC created to reimburse RVP© spinal fusion codes not listed in Medicare's Addendeum B.
The surgical procedure codes are classified by APC code in Medicare’s April 2007 Addendum B. This Addendum B should be used to determine the APC code payable under the Division’s Exhibit 4. However, not every surgical code listed under Addendum B warrants a separate facility fee. Minor procedures, including but not limited to, laceration repairs and trigger point injections, do not warrant a separate facility fee as a scheduled outpatient surgery. Therefore some APC grouper codes have a value of zero in Exhibit 4.
The APC values listed in Exhibit 4 include reimbursement for the following even if they are billed as line item charges:
· nursing,
· technician and related services,
· use by the recipient of the facility including the operating room and recovery room,
· equipment directly related to the provision of surgical procedures,
· fluoroscopy and x-rays during the surgical episode,
· supplies, drugs, biologics, surgical dressings, splints, cases and appliances that do not meet the “Supply et al.” threshold,
· administration, record keeping, housekeeping items and services, and
· materials and trained observer for anesthesia.
The April 2007 Addendum B can be accessed at Medicare’s Hospital Outpatient PPS website.
Total maximum facility value for an outpatient surgical episode of care includes the sum of:
(1) The highest valued APC code per Exhibit 4 plus 50% of any lesser-valued APC code values.
Multiple procedures and bilateral procedures 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.
The surgery discogram procedure (APC 388) value is for each level and includes conscious sedation and the technical component of the radiological procedure.
Facility fee reimbursement is limited to a maximum of four surgical procedures per surgical episode with a maximum of only one procedure reimbursed at 100% of the allowed value; and
RVP© radiological procedure codes (not the injection codes) with an appropriate modifier are to be used for all arthrograms and myelograms; and
(4) Observation room maximum allowance is limited to 6 hours without prior authorization. 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 hospital 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.
Billing Codes:
G0377 Convalescence rate after 12 hours of observation care: $500.00/day billed in and rounded to the nearest 6 hour increment.
G0378 Observation hourly rate: $50.00 per hour for the first 12 hours, rounded to the nearest 15 minute increment.
· ambulance services
· blood, blood plasma, platelets
(d) 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.
(f) In compliance with rule 16-6(B), the sum of Rule 18-6(J)(3)(c)(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.
(K) Outpatient Diagnostic Testing and Clinic Facility Fees
All providers shall indicate whether they are billing for the total, professional only or technical only component of a diagnostic test by listing the appropriate RVP© modifier on the UB-04 or CMS 1500 (08-05).
(2) Veterans’ Administration hospitals
(3) State psychiatric hospitals
“Supply et al.” is defined in Rule 16-2 and reimbursement shall be consistent with Rule 18-6(H). The billing provider is responsible for identifying and itemizing all “Supply et al.” items.
(2) No separate facility fee allowance for diagnostic testing. Facility fees for diagnostic testing are considered part of the procedure’s technical component value. Outpatient diagnostic testing is reimbursed using the RVP© code unit value. Dyes and contrasts may be reimbursed at 80% of billed charges.
(L) Outpatient Urgent Care Facility Fees
(a) 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 if requested by the payer.
(b) 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;
(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.;
(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;
(12) Written procedures exist for the facility’s stabilization and transport processes.
(c) 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.
(d) 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.
(a) Urgent care facility fees may be billed on a CMS 1500 (08-05).
The total maximum value for an urgent care episode of care includes the sum of:
(a) An Urgent Care Facility fee maximum allowance of $75.00; and
Supplies and drugs that do not meet the “Supply et al.” threshold and treatment rooms are included in the Urgent Care facility maximum fees; and
(c) All diagnostic testing, laboratory services and therapeutic services (including, but not limited to, radiology, pathology, respiratory therapy, physical therapy or occupational therapy) shall be reimbursed by multiplying the appropriate CF by the unit value for the specific CPT® code as listed in the RVP© and Rule 18; and
(e) In compliance with Rule 16-6 (B), the sum of all Urgent Care fees charged, less any amounts charged for professional fees or dispensed prescriptions per Rule 18-6(L)(4) found on the same bill, is to be compared to the maximum reimbursement allowed by the calculated value of Rule 18-6(L)(3)(a-d). The lesser of the two amounts shall be the maximum facility allowance for the episode of urgent care. A line by line comparison is not appropriate.
(M) Outpatient Emergency Room Department (ERD) Facility Fees
To be reimbursed under this section (M), all outpatient ERDs within Colorado must be physically located within a hospital licensed by the CDPHE as a general hospital, or if free-standing ERD, must have equivalent operations as a licensed ERD. To be paid as an ERD, out-of-state facilities shall meet that state’s licensure requirements.
(b) Documentation should support the “Level of Care” being billed.
(a) The following types of facilities are reimbursed at 100% of billed ERD charges:
(2) Veterans’ Administration hospitals
(3) State Psychiatric hospitals
(c) The ERD “Level of Care” is identified based upon one of five levels of care. The level of care is defined by the point system developed by the hospital in compliance with Medicare regulations and determined by the total number of points accumulated by assigning points to interventions completed by the ERD staff during an ERD visit. Upon request the provider shall supply a copy of their point system to the payer.
(d) Total maximum value for an ERD episode of care includes the sum of the following:
(1) ERD reimbursement amount for “Level of Care” points:
ERD Reimbursement
Level