Rule 13 Accreditation of Physicians
13-1 STATEMENT OF BASIS AND PURPOSE
(A) This rule is promulgated to implement and establish procedures for the physicians accreditation program as set forth in statute, to provide physicians with an understanding of their administrative, legal and medical roles in the workers’ compensation system. Accreditation requirements established shall apply to:
(1) Physicians who seek Level I accreditation under the Act; and
(2) Physicians providing permanent impairment evaluation of claimants; and
(3) Physicians serving on the Division Independent Medical Examination Panel.
(A) To obtain Level I or Level II Accreditation a physician must:
(1) be qualified under the act;
(2) complete an application form prescribed by the Division and in Level II cases, indicate if full accreditation or limited accreditation is sought;
(3) attend a Division seminar and/or review the Division materials on the worker’s compensation system; for Level II accreditation, this must include the American Medical Association Guides to the Evaluation of Permanent Impairment, Third Edition (Revised), in effect as of July 1, 1991 (‘AMA Guides’), and demonstrate an understanding of such materials by taking an examination administered by the Division; and
(4) certify agreement to comply with all Division rules, including but not limited to the medical treatment guidelines, permanent impairment rating guidelines and utilization standards adopted by the Director, and all relevant statutes.
(B) After paying the accreditation registration fee, a physician must satisfactorily complete the examination administered by the Division. If the physician does not exhibit sufficient knowledge upon completion of the examination on the third attempt, he or she shall be required to wait six months and pay a second registration fee before taking the examination again.
(C) Accreditation begins on the date the physician successfully completes the accreditation examination.
(D) Level II Accreditation expires on December 31ST of the third calendar year following the year the physician successfully completed the Level II Accreditation examinations; Level I Accreditation expires on July 31st of the third year following the year the Level I applicant successfully completed the Level I Accreditation examination.
(E) For Level II Accreditation only:
(1) Full Accreditation: A qualified physician who satisfactorily completes the Level II Accreditation examination as determined and administered by the Division shall be fully accredited to determine permanent impairment ratings on any work-related injury or illness.
(2) Limited Accreditation: A qualified physician who seeks Level II Accreditation in order to rate impairment only in connection with an area of medical specialty and who satisfactorily completes specified portions of the Level II examination as determined and administered by the Division shall receive limited accreditation to determine permanent impairment ratings on the corresponding sections of the AMA Guides.
13-3 RENEWAL OF ACCREDITATION
(A) The Division shall provide accredited physicians not less than sixty (60) days written notice of impending expiration of their accreditation.
(B) A physician who does not renew their accreditation before their accreditation expiration date may reapply and complete the process for initial accreditation under section 13-2.
(C) To renew accreditation, a qualified physician must:
(1) be qualified under the Act;
(2) complete an application form prescribed by the Division and, for Level II accreditation, indicate if full accreditation or limited accreditation is sought;
(3) complete the Division Reaccredidation Curriculum for Level I or Level II as appropriate;
(4) certify agreement to comply with all Division rules, including but not limited to the medical treatment guidelines, permanent impairment rating guidelines, and utilization standards adopted by the Director, and all relevant statutes.
(5) submit his/her first three (3) impairment rating reports to the Division following initial accreditation. Physicians who re-accredit must submit to the Division at least three (3) impairment reports during the three-year period following their reaccredidation. All such impairment rating reports may include Division Independent Medical Examination reports. A physician may not reaccredit until and unless this requirement is met, unless the physician has been unable to complete three impairment ratings during the three-year period for good cause as determined by the Director, and has met any other similar report requirement the Director may substitute. The purpose of providing these impairment reports is for education and feedback to the physician, and to assist the Division in examining its curriculum. Any correspondence or communication regarding this process is confidential and shall not be subject to discovery or examination by any person.
13-4 REVOCATION OF ACCREDITATION
(A) The Director, with input from the Medical Director, may initiate proceedings to revoke a Level I or Level II Accreditation on any of the following grounds:
(1) Refusal to comply, substantial failure to comply, or two or more incidents of failure to comply with the provisions of these Workers’ Compensation Rules of Procedure and all relevant statutes.
(2) a misrepresentation on the application for accreditation, or
(3). by final order of the Director in a proceeding held pursuant to §8-43-501, C.R.S., where the reviewing panel has unanimously recommended that accreditation be revoked.
(B) The severity of any sanctions taken under these rules shall reflect the character of the failure and the attendant circumstances.
(C) A proceeding to revoke a Level I or Level II Accreditation may be initiated by the Director, with input from the medical director, with referral for a hearing before an administrative law judge.
(D) Following a hearing before an administrative law judge to revoke a physician’s accreditation, the administrative law judge shall render proposed findings of fact and conclusions of law, and then make recommendations to the Director, who shall enter an order in the case.
Rule 14 APPLICATIONS FOR ADMISSION AND PAYMENT OF BENEFITS FROM THE MAJOR MEDICAL INSURANCE FUND, THE MEDICAL DISASTER FUND AND REQUEST FOR BENEFITS FROM THE SUBSEQUENT INJURY FUND
14-1 APPLICATIONS FOR ADMISSION TO THE MAJOR MEDICAL INSURANCE FUND AND MEDICAL DISASTER FUND
(A) All applications for admission shall be filed with the Division on the prescribed form along with copies of the payment history, orders, medical records and all available relevant documents that support the application for admission. Upon receipt of an application, the Director shall examine the claim file to determine whether the insurer has exhausted its $20,000 limit of liability for medical benefits as provided in §8-49-101 C.R.S, 1973. Those applications not meeting this requirement shall be dismissed and the applicant will be so notified by the Director.
(B) Applications meeting the above requirement shall be examined by the Director in accordance with the relevant provisions of the act. The Director may approve or disapprove an application for admission to/from the fund without conducting a hearing.
14-2 APPEAL OF ORDER DENYING ADMISSION OR DENYING BENEFITS TO THE MAJOR MEDICAL INSURANCE FUND AND MEDICAL DISASTER FUND
(A) A party who is dissatisfied with an order dismissing or denying an application for admission or dissatisfied with a written denial of benefits may apply for a hearing with the Office of Administrative Courts within 30 days from the date of the order.
(B) When a hearing is requested after a dismissal or denial of an application for admission or for a denial of benefits from the fund, the Director shall be listed as a party and served with all notices, pleadings, reports, and other documents. Where an attorney has entered an appearance for the Director in a case, such service shall be made upon that attorney.
14-3 TERMINATING BENEFITS FROM THE MAJOR MEDICAL INSURANCE FUND
(A) When a party believes that further expenditures from the Major Medical Insurance Fund will not promote recovery, alleviate pain or reduce disability, that party, may file a request with the Director to issue an order to show cause why the Director should not issue a final order to cease payments from the Major Medical Insurance Fund.
(B) Upon the discretion of the Director, an order to show cause why the claim should not be closed from the Major Medical Insurance Fund will be issued. If no response is filed to the order to show cause within 30 days the Director shall issue an order to cease payments from the Major Medical Insurance Fund. If a response to the order to show cause is received within 30 days, the Director shall determine if an order to cease payments shall be issued.
(C) If an order to cease payment is issued, and no objection is filed within 30 days of the order to cease payment, the case shall automatically be closed for payment of benefits from the Major Medical Insurance Fund.
(D) If an objection is timely filed to the order to cease payment the objecting party shall set the case for hearing within 30 days of the date of the objection by filing an application for hearing with the Office of Administrative Courts. The Major Medical Insurance Fund shall continue medical benefits until an application is filed and the matter is resolved by order.
14-4 OFFSET OF LIABILITY TO SUBSEQUENT INJURY FUND FOR ACCIDENTS THAT OCCURRED PRIOR TO 7-1-93 AND OCCUPATIONAL DISEASES THAT OCCURRED PRIOR TO 4-1-94
(A) Offset of liability to the Subsequent Injury Fund, shall be initiated by filing a request for offset with the Division upon the prescribed form and serving the Director with a copy of the request for offset. The party filing the request for offset with the Director shall also simultaneously file with the Director a copy of medical reports, orders and all available relevant documents that support the request for offset.
(B) A request pursuant to §8-46-101, C.R.S., shall list, to the extent available by the requesting party, all prior or pending workers’ compensation cases by name and number, a brief description of each injury and the award in each case.
(C) A request pursuant to §8-41-304(2), C.R.S., shall indicate the types of exposures alleged, the approximate dates of each exposure, and the location and the name of the employer in whose employ each exposure allegedly occurred.
(D) A request for offset shall be filed no later than the date the party requesting offset files an application for hearing or response to application for hearing, unless an administrative law judge rules that good cause has been shown for filing later. However, in no event shall a request for offset be filed after a determination, by admission or order, that a claimant is permanently and totally disabled under §8-46-101 or disabled under §8-41-304(2).
(E) The party requesting offset shall also file a proposed order with the Office of Administrative Courts joining the Director as a party on behalf of the Subsequent Injury Fund. Sufficient copies of the order and pre-addressed envelopes for all parties shall also be filed.
(F) The administrative law judge shall consider the proposed order to join the Director and response and rule on whether to join the Director as a party. The ruling shall be based on whether the procedural requirements of this Rule 14 have been met and whether the request states a sufficient basis upon which offset could be granted. Until the Director is joined, notices and orders are not binding on the Subsequent Injury Fund.
(G) When the Director is joined as a party and when an attorney has entered an appearance on behalf of the Subsequent Injury Fund, copies of all reports, pleadings or other documents thereafter filed by any party shall be served upon that attorney.
14-5 STATUS OF DIRECTOR ON BEHALF OF THE SUBSEQUENT INJURY FUND, IN FATAL CASES
(A) The Director shall be deemed to be an interested party in all fatal cases and shall be served with all pleadings, notices, reports, and documents as required for any party. Where an attorney has entered an appearance for the Director in a case, such service shall be made upon that attorney.
(B) In the event a compensable injury results in a death which has not been reported to the Division, the Director may initiate a claim for the death benefits provided by statute.
Rule 15 Vocational Rehabilitation Rules Applicable to Claims based upon an Injury or Illness Occurring prior to July 2, 1987 at 4:16 p.m.
15-1 STATEMENT OF BASIS AND PURPOSE
The rules of procedure governing the vocational rehabilitation component of worker's compensation as originally promulgated pursuant to §8-49-101(4), C.R.S 1973 (repealed 1987) provide a qualified worker an opportunity to re-enter the workforce by establishing guidelines for vocational rehabilitation.
In addition to the definitions already adopted in the rules, the following definitions apply to vocational rehabilitation procedures:
(A) "Job Modification" is the adaptation of a job either through the use of aids or devices or the alteration of the physical environment of the job, or both, to allow an impaired individual to perform within the scope of tasks originally designed for the job flow.
(B) "Qualified Worker" means a claimant who because of the effects of a work-related injury or occupational disease, (a) is permanently precluded from engaging in his/her usual and customary occupation and is unable to perform work for which the individual has previous training or experience, and (b) can reasonably be expected to attain suitable, gainful employment upon successful completion of a vocational rehabilitation program.
(C) "Qualified Rehabilitation Consultant" means a person authorized by a rehabilitation vendor to conduct a vocational evaluation and develop a rehabilitation plan for a qualified worker.
(D) "Rehabilitation Vendor" means an individual, firm or facility which exists to provide any or all of the services necessary to determine a claimant’s eligibility as a qualified worker, and/or provide those services designed to return an individual to work.
(E) "Suitable Gainful Employment" means employment which is reasonably attainable and which offers an opportunity to restore the qualified worker as soon as possible and as nearly as possible to employment with the claimant’s qualifications, including but not limited to the claimant’s age, education, previous work history, interests and skills. Special consideration shall also be given to the economic level of the claimant at the time of injury and to the present and future labor markets, to attempt to restore him/her to the maximum level attainable.
(F) "Transferable Skills" means those skills an individual possesses which were attained through previous training or experience and are readily marketable and a need for them exists in the current labor market and would provide suitable gainful employment.
(G) "Vocational Evaluation" means the rehabilitation services and testing required by the Director to determine a claimant’s eligibility as a qualified worker.
(H) "Vocational Rehabilitation Plan" means a written document completed and signed by a qualified rehabilitation consultant which describes the manner and means by which it is proposed that a qualified worker may be returned to suitable gainful employment through the participation in a rehabilitation program.
(I) "Vocational Rehabilitation Program" means the actual providing of services as prescribed in the vocational rehabilitation plan and approved by the Director as reasonably necessary to restore a qualified worker to suitable gainful employment.
15-3 INITIATION OF VOCATIONAL EVALUATION AND DIRECTOR'S DETERMINATION OF ELIGIBILITY
(A) A vocational evaluation shall be provided by a rehabilitation vendor designated by the insurer, or upon failure of such designation, by the Division in consultation with the claimant, immediately upon knowledge that a claimant is unlikely to be able to return to his/her usual and customary occupation on a permanent basis as determined by competent medical evidence and opinion.
(B) A vocational evaluation summary report shall be submitted to the Director on a form prescribed by the Director and shall include the minimum elements listed on the form. The Director may request additional information necessary to determine eligibility.
(C) The vocational evaluation summary report shall be signed by a qualified rehabilitation consultant responsible for the evaluation and shall contain a recommendation by the consultant whether the claimant is eligible for a vocational rehabilitation program. If the recommendation indicates the claimant is in need of vocational rehabilitation and would benefit from vocational rehabilitation, the summary shall include a description of suggested occupation(s) that would be considered for plan development.
(D) A vocational evaluation shall be completed within sixty (60) days of assignment to the rehabilitation vendor.
(E) Upon submission of the vocational evaluation summary report, the insurer shall indicate whether it is providing vocational rehabilitation voluntarily or is requesting that the Director determine eligibility. Upon a request to determine eligibility the Director shall issue a “Notice of Determination of Eligibility for Vocational Rehabilitation Benefits” within twenty days.
(F) A party may object to the determination of eligibility by filing an application for hearing with the Office of Administrative Courts within fifteen (15) days of the date of the Director's determination.
15-4 SUBMISSION AND IMPLEMENTATION OF THE VOCATIONAL REHABILITATION PLAN
(A) If the claimant is determined a qualified worker, the Director shall order that a vocational rehabilitation plan be developed. The plan shall be developed and submitted to the Director and the parties within forty-five (45) days of the Director's determination of eligibility, unless said determination has been contested.
(B) In developing the plan, the rehabilitation vendor shall strive to return the qualified worker to suitable gainful employment within the qualified worker’s medical and physical limitations as determined in the vocational evaluation in the following priorities:
(1) Return to work for the same employer to a modified job requiring rehabilitation services.
(2) Return to work for the same or a new employer in a related occupation, for which the individual has received rehabilitation services to upgrade skills attained from previous training or experience.
(3) Return to work in an on-the-job training capacity.
(4) Return to work after the completion of a vocational program into a new occupation.
(C) Once developed, the proposed plan shall be written and submitted to the parties on the form prescribed by the Director. The written plan shall include the minimum elements listed on the form. All parties shall sign the vocational plan prior to submitting the plan to the Director for approval. The Director may request additional information necessary to determine if the plan should be approved.
(D) The Director, upon receipt of a proposed vocational rehabilitation plan and upon review, shall order the plan either approved or disapproved or modified. Implementation of the plan may begin as soon as the qualified worker is capable of participating in the program, as indicated by competent medical evidence. The plan shall begin upon the Director's approval or the date specified in the plan as applicable, whichever is later. The insurer shall continue to provide temporary disability benefits, if applicable, until implementation of the plan and the employee begins his vocational rehabilitation program.
(E) All matters regarding rehabilitation plans or programs shall be initially submitted to the Director except in those cases where the question of need for vocational rehabilitation first arises during the course of a hearing or hearings on other issues.
(F) If there is a dispute regarding the vocational rehabilitation plan, the disputing party shall request a hearing by filing an application for hearing at the Office of Administrative Courts.
(G) If the qualified worker does not choose to enroll in a vocational rehabilitation program, nothing in these rules and regulations shall require the qualified worker to do so.
15-5 MODIFICATION, SUSPENSION OR TERMINATION OF THE VOCATIONAL REHABILITATION PLAN OR VOCATIONAL EVALUATION
(A) If a vocational evaluation or an approved vocational plan is modified, terminated or suspended for any reason, and the parties are in agreement, the Director shall be notified. Plan modifications shall be submitted to the Director for approval on the prescribed form for vocational plans.
(B) If there is a dispute regarding the progress of a vocational evaluation or vocational rehabilitation plan, the disputing party shall request a hearing by filing an application for hearing at the Office of Administrative Courts.
15-6 REPORTING REQUIREMENT
All vocational rehabilitation forms and reports based upon an injury occurring on or prior to July 2, 1987 at 4:16 P.M. shall be filed with the Division and all parties copied.
15-7 QUALIFIED REHABILITATION VENDOR
(A) A vendor will be considered qualified by the Director if the vendor has the services of a consultant who had previously registered with the Division when the registration program existed or can demonstrate one of the following credentials:
(1) The individual is a Certified Rehabilitation Counselor under the guidelines of the Commission on Rehabilitation Counselor Certification or can demonstrate equivalent credentials.
(2) The individual has a Master's degree in Vocational Rehabilitation, Guidance and Counseling, Psychology, or in a related field or can demonstrate equivalent work experience on a year for year basis for formal education. The individual must also have one (1) year of experience as a practitioner in the field of vocational rehabilitation.
(3) The individual has a Bachelor's degree in Vocational Rehabilitation, Guidance and Counseling, Psychology, or a related field or can demonstrate equivalent work experience on a year for year basis for formal education. The individual must also have two (2) years experience as a practitioner in the field of vocational rehabilitation.
(B) If a dispute occurs concerning a counselor’s credentials, the counselor shall submit to the Director a resume, transcripts, diploma and any other requested documentation. The Director will determine whether the counselor is qualified.
Rule 16 UTILIZATION STANDARDS
16-1 STATEMENT OF PURPOSE
In an effort to comply with its legislative charge to assure appropriate and timely medical care at a reasonable cost, the Director (Director) of the Division of Workers' Compensation (Division) has promulgated these utilization standards, effective January 1, 2008. This rule defines the standard terminology, administrative procedures and dispute resolution procedures required to implement the Division's Medical Treatment Guidelines and Medical Fee Schedule. With respect to any matter arising under the Colorado Workers' Compensation Act and/or the Workers' Compensation Rules of Procedure and to the extent not otherwise precluded by the laws of this state, all providers and payers shall use and comply with the provisions of the "Medical Treatment Guidelines," Rule 17, and the "Medical Fee Schedule," Rule 18, as incorporated and defined in the Workers' Compensation Rules of Procedure, 7 CCR 1101-3.
16-2 STANDARD TERMINOLOGY FOR RULES 16 AND 18
(A) Ambulatory Surgical Center (ASC) – licensed as an ambulatory surgery center by the Colorado Department of Public Health and Environment.
(B) Authorized Treating Provider (ATP) – (may be any of the following):
(1) The treating physician designated by the employer and selected by the injured worker;
(2) A health care provider to whom an authorized treating physician refers the injured worker for treatment, consultation, or impairment rating;
(3) A health care provider selected by the injured worker when the injured worker has the right to select a provider;
(4) A health care provider authorized by the employer when the employer has the right or obligation to make such an authorization;
(5) A health care provider determined by the director or an administrative law judge to be an ATP;
(6) A provider who is designated by the agreement of the injured worker and the payer.
(C) Billed Service(s) -- any billed service, procedure, equipment or supply provided to an injured worker by a provider.
(D) Billing Party -- a service provider or an injured worker who has incurred authorized medical costs.
(E) Certificate of Mailing -- a signed and dated statement containing the names and mailing addresses of all persons receiving copies of attached or referenced document(s), certifying the documents were placed in the U.S. Mail, postage pre-paid, to those persons.
(F) Children’s Hospital – as identified and Medicare certified by the Colorado Department of Public Health and Environment.
(G) Convalescent Center – as licensed by the Colorado Department of Public Health and Environment.
(H) Critical Access Hospital (CAH) – as identified and Medicare certified by the Colorado Department of Public Health and Environment.
(I) Day -- for the purpose of Rule 16, day is defined as a calendar day unless otherwise noted.
(J) Hospital – as identified and licensed by the Colorado Department of Public Health and Environment.
(K) Long-Term Care Facility – as identified and Medicare certified by the Colorado Department of Public Health and Environment
(L) Medical Fee Schedule -- Division's Rule 18, its Exhibits, and the documents incorporated by reference in that rule.
(M) Medical Treatment Guidelines -- the medical treatment guidelines as incorporated into Rule 17, "Medical Treatment Guidelines."
(N) Payer -- an insurer, employer, or their designated agent(s) who is responsible for payment of medical expenses.
(O) Private Psychiatric Facilities – Licensed as a psychiatric hospital by the Colorado Department of Public Health and Environment.
(P) Provider -- a person or entity providing authorized healthcare service, whether involving treatment or not, to a worker in connection with work-related injury or occupational disease.
(Q) Rehabilitation Facilities – licensed as a rehabilitation hospital by the Colorado Department of Public Health and Environment.
(R) Rural Health Facility – as identified and Medicare certified by the Colorado Department of Public Health and Environment.
(S) State Psychiatric Hospitals and State Mental Health Institutions – licensed as a psychiatric facility and operated by the state.
(T) “Supply et al.” -- any single supply, durable medical equipment (DME), orthotic, prosthesis, biologic, or single drug dose, for which the billed amount exceeds $500.00 and all implants.
(U) Veterans’ Administration Medical Facilities – all medical facilities overseen by the Federal Veterans’ Administration.
16-3 REQUIRED USE OF THE MEDICAL TREATMENT GUIDELINES
When an injury or occupational disease falls within the purview of Rule 17 "Medical Treatment Guidelines" and the date of injury occurs on or after July 1, 1991, providers shall use the medical treatment guidelines, in effect at the time of service, to prepare their treatment plan(s) for the injured worker.
16-4 REQUIRED USE OF THE MEDICAL FEE SCHEDULE
When services provided to an injured worker fall within the purview of the medical fee schedule, all payers shall use the fee schedule to determine maximum allowable fees.
16-5 RECOGNIZED HEALTH CARE PROVIDERS
(A) Physician and Non-Physician Providers
(1) For the purpose of this rule, recognized health care providers are divided into the major categories of "physician" and "non-physician". Recognized providers are defined as follows:
(a) "Physician providers" are those individuals who are licensed by the State of Colorado through one of the following state boards:
(1) Colorado State Board of Medical Examiners;
(2) Colorado State Board of Chiropractic Examiners;
(3) Colorado Podiatry Board; and
(4) Colorado State Board of Dental Examiners.
(b) "Non-physician providers" are those individuals who are registered or licensed by the State of Colorado Department of Regulatory Agencies, or certified by a national entity recognized by the State of Colorado as follows:
(1) Audiologist (AU.D., CCC-A) – certified by the American Speech/Language and Hearing Association or board certified in audiology from the American Board of Audiology;
(2) Acupuncturist (LAc) – licensed by the Office of Acupuncturist Registration, Colorado Department of Regulatory Agencies;
(3) Licensed Clinical Social Worker (LCSW) – licensed by the Colorado State Board of Social Work Examiners;
(4) Licensed Practical Nurse (LPN) – licensed by the Colorado State Board of Nursing;
(5) Licensed Professional Counselor (LPC) – licensed by the Colorado State Board of Professional Counselor Examiners;
(6) Marriage and Family Therapist (LMFT) – licensed by the Colorado State Board of Marriage and Family Therapist Examiners;
(7) Advanced Practice Nurse– licensed by the Colorado State Board of Nursing; Advanced Practice Nurse Registry;
(8) Occupational Therapist (OTR) – certified by the National Occupational Therapy Certification Board;
(9) Optometrist (OD) – licensed by the Colorado State Board of Optometric Examiners;
(10) Orthopedic Technologist (OTC) – certified by the Board for Certification of Orthopedic Technologists, National Association of Orthopedic Technologists;
(11) Psychologist (PsyD, PhD, EdD) – licensed by the Colorado State Board of Psychologist Examiners;
(12) Physical Therapist (LPT) – licensed by the Colorado State Board of Physical Therapy;
(13) Physician Assistant (PA) – licensed by the Colorado State Board of Medical Examiners;
(14) Registered Nurse (RN) – licensed by the Colorado State Board of Nursing;
(15) Respiratory Therapist (RTL) – certified by the National Board of Respiratory Care and licensed by the Colorado Department Of Regulatory Agencies;
(16) Speech Language Pathologist (CCC-SLP) – certified by the American Speech and Hearing Association; and
(17) Surgical Technologist (CST) – certified under direction of the Association of Surgical Technologists.
(2) Any provider not listed in Rule 16-5(A)(1)(a) or (b) must comply with Rule 16-9, Prior Authorization when providing all services.
(3) All non-physician providers must have a referral from an authorized treating physician. An authorized physician making the referral to any listed or unlisted non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care.
(4) Any listed or non-listed non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care with the referring authorized treating physician.
(5) Rule 18 (medical fee schedule) applies to authorized services provided in relation to a specific workers’ compensation case.
(B) Upon request, healthcare providers must provide copies of license, registration, certification or evidence of healthcare training for billed services.
(C) Out-of-State Provider
(1) Injured Worker Relocated
(a) Upon receipt of the "Employer's First Report of Injury" or the "Worker's Claim for Compensation” form, the payer shall notify the injured worker that the procedures for change-of-provider, should s/he relocate out-of-state, can be obtained from the payer.
(b) A change of provider must be made:
(1) Through referral by the injured worker's authorized provider; or
(2) In accordance with § 8-43-404 (5)(a), C.R.S.
(2) Injured Worker Referred
In the event an injured worker has not relocated out-of-state but is referred to an out-of-state provider for treatment or services not available within Colorado, the referring provider shall obtain prior authorization from the payer as set forth in Rule 16-9, Prior Authorization, and 16-10, Contest of a Request for Prior Authorization. The referring provider's written request for out-of-state treatment shall include the following information:
(a) Medical justification prepared by the referring provider;
(b) Written explanation as to why the requested treatment/services cannot be obtained within Colorado;
(c) Name, complete mailing address and telephone number of the out-of-state provider;
(d) Description of the treatment/services requested, including the estimated length of time and frequency of the treatment/service, and all associated medical expenses; and
(e) Out-of-state provider’s qualifications to provide the requested treatment or services.
(3) The Colorado fee schedule should govern reimbursement for out-of-state providers.
16-6 HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS
(A) Use of agents, including but not limited to PPO networks, bill review companies, third party administrators (TPAs) and case management companies, shall not relieve the employer or insurer from their legal responsibilities for compliance with these rules.
(B) Payment for billed services identified in the fee schedule shall not exceed those scheduled rates and fees, or the provider's actual billed charges, whichever is less.
(C) Payment for billed services not identified or identified but without established value in the fee schedule shall require prior authorization from the payer as set forth in Rule 16-9 Prior Authorization and Rule 16-10 Contest of a Request for Prior Authorization. Determination of the payment amount shall be made by the payer and reflect the complexity, time, level of training and expertise required to perform the service or procedure, but shall at no time exceed the amount billed. The methodology for determination of payment used by the payer shall be made available to the provider upon request. If the payer uses a usual and customary rate data base (UCR), the payer must specify the percentile used, the zip code used and the source of the data base. Rule 16-11, Payment of Medical Benefits, sets forth the procedures for contesting any portion of a bill. If there are no reasonable methods to determine a fee, the payer shall pay the billed charges.
16-7 REQUIRED BILLING FORMS AND ACCOMPANYING DOCUMENTATION
(A) Providers may use electronic reproductions of any required form(s) referenced in this section; however, any such reproduction shall be an exact duplication of such form(s) in content and appearance.
(B) Required Billing Forms
All health care providers shall use only the following billing forms or electronically produced formats when billing for services:
(1) CMS (Centers for Medicare & Medicaid Services) 1500 (08-05) - shall be used by all providers billing for professional services, durable medical equipment (DME) and ambulance with the exception of those providers billing for dental services or procedures; hospitals are required to use the CMS 1500 (08-05) when billing for professional services. Health care providers shall provide their name and credentials in an appropriate box of the CMS 1500 (08-05).
(2) UB-04 - shall be used by all hospitals, Children’s Hospitals, CAHs, Veterans’ Administration Facilities, home health and facilities meeting the definitions found in Rule 16-2 when billing for hospital services or any facility fees billed by any other provider, such as ASCs, except for urgent care which may use the CMS 1500 (08-05).
(3) American Dental Association’s Dental Claim Form, Version 2006 shall be used by all providers billing for dental services or procedures.
(4) With the agreement of the payer, the ANSI ASC X12 (American National Standards Institute Accredited Standards Committee) or NCPDP (National Council For Prescription Drug Programs) electronic billing transaction containing the same information as in (1), (2) or (3) in this subsection may be used.
(C) Required Billing Codes
All billed services shall be itemized on the appropriate billing form as set forth in Rule 16-7(A) and (B), and shall include applicable billing codes and modifiers from the fee schedule. Currently national provider identification (NPI) numbers are not required for workers’ compensation bills.
(D) Inaccurate Billing Forms or Codes
Payment for any services not billed on the forms identified and/or not itemized as instructed in Rule 16-7(B) and (C), may be contested until the provider complies. However, when payment is contested, the payer shall comply with the applicable provisions set forth in Rule 16-11 Payment of Medical Benefits
(E) Accompanying Documentation
(1) Authorized treating physicians sign (or countersign) and submit to the payer, with their initial and final visit billings, a completed “Physician’s Report of Workers’ Compensation Injury” (Form WC164) specifying:
(a) The report type as “initial” when the injured worker has their initial visit with the authorized treating physician for this workers’ compensation injury. 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) The report type as “closing” when the physician determines the injured worker has reached maximum medical improvement (MMI) for all injuries or diseases covered under this workers’ compensation claim. 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 also 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) Referral to a 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.
(2) At no charge, the physician shall supply the injured worker with one legible copy of all completed “Physician’s Report of Workers’ Compensation Injury” (WC164) forms at the time the form is completed.
(3) The provider shall submit to the payer the completed WC164 form as specified in Rule 16-7(E), no later than fourteen (14) days from the date of service.
(4) Providers, other than hospitals, shall provide the payer with all supporting documentation at the time of submission of the bill unless other agreements have been made between the payer and provider. This shall include copies of the examination, surgical, and/or treatment records.
(5) Hospital documentation shall be available to the payer upon request. Payers shall specify what portion of a hospital record is being requested. (For example, only the emergency room (ER) chart notes, in-patient physician orders and chart notes, x-rays, pathology reports, etc.)
(6) In accordance with Rule 16-11, the payer may contest payment for billed services until the provider completes and submits the required accompanying documentation as specified by Rule 16-7(E).
16-8 REQUIRED MEDICAL RECORD DOCUMENTATION
(A) A provider shall maintain medical records for each injured worker when the provider intends to bill for the provided services.
(B) All medical records shall contain legible documentation substantiating the services billed. The documentation shall itemize each contact with the injured worker and shall detail at least the following information per contact or, at a minimum for cases where contact occurs more than once a week, be summarized once per week:
(1) Patient's name;
(2) Date of contact, office visit or treatment;
(3) Name and professional designation of person providing the billed service;
(4) Assessment or diagnosis of current condition with appropriate objective findings;
(5) Treatment status or patient’s functional response to current treatment;
(6) Treatment plan including specific therapy with time limits and measurable goals and detail of referrals;
(7) If being completed by an authorized treating physician, all pertinent changes to work and/or activity restrictions which reflect lifting, standing, stooping, kneeling, hot or cold environment, repetitive motion or other appropriate physical considerations; and
(8) All prior authorization(s) for payment received from the payer (i.e., who approved the prior authorization for payment, services authorized, dollar amount, length of time, etc.).
16-9 PRIOR AUTHORIZATION
(A) Prior authorization for payment shall be requested by the provider when:
(1) A prescribed service exceeds the recommended limitations set forth in the medical treatment guidelines;
(2) The medical treatment guidelines otherwise require prior authorization for that specific service;
(3) A prescribed service is identified within the medical fee schedule as requiring prior authorization for payment; or
(4) A prescribed service is not identified in the fee schedule as referenced in Rule 16-6(C).
(B) All prior authorization for a prescribed service or procedure may be granted immediately and without medical review. However, the payer shall respond to all providers requesting prior authorization within seven (7) business days from receipt of the provider’s completed request as defined in Rule 16-9(E). The duty to respond to a provider's written request applies without regard for who transmitted the request.
(C) The payer, upon receipt of the "Employer's First Report of Injury" or a "Worker's Claim for Compensation,” shall give written notice to the injured worker stating that the requirements for obtaining prior authorization for payment are available from the payer.
(D) The payer, unless they have previously notified said provider, shall give notice to the provider of these procedures for obtaining prior authorization for payment upon receipt of the Division form titled "Physician's Report of Workers’ Compensation Injury” (WC164).
(E) To complete a prior authorization request, the provider shall concurrently explain the medical necessity of the services requested and provide relevant supporting medical documentation. Supporting medical documentation is defined as documents used in the provider’s decision-making process to substantiate the need for the requested service or procedure.
(F) To contest a request for prior authorization, the payer is required to comply with the provisions outlined in Rule 16-10.
(G) The Division recommends payers confirm in writing, to providers and all parties, when a request for prior authorization is approved.
(H) If, after the service was provided, the payer agrees the service provided was reasonable and necessary, lack of prior authorization for payment does not warrant denial of payment.
16-10 CONTEST OF A REQUEST FOR PRIOR AUTHORIZATION
(A) If the payer contests a request for prior authorization for non-medical reasons as defined under Rule 16-11(B)(1), the payer shall notify the provider and parties, in writing, of the basis for the contest within seven (7) business days from receipt of the provider’s completed request as defined in Rule 16-9(E). A certificate of mailing of the written contest must be sent to the provider and parties.
If an ATP requests prior authorization and indicates in writing, including their reasoning and relevant documentation, that they believe the requested treatment is related to the admitted workers’ compensation (WC) claim, the insurer cannot deny based solely on relatedness without a medical review as under Rule 16-10(B).
(B) If the payer is contesting a request for prior authorization for medical reasons, the payer shall, within seven (7) business days of the completed request:
(1) Have all the submitted documentation under Rule 16-9(E) reviewed by a physician or other health care professional, as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review; and
(2) After reviewing all the submitted documentation, the reviewing provider may call the requesting provider to expedite communication and processing of prior authorization requests. However, the written contest or approval still needs to be completed within the specified seven (7) days under Rule 16-10(B).
(3) Furnish the provider and the parties with either a verbal or written approval, or a written contest that sets forth the following information:
(a) An explanation of the specific medical reasons for the contest, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;
(b) The specific cite from the Division’s Medical Treatment Guidelines exhibits to Rule 17, when applicable;
(c) Identification of the information deemed most likely to influence the reconsideration of the contest when applicable; and
(d) A certificate of mailing to the provider and parties.
(C) Prior Authorization Disputes
(1) The requesting party or provider shall have seven (7) business days from the date of the certificate of mailing on the written contest to provide a written response to the payer, including a certificate of mailing. The response is not considered a "special report" when prepared by the provider of the requested service.
(2) The payer shall have seven (7) business days from the date of the certificate of mailing of the response to issue a final decision, including a certificate of mailing to the provider and parties.
(3) In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts..
(D) An urgent need for prior authorization of health care services, as recommended in writing by an authorized treating provider, shall be deemed good cause for an expedited hearing.
(E) Failure of the payer to timely comply in full with the requirements of Rule 16-10(A) or (B), shall be deemed authorization for payment of the requested treatment unless a hearing is requested within the time prescribed for responding as set forth in Rule 16-10(A) or (B).
(F) Unreasonable delay or denial of prior authorization, as determined by the Director or an administrative law judge, may subject the payer to penalties under the Workers’ Compensation Act.
16-11 PAYMENT OF MEDICAL BENEFITS
(A) Uncontested Payment For Billed Services
(1) Providers shall submit their bills for services rendered within one hundred twenty (120) days of the date of service or the bill may be denied unless extenuating circumstances exist. Extenuating circumstances may include but are not limited to delays in compensability being decided or the provider has not been informed where to send the bill.
(2) Unless contested in accordance with the provisions set forth in this section 16-11(B) and (C), all bills submitted by a provider are due and payable in accordance with the Medical Fee Schedule within thirty (30) days after receipt of the bill by the payer. Date of receipt may be established by the payer’s date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) days after the date the bill was mailed to the payer’s correct address. The payer shall notify the billing provider that the injured worker shall not be balance-billed for services related to a compensable work-related injury or occupational disease.
(3) When the payer fails to make timely payment of uncontested billed services, the billing party shall first attempt to resolve payment with the payer. Where such attempt is unsuccessful, the billing party may request assistance from the Division’s Carrier Practices Unit.
(B) Contested Payment for Billed Services Based on Non-Medical Issues.
(1) Non-medical reasons for contesting payment may include, but are not limited to: compensability has not been established; the billed services are not related to the admitted injury; the provider is not authorized to treat; the insurance coverage is at issue; or the billed code does not appear to be accurate based upon the information submitted.
(2) IIf an ATP bills for medical services and indicates in writing, including their reasoning and relevant documentation, that they believe the medical services are related to the admitted WC claim, the insurer cannot deny based solely on relatedness without a medical review as under Rule 16-11(C).
(3) In all cases where a billed service is contested for non-medical reasons by the payer, the payer shall, within thirty (30) days of receipt of the bill, submit to the billing party a written notification of contest.
The written non-medical notification of contest shall include the following information:
(a) Name of the injured worker;
(b) Date(s) of service(s) being contested;
(c) Payer’s accident number and/or Division’s workers’ compensation claim number;
(d) If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(e) Reference to the bill and each item of the bill being contested;
(f) Reason(s) for contesting the payment of any item. The explanation shall include the citing of appropriate statutes, rules and/or documents supporting the payer’s reasons for contesting payment; and
(g) Notice that the billing party may resubmit the bill or corrected bill within sixty (60) days.
(4) Prior to modifying a billed code, the payer must contact the billing provider and determine if the modified code is accurate.
(a) IIf the billing provider agrees with the payer, then the payer shall process the service with the agreed upon code and shall document on their explanation of benefits (EOB) the agreement with the provider. The EOB shall include the name of the person at the provider’s office who made the agreement.
(b) If the provider is in disagreement, then the payer shall proceed according to Rule 16-11(B)(3) or 16-11(C), as appropriate.
(5) If the payer agrees a service or procedure was reasonable and necessary, the provider’s lack of prior authorization for payment does not warrant denial of liability for payment.
(C) Contested Payment for Billed Services Based on Medical Issues:
The payer shall within thirty (30) days of receipt of the medical bill and supporting medical documentation do the following:
(1) Have the bill and all supporting medical documentation under Rule 16-7(E) reviewed by a physician or other healthcare professional as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review. After reviewing the supporting medical documentation, the reviewing provider may call the billing provider to expedite communication and timely processing of the contested or paid medical bill. However, the written contest or payment still needs to be completed within the specified thirty (30) days under Rule 16-11.
(2) Furnish the provider and the parties with a written contest setting forth the following information:
(a) An explanation of the specific medical reasons for the decision, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;
(b) The specific cite from the Division’s Medical Treatment Guidelines exhibits to Rule 17, when applicable;
(c) Identification of the information deemed most likely to influence the reconsideration of the contest, when applicable; and
(d) A certificate of mailing to the provider and parties.
(D) Medical Bill Disputes
(1) The billing party shall have sixty (60) days to respond to the payer’s written notification of contest. The payer shall have thirty (30) days to respond to the provider’s response to the notification of contest. If the parties are unable to resolve a dispute relating to the Medical Fee Schedule, either party may contact the Medical Policy Unit (MPU) at the Division.
(2) If the payer discounts a bill and the provider requests clarification in writing, the payer shall furnish to the requester the specifics of the discount within 30 days including a copy of any contract relied on for the discount. If no response is forthcoming within 30 days, the payer must pay the maximum fee schedule allowance or the billed charges, whichever is less.
(3) When seeking clarification or dispute resolution from the MPU, the requesting party must provide:
(a) A copy of the bill with the contested codes and dates of services in dispute;
(b) A copy of the payer’s explanation as to why the billed services are being contested; and
(c) A copy of any applicable medical record documentation.
The MPU will try to provide a written analysis and opinion to the parties regarding the appropriate application of the Medical Fee Schedule within thirty (30) days of receipt of the complete documentation and the written request for assistance; or as soon thereafter as possible.
(4) In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
(E) Retroactive Adjustments of Medical Bills
(1) All medical bills paid by a payer shall be considered final unless adjustments are made within twelve months after the date of the original explanation of benefits.
(2) A written notice shall be sent to a provider prior to any recovery of overpayments being undertaken by the payer. The written notice shall contain complete and specific explanation of the amounts being recovered, the specific reasons why these amounts are believed to be overpayments, and evidence that these payments were in fact made. The provider shall have at least 60 days to respond to the written notice before any recovery of the overpayment is started.
(F) An injured worker shall never be required to directly pay for admitted or ordered medical benefits covered under the Workers’ Compensation Act. In the event the injured worker has directly paid for medical services that are then admitted or ordered as covered under the Workers’ Compensation Act , the payer shall reimburse the injured worker for the amounts actually paid for authorized services within thirty (30) days after receipt of the bill. If the actual costs exceed the maximum fee allowed by the medical fee schedule (Rule 18), the payer may seek a refund from the medical provider for the difference between the amount charged to the injured worker and the maximum fee. Each request for a refund shall indicate the service provided and the date of service(s) involved.
G) To the extent not otherwise precluded by the laws of this state, contracts between providers, payers and any agents acting on behalf of providers or payers shall comply with Rule 16-11..
16-12 ONSITE REVIEW OF HOSPITAL OR OTHER MEDICAL CHARGES
(A) The payer may conduct a review of billed and non-billed hospital or medical facility charges related to a specific workers’ compensation claim.
(B) The payer shall comply with the following procedures:
Within thirty (30) days of receipt of the billing, notify the hospital or other medical facility of its intent to conduct a review. Notification shall be in writing and shall set forth the following information:
(1) Name of the injured worker;
(2) Claim and/or hospital or other medical facility I.D. number associated with the injured worker's bill;
(3) An outline of the items to be reviewed; and
(4) If applicable, the name, address and telephone number of any person who has been designated by the payer to conduct the review (reviewer).
(C) The hospital or other medical facility shall comply with the following procedures:
(1) Allow the review to begin within thirty (30) days of the payer's notification;
(2) Upon receipt of the patient's signed release of information form, allow the reviewer access to all items identified on the injured worker's signed release of information form;
(3) Designate an individual(s) to serve as the primary liaison(s) between the hospital or other medical facility and the reviewer who will acquaint the reviewer with the documentation and charging practices of the hospital or other medical facility;
(4) Provide a written response to each of the preliminary review findings within ten (10) days of receipt of those findings; and
(5) Participate in the exit conference in an effort to resolve discrepancies.
(D) The reviewer shall comply with the following procedures:
(1) Obtain from the injured worker a signed information release form;
(2) Negotiate the starting date for the review;
(3) Assign staff members who are familiar with medical terminology, general hospital or other medical facility charging and medical records documentation procedures or have a level of knowledge equivalent at least to that of an LPN;
(4) Establish the schedule for the review which shall include, at a minimum, the dates for the delivery of preliminary findings to the hospital or other medical facility, a 10-day response period for the hospital or other medical facility, and the delivery of an itemized listing of discrepancies at an exit conference upon the completion of the review; and
(5) Provide the payer and hospital or other medical facility with a written summary of the review within twenty (20) working days of the exit conference.
Rule 17 MEDICAL TREATMENT GUIDELINES
17-1. STATEMENT OF PURPOSE
(A) In an effort to comply with its legislative charge to assure appropriate medical care at a reasonable cost, the director of the Division has promulgated these "Medical Treatment Guidelines." This rule provides a system of evaluation and treatment guidelines for high cost or high frequency categories of occupational injury or disease to assure appropriate medical care at a reasonable cost.
(B) Pursuant to section 8-42-101(3)(a)(I), C.R.S., prior to July 1 of each year the Division Director shall review all medical treatment guidelines. Written comments which have been submitted by the public to the director or the Division's medical director will be considered during such reviews.
17-2. USE OF THE MEDICAL TREATMENT GUIDELINES
(A) All health care providers shall use the medical treatment guidelines adopted by the Division.
(B) Payers shall routinely and regularly review claims to ensure that care is consistent with the Division's medical treatment guidelines.
17-3. STANDARD TERMINOLOGY FOR THIS RULE
See Rule 16, Utilization Standards.
17-4. PROVIDER'S RESPONSIBILITIES
(A) The health care provider shall prepare a diagnosis-based treatment plan that includes specific treatment goals with expected time frames for completion in all cases where treatment falling within the purview of the medical treatment guidelines continues beyond 6 weeks.
(B) Within 14 days of request by any party, the provider shall supply a copy of the treatment plan both to the patient and to the payer. Should the patient otherwise require care that deviates from the medical treatment guidelines, the provider shall supply the patient and the payer with a written explanation of the medical necessity for such care.
17-5. PROCEDURE FOR QUESTIONING CARE
(A) In cases where treatment falls within the purview of a medical treatment guideline, prior authorization for payment is unnecessary unless the guideline specifies otherwise, or Rule 16-9 (A)(I)-(4) apply.
(B) If prior authorization is required by the Medical Treatment Guidelines or a provider requests prior authorization then the procedure for contesting a request for prior authorization for payment is under Rule 16-10.
(C) The treatment guidelines set forth care that is generally considered reasonable for most injured workers. However, the Division recognizes that reasonable medical practice may include deviations from these guidelines, as individual cases dictate. For cases in which the provider requests care outside the guidelines the provider should follow the procedure for prior authorization in Rule 16-9.
(2) If the payer questions whether treatment is consistent with the medical treatment guidelines then the procedure for contesting payment of a billed service is covered under Rule 16-11 (B) and (C)
17-6. FAILURE TO COMPLY
See Rule 1, General Definitions and General Provisions
17-7. EXHIBITS TO RULE 17
(A) Exhibit 1 – Low Back Pain Medical Treatment Guidelines
(B) Exhibit 2 –Carpal Tunnel Syndrome Medical Treatment Guidelines
(C) Exhibit 3 - Thoracic Outlet Syndrome Medical Treatment Guidelines
(D) Exhibit 4 – Shoulder Injury Medical Treatment Guidelines
(E) Exhibit 5 – Cumulative Trauma Disorder Medical Treatment Guidelines
(F) Exhibit 6 – Lower Extremity Medical Treatment Guidelines
(G) Exhibit 7 –Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment Guidelines
(H) Exhibit 8 – Cervical Spine Injury Medical Treatment Guidelines
(I) Exhibit 9 – Chronic Pain Disorder Medical Treatment Guidelines
(J) Exhibit 10 – Traumatic Brain Injury Medical Treatment Guidelines
Rule 18 MEDICAL FEE SCHEDULE
18-1 STATEMENT OF PURPOSE
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 80202-3626. 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
(A) CPTâ - CPTâ 2007 Current Procedural Terminology, copyrighted and distributed by the American Medical Association (AMA).
(B) DoWC – Colorado Division of Workers’ Compensation created codes
(C) 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 16-2, Utilization Standards.
18-3 HOW TO OBTAIN COPIES
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 .
18-4 CONVERSION FACTORS (CF)
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
Surgery X Procedures $37.69/RVU
(see Rule 18-5(D)(1)( d))
Medicine $ 7.56/RVU
Physical Medicine $ 5.57/RVU
Physical Medicine and Rehabilitation
Medical Nutrition Therapy and
Evaluation & Management (E&M) $ 8.47/RVU
18-5 INSTRUCTIONS AND/OR MODIFICATIONS TO THE RVP©
(A) Maximum allowance for all providers under Rule 16-5 is 100% of the RVP© value or as defined in this Rule 18.
(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.
(C) Temporary codes listed in the RVP© may be used for billing with agreement of the payer as to reimbursement. Payment shall be in compliance with Rule 16-6(B).
(1) Anesthesia Section:
(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:
(1) Not under the medical direction of an anesthesiologist, reimbursement shall be 90% of the maximum anesthesia value,
(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 are 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 IX, “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
(d) Surgery X Procedures
(1) The Surgery X procedures are limited to those listed below and found in the table under the RVP©, Anesthesia section’s Guidelines XI, “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 XI 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 XI, “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.
(2) Surgical Section:
(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, 80202-3626.
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.
(b) Incidental procedures are commonly performed as an integral part of a total service and do not warrant a separate benefit.
(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) Non-physician, minimum assistant surgeons used as surgical assistants shall be reimbursed at 10 % of the listed value.
(f) Global Period
(1) The following services performed during a global period would warrant separate billing if documentation demonstrates significant identifiable services were involved, such as:
¨ 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.
(2) Separate identifiable services shall use an appropriate RVP© modifier in conjunction with the billed service.
(g) Bilateral procedures are reimbursed the same as all multiple procedures: 100% for the first primary procedure and then 50% for all other procedures, including the 2nd "primary" procedure.
(h) The “Services with Significant Direct Costs” section of the RVP© is not adopted. Supplies shall be reimbursed as set out in Rule 18-6(H).
(E) Radiology Section:
(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);
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).
(G) Medicine Section:
(1) Medicine home therapy services in the RVP© are not adopted. For appropriate codes see Rule 18-6(N), Home Therapy.
(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.
(4) Appendix J of the 2007 CPTâ identifies mixed, motor and sensory nerve conduction studies and their appropriate billing.
(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 no more than 34 visits or 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.
(b) An office visit may be billed on the same day as manipulation codes when the documentation meets the E&M requirement and an appropriate modifier is used.
(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.
(b) Most initial evaluations for delayed recovery can be completed in two (2) hours. Prior authorization for payment is required any time the following limitations are exceeded:
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).
(2) For recommendations on the use of the physical medicine and rehabilitation procedures, modalities, and testing, see Rule 17, Medical Treatment Guidelines Exhibits.
(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)
An interdisciplinary rehabilitation program is one that provides focused, coordinated, and goal-oriented services using a team of professionals from varying disciplines to deliver care. These programs can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning. As defined in Rule 17, rehabilitation programs may include, but are not limited to: chronic pain, spinal cord, or brain injury programs.
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) 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,
(7) Evaluation Services for Therapists: Physical Therapy (PT), Occupational Therapy (OT) and Athletic Trainers (cf. §12-36-106 C.R.S.)
(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©.
(c) A patient may be seen by more than one health care professional on the same day. An evaluation service with appropriate documentation may be charged for each professional per patient per day.
(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).
(8) Special Tests
The following respective tests are considered special tests:
• Job Site Evaluation
• Computer- Enhanced Evaluation
Functional Capacity Evaluation
Work Tolerance Screening
• Assistive technology assessment
(a) Billing Restrictions:
(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.
(4) No E&M services or PT, OT, or acupuncture evaluations shall be charged separately for these tests.
(5) Data from computerized equipment shall always include the supporting analysis developed by the physical medicine professional before it is payable as a special test.
(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).
(11) Unattended Treatment
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
(12) Non-Medical Facility
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.
(2) Provider Restrictions: All procedures must be performed by or under the onsite supervision of a physician, PT, OT, speech language pathologist or audiologist.
(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
An E&M visit shall be billed as a “new” patient service for each “new injury” even though the provider has seen the patient within the last three years. Any subsequent E&M visits are to be billed as an “established patient” and reflect the level of service indicated by the documentation when addressing all of the current injuries.
(3) Number of Office Visits
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.
(4) Case Management
(a) Telephone case management services may be billed if the services are performed on a separate day from an E&M office visit and when the medical records/documentation specifies all the following:
(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.
(b) An interdisciplinary team conference, consisting of medical professionals caring for the injured worker, shall select a team member to perform the following duties:
(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, multiples times its RVUs to reimburse 15, 30 or 45 minute conferences, respectively.
(2) Prepare and submit a written report for each conference that includes at least the following information:
¨ Patient's identifying information;
¨ 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
(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 99910
(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 this Rule 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 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
(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 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 Rule 18-6(D) in that case.
(2) By prior agreement, the physician may charge for preparation time for a deposition, for reviewing and signing the deposition or for preparation time for testimony.
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.
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, the physician may request 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.
Treating or Non-treating physician:
Maximum Rate of $450.00 per hour
(E) Mileage Expenses
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.
(2) Provider Restrictions
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.
(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.
(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.
(G) Report Preparation
(1) Routine Reports
Completion of routine reports or records are incorporated in all fees for service and include:
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)
(a) Initial Report
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.
(b) Closing Report
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
(3) Special Reports
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
(1) Unless otherwise indicated, payment for supplies shall reflect the provider’s actual cost plus a 20% markup. Cost includes shipping and handling charges.
(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
(1) Provider Restrictions
All non-emergency, inpatient admissions require prior authorization for payment.
(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. 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:
(1) Children’s hospital
(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
(3) Colorado Department of Public Health and Environment (CDPHE) licensed rehabilitation facility, and,
(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:
(1) (MS-DRG Relative Wt x Specific hospital base rate x 185%) + (reimbursement for all “Supply et al.”) + (trauma center activation allowance)
(2) “Supply et al.” is defined in Rule 16-2. Reimbursement shall be consistent with Rule 18-6(H). The billing provider is responsible for identifying and itemizing all “Supply et al.” items.
(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) 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.
(3) The “Difference” = “Hospital’s Cost” – “Maximum Fee Allowance” excluding any “Supply et al.” allowance (see (c) above)
(4) If the “Difference” is greater than $25,800.00, additional reimbursement is warranted. The additional reimbursement is determined by the following equation:
“Difference” x .80 = additional fee allowance
(e) Inpatient combined with ERD or Trauma Center 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) Except, Trauma Center activation fees (see 18-6(M)(3)(g)) 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 DRG maximum value. The per diem value is calculated based upon the transferring hospital’s DRG relative weight multiplied by the hospital’s specific base rate (Exhibit 2 to Rule 18) divided by the 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 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
(1) Provider Restrictions
(a) All non-emergency outpatient surgeries require prior authorization from the payer.
(b) A separate facility fee is only payable if the facility is licensed by the Colorado Department of Public Health and Environment (CDPHE) as:
(1) a hospital; or
(2) an Ambulatory Surgery Center (ASC.
(2) Bills for Services
(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 Rule 18.
(c) ASCs and hospitals shall bill using the surgical RVP© code(s) as indicated by the surgeon’s operative note up to a maximum of four surgery codes per surgical episode.
(3) Outpatient Surgery Facility Reimbursement:
(a) The following types of outpatient facilities are reimbursed at 100% of billed outpatient charges:
(1) Children’s hospital
(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:
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
(2) “Supply et al.” is defined in Rule 16-2. Reimbursement shall be consistent with Rule 18-6(H). The billing provider is responsible for identifying and itemizing all “Supply et al.” items; and
(3) Diagnostic testing and preoperative labs are reimbursed by applying the appropriate CF to the unit values for the specific CPT® code as listed in the RVP.
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.
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.
(5) Additional reimbursement is payable for the following services not included in the values found in Exhibit 4 of Rule 18:
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.
(e) 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.
(f) In compliance with rule 16-6(A), 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
(1) Bills for Services
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).
(a) The following types of outpatient diagnostic testing and clinic facilities are reimbursed at 100% of billed charges:
(1) Children’s hospitals,
(2) Veterans’ Administration hospitals
(3) State psychiatric hospitals
(b) Rural health facilities listed in Exhibit 5 are reimbursed at 80% of billed charges for clinic visits, diagnostic testing, and supplies and drugs that do not meet the “Supply et al.” threshold.
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.
(c) All other facilities:
(1) No separate allowance for clinic visit fees. Supplies are reimbursed in accordance with Rule 18-6(H).
(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.
(3) “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.
(d) 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 Rule 18-6(O).
(L) Outpatient Urgent Care Facility Fees
(1) Provider Restrictions:
(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.
(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
(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.
(2) Bills for Services
(a) Urgent care facility fees may be billed on a CMS 1500 (08-05)
(b) Urgent care facility fees shall be billed using HCPCS Level II code: S9088 – “Services provided in an Urgent care facility.”
(3) Urgent Care Reimbursement
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,
(b) “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.
Supplies and drugs that do not meet the “Supply et al.” threshold and treatment rooms are included in the Urgent Care 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
(d) The Observation Room allowance shall not exceed a rate of $50.00 per hour and is limited to a maximum of 3 hours without prior authorization.
(e) In compliance with Rule 16-6 (A), 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.
(4) Any prescription for a drug supply to be used longer than a 24 hour period, filled at any Urgent Care facility, shall fall under the requirements and be reimbursed as a pharmacy fee. See Rule 18-6(O).
(M) Outpatient Emergency Room Department (ERD) Facility Fees
(1) Provider Restrictions
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.
(2) Bills For Services
(a) ERD 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) Documentation should support the “Level of Care” being billed.
(3) ERD Reimbursement
(a) The following types of facilities are reimbursed at 100% of billed ERD charges:
(1) Children’s hospitals
(2) Veterans’ Administration hospitals
(3) State Psychiatric hospitals
(b) Medicare certified Critical Access Hospitals (CAH) (listed in Exhibit 3 of Rule 18) are reimbursed at 80% of billed charges.
(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 Level Reimbursement
1 $ 150.00
2 $ 250.00
3 $ 400.00
4 $ 700.00
5 $ 1,500.00
(2) All diagnostic testing, laboratory services and therapeutic services not included in the hospital’s point system (including, but not limited to, radiology, pathology, any respiratory therapy, PT or OT) shall be reimbursed by the appropriate CF multiplied by the unit value for the specific code as listed in the RVP© and Rule 18; and
(3) The observation room allowance shall not exceed a rate of $50.00 per hour and is limited to a maximum of 3 hours without prior authorization. The documentation should support the medical necessity for observation; and
(4) ERD level of care maximum fees include supplies and drugs that do not meet the “Supply et al.” threshold and treatment rooms. “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
(e) For the purposes of Rule 16-6 (A), 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 Rule 18-6(M)(3)(d). The lesser of the two amounts shall be the maximum facility allowance for the ERD episode of care. A line by line comparison is not appropriate.
(f) 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).
(g) Trauma Center Fees are not paid for alerts. Activation fees are as follows:
Level I $3,000.00
Level II $2,500.00
Level III $1,000.00
Level IV $00.00
(1) These fees are in addition to ER and inpatient fees.
(2) Activation Fees mean a Trauma Team has been activated, not just alerted.
(N) Home Therapy
Prior authorization 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 Rule 18-6(N)(2)
(a) Parenteral Nutrition:
0 -1 liter $140.00/day
1.1 - 2.0 liter $200.00/day
2.1 - 3.0 liter $260.00/day
(b) Antibiotic Therapy:
$105.00/day + Average Wholesale Price (AWP)
$ 85.00/day + AWP
(d) Enteral nutrition:
Category I $ 43.00/day
Category II $ 41.00/day
Category III $ 52.00/day
(e) Pain Management: $ 95.00/day + AWP
(f) Fluid Replacement: $ 70.00/day + AWP
(g) Multiple Therapies:
Rate per day for highest cost therapy only + AWP for all drugs
Medication/Drug Restrictions - the payment for drugs may be based upon the AWP of the drug as determined through the use of industry publications such as the monthly Price Alert, First Databank, Inc.
(2) Nursing Services
DoWC 99970 Skilled Nursing (LPN & RN)
$95.79 per hour
There is a limit of 2 hours without prior authorization.
DoWC 99972 Certified Nurse Assistant (CNA):
$31.67 per hour for the first hour;
$9.46 for each additional half hour. Service must be at least 15 minutes
to bill an additional half hour charge.
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 of Rule 18.
Travel allowances should be agreed upon with the payer and the mileage rate should not exceed $0.40 per mile, portal to portal.
DoWC Bill code: 99971
(5) Travel Time
Travel is typically included in the fees listed. Travel time greater than 1 hr. one-way shall be reimbursed. The fee shall be agreed upon at the time of prior authorization and shall not exceed $30.00 per hour.
DoWC code: 99972
(O) Pharmacy Fees
(1) AWP + $4.00
(2) All bills shall reflect the National Drug Code (NDC)
(3) All prescriptions shall be filled with bio-equivalent generic drugs unless the physician indicates "Dispense As Written" (DAW) on the prescription.
(4) The above formula applies to both brand name and generic drugs.
(5) The provider shall dispense no more than a 60-day supply per prescription.
(6) 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.
(7) AWP for brand name and generic pharmaceuticals may be
determined through the use of such monthly publication
s as Price Alert,
First Databank, Inc.
(8) Compounding Pharmacies
Reimbursement for compounding pharmacies shall be based on the cost of the materials plus 20 percent, $50.00 per hour for the pharmacist’s documented time, and actual cost of any mailing & handling.
DoWC 99913 Materials, mailing, handling
DoWC 99914 Pharmacist
(9) Injured Worker Reimbursement
The payer is responsible for timely payment of pharmaceutical costs. The provision for repayment is the same as that set out in Rule 16-11(F).
(10) 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 for specific vitamins supported by Rule 17.
(11) Prescription Writing
Physicians shall indicate on the prescription form that the medication is related to a workers’ compensation claim.
(12) Provider Reimbursement
Provider offices that prescribe and dispense medications from their office have a maximum allowance of AWP plus $4.00.
All medications administered in the course of the provider’s care shall be reimbursed at actual cost incurred.
(13) Required Billing Forms
(a) All parties shall use one of the following forms:
(1) CMS 1500 (08-05) (formerly CMS 1500) – the dispensing provider shall bill by using the RVP© supply code and shall include the metric quantity and NDC number of the drug being dispensed; 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.
(b) Items prescribed for the work-related injury that do not have an NDC code shall be billed as a supply, using procedure code 99070 for the billed supply.
(c) The payer may return any prescription billing form if the information is incomplete.
(d) A signature shall be kept on file indicating the patient or his/her authorized representative has received the prescription.
(P) Complementary Alternative Medicine (CAM) (Requires prior authorization)
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. Providers of CAM may be both licensed and non-licensed health practitioners with training in one or more forms of therapy. Refer to Rule 17, Medical Treatment Guidelines for the specific types of CAM modalities.
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 providers must be Registered Acupuncturists (LAc) or certified by an existing licensing board as provided in Rule 16, Utilization Standards, and must provide evidence of training, registration and/or certification upon request of the payer.
(2) Billing Restrictions
(a). For treatments of more than fourteen (14) sessions, the provider must obtain prior authorization from the payer.
(b) 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 for acupuncture and procedures is one 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.
(2) LAc new patient visit:
DoWC 97041 Maximum value $89.12
(3) LAc established patient visit:
DoWC 97044 Maximum value $60.16
(c) Herbs require prior authorization and fee agreements as in this Rule 18-6(O)(10);
(d) See the appropriate physical medicine and rehabilitation section of the RVP© for other billing codes and limitations (see also Rule 18-5.H).
(e) Acupuncture supplies are reimbursed in accordance with Rule 18-6(H).
18-7 DENTAL FEE SCHEDULE
The dental schedule is adopted using the American Dental Association’s Current Dental Terminology, 2007-2008 (CDT-2007/2008). However, surgical treatment for dental trauma and subsequent, related procedures may be billed using medical codes from the RVP©. If billed using medical codes as listed in the RVP© , reimbursement shall be in accordance with the Surgery/Anesthesia section of the RVP© and its corresponding conversion factor. All dental billing and reimbursement shall be in accordance with the Division's Rule 16, Utilization Standards, and Rule 17, Medical Treatment Guidelines. See Exhibit 6 for the listing and maximum allowance for CDT-2007/2008 dental codes.
Regarding prosthetic appliances, the provider may bill and be reimbursed for 50% of the allowed fee at the time the master casts are prepared for removable prosthodontics or the final impressions are taken for fixed prosthodontics. The remaining 50% may be billed on insertion of the final prosthesis.