DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 ccr 1101-3
WORKERS’ COMPENSATION RULES OF PROCEDURE
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 Ingenix St. Anthony Publishing, and Medicare  Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 25.0 (DRGs Definitions Manual) developed and published by 3M Health Information Systems using MS-DRGs effective after October 1, 2007.  The incorporation is limited to the specific editions named and does not include later revisions or additions.  For information about inspecting or obtaining copies of the incorporated materials, contact the Medical Fee Schedule Administrator, 633 17th Street, Suite 400, Denver, Colorado 80202-3660.  These materials may be examined at any state publications depository library.  All guidelines and instructions are adopted as set forth in the RVP© or MS-DRGs: Definitions Manual, unless otherwise specified in this rule.
This rule applies to all services rendered on or after January 1, 2008.  All other bills shall be reimbursed in accordance with the fee schedule in effect at the time service was rendered.
18-2	STANDARD TERMINOLOGY FOR THIS RULE
(A)	CPT - CPT 2007  Current Procedural Terminology, copyrighted and distributed by the American Medical Association (AMA).
(B)	DoWC – Colorado Division of Workers’ Compensation created codes 
(C)	MS-DRGs Definitions Manual – version 25.0  incorporated by reference in Rule 18-1.
(D)	RVP© – the 2007 edition incorporated by reference in Rule 18-1.
(E)	For other terms, see Rule 16, Utilization Standards.
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 Ingenix 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
Anesthesia					$ 48.89/RVU
Surgery						$ 90.97/RVU
Surgery X Procedures				$ 37.69/RVU
(see Rule 18-5(D)(1)( d))
Radiology					$ 17.26/RVU
Pathology					$ 12.99/RVU
Medicine					$  7.56/RVU
Physical Medicine				$  5.57/RVU
	Physical Medicine and Rehabilitation, Medical Nutrition Therapy and Acupuncture
Evaluation & Management (E&M)		$  8.47/RVU
18-5	INSTRUCTIONS AND/OR MODIFICATIONS TO THE RVP©
(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(C).
(D)	Surgery/Anesthesia
(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 is performed by a qualified anesthetist,
	Monitors the course of anesthesia administration at frequent intervals,
	Remains physically present and available for immediate diagnosis and treatment of emergencies, and
	Provides indicated post-anesthesia care.
(b)	Anesthesia add-on codes are reimbursed using the anesthesia CF and unit values found in the RVP©, Anesthesia section’s Guidelines XIII, “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 XIII, “Anesthesia Services Where Time Units Are Not Allowed”:
•	Providing local anesthetic or other medications through a regional IV
•	Daily drug management
•	Endotracheal intubation
•	Venipuncture, including cutdowns
•	Arterial punctures
•	Epidural or subarachnoid spine injections
•	Somatic and Sympathetic Nerve Injections 
•	Paravertebral facet joint injections and rhizotomies
In addition, lumbar plexus spine anesthetic injection, posterior approach with daily administration = 7 RVUs.
(2)	The maximum reimbursement for these procedures shall be based upon the anesthesia value listed in the table in the RVP©, Anesthesia section’s Guideline XIII multiplied by $37.69 CF.  No additional unit values are added for time when calculating the maximum values for reimbursement.  
(3)	When performing more than one surgery X procedure in a single surgical setting, multiple surgery guidelines shall apply (100% of the listed value for the primary procedure and 50% of the listed value for additional procedures).  Use modifier -51 to indicate multiple surgery X procedures performed on the same day during a single operative setting.  The 50% reduction does not apply to procedures that are identified in the RVP© as “Add-on” procedures.
(4)	Bilateral injections:  see 18-5(D)(2)(g). 
(5)	Other procedures from Table XIII not described above may be found in another section of the RVP© (e.g., surgery).  Any procedures found in the table under the RVP©, Anesthesia section’s Guidelines XIII, “Anesthesia Services Where Time Units Are Not Allowed” but not contained in this list (Rule 18-5(D)(1)(d)(1)) are reimbursed in accordance with the assigned units from their respective sections multiplied by their respective CF.
(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, 80202-3660.  
Where the publication restricts use of such assistants to "almost never" or a procedure is not referenced in the publication, prior authorization for payment shall be obtained from the payer.
(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: 
(1)	General
(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).
(2)	Thermography
(a)	The physician supervising and interpreting the thermographic evaluation shall be board certified by the examining board of one of the following national organizations and follow their recognized protocols:
American Academy of Thermology;
American Chiropractic College of Infrared Imaging.
(b)	Indications for thermographic evaluation must be one of the following:
Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy (CRPS/RSD);
Sympathetically Maintained Pain (SMP);
Autonomic neuropathy;
Chronic Neuropathic Pain (involving small caliber sensory fiber neuropathy).
(c)	Protocol for stress testing is outlined in the Medical Treatment Guidelines found in Rule 17.
(d)	Thermography Billing Codes:
DoWC 79993 Upper body w/ Autonomic Stress Testing	$856.80
DoWC 79995 Lower body w/Autonomic Stress Testing	$856.80
 (e)	Prior authorization for payment is required for thermography services only if the requested study does not meet the indicators for thermography as outlined in this radiology section.  The billing shall include a report supplying the thermographic evaluation and reflecting compliance with Rule 18-5(E)(2).
(F)	Pathology Section: The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate modifier should have been used on the bill.   To modify a billed code refer to Rule 16-11(B)(4).
(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.
(3)	Biofeedback
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 CPT  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 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.
(6)	Modalities
RVP© Timed and Non-timed Modalities 
Billing Restrictions:  There is a total limit of two (2) modalities (whether timed or non-timed), including one DoWC code 99915 or 99917, per visit, per discipline, per day.
NOTE:  Instruction and application of a TENS unit for the patient's independent use shall be billed using the timed e-stim RVP© code.
Dry Needling of Trigger Points DoWC Codes:
DoWC 99915	Single or multiple needles, one or two muscles, 
		5.4 RVUs				
DoWC 99917	three or more muscles,
		5.8 RVUs

(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
•	Speech
(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.
(10)	Supplies
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, multiplied 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;
	Diagnosis;
	Medical professionals attending the conference;
	A brief statement of conference recommendations and actions (no additional allowance shall be made for this statement); and
	Length of time of meeting.
18-6	DIVISION ESTABLISHED CODES AND VALUES 
(A)	Conferences Held at the Request of a Party
Telephonic or face-to-face conferences shall be related to the injured worker's treatment. All parties shall receive actual notification from the requesting party in advance and within 24 hours of scheduling.
DoWC 99901	Maximum	$300.00 per hour;
		billed at $75.00 per 15-minute increments.
(B)	Cancellation Fees For Payer Made Appointments
(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 for paper copies shall not exceed $14.00 for the first 10 or fewer pages, $0.50 per page for pages 11-40, and $0.33 per page thereafter. Actual postage or shipping costs and applicable sales tax, if any, may also be charged.  The per-page fee for records copied from microfilm shall be $1.50 per page.  
If the requester and provider agree, the copy may be provided on a disc.  The fee will not exceed $14.00 per disc.  
If the requester and provider agree and appropriate security is in place, including, but not limited to, compatible encryption, the copies may be submitted electronically.  Requester and provider should attempt to agree on a reasonable fee.  Absent an agreement to the contrary, the fee shall be $0.10/page.
Copying charges do not apply for the initial submission of records that are part of the required documentation for billing.    
Copying Fee Billing Code:	DoWC 99911
(D)	Deposition and Testimony Fees
(1)	When requesting deposition or testimony from physicians or any other type of provider, guidance should be obtained from the Interprofessional Code, as prepared by the Colorado Bar Association, the Denver Bar Association, the Colorado Medical Society and the Denver Medical Society.  If the parties cannot agree upon lesser fees for the deposition or testimony services, or cancellation time frames and/or fees, the following deposition and testimony rules and fees shall be used.  
If, in an individual case, a party can show good cause to an Administrative Law Judge (ALJ) for exceeding the fee schedule, that ALJ may allow a greater fee than listed in 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.
		Preparation Time:	
		Treating or Non-treating Physician:
				DoWC 99985		$325.00 per hour
 (3)	Deposition:
Payment for a treating or non-treating physician's testimony at a deposition shall not exceed $325.00 per hour billed in half-hour increments.  Calculation of the physician's time shall be "portal to portal."
If requested, the physician is entitled to a full hour deposit in advance in order to schedule the deposition.
If the physician is notified of the cancellation of the deposition at least seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours s/he has reasonably spent in preparation and shall refund to the deposing party any portion of an advance payment in excess of time actually spent preparing and/or testifying.
If the provider is notified of the cancellation of the deposition at least five (5) business days but less than seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours he or she has reasonably spent in preparation and one-half the time scheduled for the deposition.
If the provider is notified less than five (5) business days in advance of a cancellation, or the deposition is shorter than the time scheduled, the provider shall be paid the number of hours he or she has reasonably spent in preparation and has scheduled for the deposition.
Deposition: 			
Treating or Non-treating  physician:
		DoWC 99975	$325.00 per hr.
				Billed in half-hour increments
(4)	Testimony:
Calculation of the physician's time shall be "portal to portal."
For testifying at a hearing, if requested the physician is entitled to a four (4) hour deposit in advance in order to schedule the testimony.
If the physician is notified of the cancellation of the testimony at least seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours s/he has reasonably spent in preparation and shall refund any portion of an advance payment in excess of time actually spent preparing and/or testifying.
If the provider is notified of the cancellation of the testimony at least  five (5) business days but less than seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours he or she has reasonably spent in preparation and one-half the time scheduled for the testimony.
	If the provider is notified of a cancellation less than five (5) business days prior to the date of the testimony or the testimony is shorter than the time scheduled, the provider shall be paid the number of hours s/he has reasonably spent in preparation and has scheduled for the testimony.
Testimony:		
Treating or Non-treating  physician:
		DoWC 99085
		Maximum Rate of $450.00 per hour
(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:
Diagnostic Testing
Procedure Reports
Progress notes
Office notes 
Operative reports
Supply invoices, if requested by the payer
Providers shall submit routine reports free of charge as directed in Rule 16-7(E) and by statute.  Requests for additional copies of routine reports and for reports not in Rule 16-7(E) or in statute are reimbursable under the copying fee section of Rule 18.
(2)	Completion of the Physician’s Report of Workers’ Compensation Injury (WC164) 
(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 and trauma center activation billed charges) multiplied by the hospital’s cost-to-charge ratio.
(2)	Each hospital’s cost-to-charge ratio is given in Exhibit 2 of Rule 18.
(3)	The “Difference” = “Hospital’s Cost” – “Maximum Fee Allowance” excluding any “Supply et al.” allowance and trauma center activation 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 MS-DRG maximum value.  The per diem value is calculated based upon the transferring hospital’s MS-DRG relative weight multiplied by the hospital’s specific base rate (Exhibit 2 to Rule 18) divided by the MS-DRG geometric mean length of stay.  This per diem amount is multiplied by the actual LOS.  If the patient is admitted and transferred on the same day, the actual LOS equals one (1).  The receiving hospital shall receive the appropriate MS-DRG maximum value.
(g)	To comply with Rule 16-6(B), the payer shall compare each billed charge type:
o	The MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier allowance),
o	 "Supply et al." billed charges to the "Supply et al." allowance [cost + 20%], and
o	the trauma center activation billed charge to the trauma center activation allowance.  
	The MS-DRG adjusted billed charges are determined by subtracting the "Supply et al." billed charges and the trauma center activation billed charges from the total billed charges.  The final payment is the sum of the lesser of each of these comparisons.
(J)	Scheduled Outpatient Surgery Facility Fees
(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:
•	nursing, 
•	technician and related services, 
•	use by the recipient of the facility including the operating room and recovery room, 
•	equipment directly related to the provision of surgical procedures, 
•	fluoroscopy and x-rays during the surgical episode, 
•	supplies, drugs, biologics, surgical dressings, splints, cases and appliances that do not meet the “Supply et al.” threshold,
•	administration, record keeping, housekeeping items and services, and
•	materials and trained observer for anesthesia.
The April 2007  Addendum B can be accessed at Medicare’s Hospital Outpatient PPS website.  
Total maximum facility value for an outpatient surgical episode of care includes the sum of:
(1)	The highest valued APC code per Exhibit 4 plus 50% of any lesser-valued APC code values.
Multiple procedures and bilateral procedures are to be indicated by the use of modifiers –51 and –50, respectively.  The 50% reduction applies to all lower valued procedures, even if they are identified in the RVP© as modifier -51 exempt.  The reduction also applies to the second "primary" procedure of bilateral procedures.
The surgery discogram procedure (APC 388) value is for each level and includes conscious sedation and the technical component of the radiological procedure.
Facility fee reimbursement is limited to a maximum of four surgical procedures per surgical episode with a maximum of only one procedure reimbursed at 100% of the allowed value; and
(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.
	Billing Codes:
G0377	Convalescence rate after 12 hours of observation care:   $500.00/day billed in and rounded to the nearest 6 hour increment.
G0378	Observation hourly rate:  $50.00 per hour for the first 12 hours, rounded to the nearest 15 minute increment.
(5)	Additional reimbursement is payable for the following services not included in the values found in Exhibit 4 of Rule 18:
•	ambulance services 
•	blood, blood plasma, platelets 
(d)	Discontinued surgeries require the use of modifier -73 (discontinued prior to administration of anesthesia) or modifier -74 (discontinued after administration of anesthesia).  Modifier -73 results in a reimbursement of 50% of the APC value for the primary procedure only.  Modifier -74 allows reimbursement of 100% of the primary procedure value only.
(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(B), the sum of Rule 18-6(J)(3)(c)(1-5) is compared to the total facility fee billed charges.  The lesser of the two amounts shall be the maximum facility allowance for the surgical episode of care.  A line by line comparison of billed charges to the calculated maximum fee schedule allowance of 18-6(J)(3)(c) is not appropriate.
(K)	Outpatient Diagnostic Testing and Clinic Facility Fees
(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).
(2)	Reimbursement
(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.
“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.
(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; and
(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 facility maximum fees; and 
(c)	All diagnostic testing, laboratory services and therapeutic services (including, but not limited to, radiology, pathology, respiratory therapy, physical therapy or occupational therapy) shall be reimbursed by multiplying the appropriate CF by the unit value for the specific CPT® code as listed in the RVP© and Rule 18; and 
(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 (B), the sum of all Urgent Care fees charged, less any amounts charged for professional fees or dispensed prescriptions per Rule 18-6(L)(4) found on the same bill, is to be compared to the maximum reimbursement allowed by the calculated value of Rule 18-6(L)(3)(a-d).  The lesser of the two amounts shall be the maximum facility allowance for the episode of urgent care.  A line by line comparison is not appropriate. 
(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 of, 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		Reimbursement
Level					
1		$	150.00 
2		$	250.00 
3		$	400.00 
4		$	700.00 
5		$	1,500.00 
and
(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 (B), the sum of all outpatient ERD fees charged, less any amounts charged for professional fees found on the same bill, is to be compared to the maximum reimbursement allowed by the calculated value of 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 ERD 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)
 (c)	Chemotherapy:
$ 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.
(4)	Mileage 
Travel allowances should be agreed upon with the payer and the mileage rate should not exceed $0.40 per mile, portal to portal.
DoWC 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:	99973
(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 as Price Alert, First Databank, Inc.
(8)	Compounding Pharmacies
Reimbursement for compounding pharmacies shall be based on the cost of the materials plus 20%, $50.00 per hour for the pharmacist’s documented time, and actual cost of any mailing & handling.
Bill Code:
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 the RVP© supply code.
(c)	The payer may return any prescription billing form if the information is incomplete.
(d)	A signature shall be kept on file indicating that the patient or his/her authorized representative has received the prescription.
(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. 
(Q)	Acupuncture 
Acupuncture is an accepted procedure for the relief of pain and tissue inflammation.  While commonly used for treatment of pain, it may also be used as an adjunct to physical rehabilitation and/or surgery to hasten return of functional recovery.  Acupuncture may be performed with or without the use of electrical current on the needles at the acupuncture site.
(1)	Provider Restrictions
All 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.

Exhibit 1
MS-DRGs with Relative Weights, Geometric and Arithmetic Means
MS-DRG	MDC	TYPE	MS-DRG Title	Weights 	Geometric Mean LOS	Arithmetic Mean LOS	
1	PRE	SURG	Heart transplant or implant of heart assist system w MCC	23.1117	30.8	45.6	
2	PRE	SURG	Heart transplant or implant of heart assist system w/o MCC	16.2735	16.1	22.8	
3	PRE	SURG	ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R.	18.7707	33.4	40.6	
4	PRE	SURG	Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R.	11.4219	23.8	29.3	
5	PRE	SURG	Liver transplant w MCC or intestinal transplant	10.6120	17.6	23.5	
6	PRE	SURG	Liver transplant w/o MCC	7.2562	9.1	10.5	
7	PRE	SURG	Lung transplant	8.4002	14.6	17.3	
8	PRE	SURG	Simultaneous pancreas/kidney transplant	5.1726	10.1	11.8	
9	PRE	SURG	Bone marrow transplant	6.4842	18.1	21.7	
10	PRE	SURG	Pancreas transplant	3.8902	9.2	10.5	
11	PRE	SURG	Tracheostomy for face,mouth & neck diagnoses w MCC	4.1482	12.8	16.2	
12	PRE	SURG	Tracheostomy for face,mouth & neck diagnoses w CC	3.2472	8.9	10.9	
13	PRE	SURG	Tracheostomy for face,mouth & neck diagnoses w/o CC/MCC	2.6760	6.1	7.2	
20	01	SURG	Intracranial vascular procedures w PDX hemorrhage w MCC	7.7073	15.2	19.1	
21	01	SURG	Intracranial vascular procedures w PDX hemorrhage w CC	6.7021	13.4	15.5	
22	01	SURG	Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC	5.6085	7.8	9.6	
23	01	SURG	Cranio w major dev impl/acute complex CNS PDX w MCC or chemo implant	4.7036	9.0	12.8	
24	01	SURG	Cranio w major dev impl/acute complex CNS PDX w/o MCC	3.8978	6.1	8.9	
25	01	SURG	Craniotomy & endovascular intracranial procedures w MCC	4.2362	10.3	13.3	
26	01	SURG	Craniotomy & endovascular intracranial procedures w CC	3.1582	6.5	8.2	
27	01	SURG	Craniotomy & endovascular intracranial procedures w/o CC/MCC	2.3259	3.5	4.6	
28	01	SURG	Spinal procedures w MCC	4.2339	10.8	14.7	
29	01	SURG	Spinal procedures w CC or spinal neurostimulators	2.8356	5.3	7.3	
30	01	SURG	Spinal procedures w/o CC/MCC	1.7617	2.8	3.7	
31	01	SURG	Ventricular shunt procedures w MCC	3.2226	9.2	13.2	
32	01	SURG	Ventricular shunt procedures w CC	1.9342	3.8	5.8	
33	01	SURG	Ventricular shunt procedures w/o CC/MCC	1.4281	2.3	3.1	
34	01	SURG	Carotid artery stent procedure w MCC	2.5438	4.8	7.3	
35	01	SURG	Carotid artery stent procedure w CC	1.8996	2.0	2.9	
36	01	SURG	Carotid artery stent procedure w/o CC/MCC	1.6977	1.3	1.6	
37	01	SURG	Extracranial procedures w MCC	2.2630	6.0	8.7	
38	01	SURG	Extracranial procedures w CC	1.4686	2.5	3.7	
39	01	SURG	Extracranial procedures w/o CC/MCC	1.0909	1.5	1.8	
40	01	SURG	Periph/cranial nerve & other nerv syst proc w MCC	3.2550	10.0	13.6	
41	01	SURG	Periph/cranial nerve & other nerv syst proc w CC or periph neurostim	2.3595	5.4	7.3	
42	01	SURG	Periph/cranial nerve & other nerv syst proc w/o CC/MCC	1.8710	2.5	3.6	
52	01	MED	Spinal disorders & injuries w CC/MCC	1.4329	4.7	7.0	
53	01	MED	Spinal disorders & injuries w/o CC/MCC	1.1172	3.1	4.0	
54	01	MED	Nervous system neoplasms w MCC	1.4228	5.3	7.2	
55	01	MED	Nervous system neoplasms w/o MCC	1.1213	3.8	5.0	
56	01	MED	Degenerative nervous system disorders w MCC	1.2820	5.8	7.8	
57	01	MED	Degenerative nervous system disorders w/o MCC	0.8951	3.9	4.9	
58	01	MED	Multiple sclerosis & cerebellar ataxia w MCC	1.2669	5.8	8.0	
59	01	MED	Multiple sclerosis & cerebellar ataxia w CC	0.9226	4.3	5.2	
60	01	MED	Multiple sclerosis & cerebellar ataxia w/o CC/MCC	0.8160	3.4	4.1	
61	01	MED	Acute ischemic stroke w use of thrombolytic agent w MCC	2.5541	7.3	9.6	
62	01	MED	Acute ischemic stroke w use of thrombolytic agent w CC	2.0886	5.3	6.3	
63	01	MED	Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC	1.8642	3.9	4.5	
64	01	MED	Intracranial hemorrhage or cerebral infarction w MCC	1.5470	5.6	7.6	
65	01	MED	Intracranial hemorrhage or cerebral infarction w CC	1.1901	4.3	5.3	
66	01	MED	Intracranial hemorrhage or cerebral infarction w/o CC/MCC	1.0303	3.1	3.8	
67	01	MED	Nonspecific cva & precerebral occlusion w/o infarct w MCC	1.2194	4.7	6.2	
68	01	MED	Nonspecific cva & precerebral occlusion w/o infarct w/o MCC	0.9131	2.8	3.6	
69	01	MED	Transient ischemia	0.7339	2.5	3.1	
70	01	MED	Nonspecific cerebrovascular disorders w MCC	1.6212	6.0	7.9	
71	01	MED	Nonspecific cerebrovascular disorders w CC	1.2522	4.5	5.6	
72	01	MED	Nonspecific cerebrovascular disorders w/o CC/MCC	0.9586	2.9	3.7	
73	01	MED	Cranial & peripheral nerve disorders w MCC	1.1717	4.8	6.4	
74	01	MED	Cranial & peripheral nerve disorders w/o MCC	0.8954	3.4	4.4	
75	01	MED	Viral meningitis w CC/MCC	1.5369	6.0	7.6	
76	01	MED	Viral meningitis w/o CC/MCC	1.1439	3.4	4.2	
77	01	MED	Hypertensive encephalopathy w MCC	1.4611	5.6	7.2	
78	01	MED	Hypertensive encephalopathy w CC	1.0996	3.7	4.6	
79	01	MED	Hypertensive encephalopathy w/o CC/MCC	0.9839	2.8	3.4	
80	01	MED	Nontraumatic stupor & coma w MCC	0.9014	3.6	4.9	
81	01	MED	Nontraumatic stupor & coma w/o MCC	0.7161	2.7	3.4	
82	01	MED	Traumatic stupor & coma, coma >1 hr w MCC	1.6724	3.9	6.4	
83	01	MED	Traumatic stupor & coma, coma >1 hr w CC	1.3328	3.7	5.2	
84	01	MED	Traumatic stupor & coma, coma >1 hr w/o CC/MCC	1.1106	2.3	3.1	
85	01	MED	Traumatic stupor & coma, coma <1 hr w MCC	1.6946	5.7	7.9	
86	01	MED	Traumatic stupor & coma, coma <1 hr w CC	1.2337	4.0	5.1	
87	01	MED	Traumatic stupor & coma, coma <1 hr w/o CC/MCC	0.9235	2.6	3.4	
88	01	MED	Concussion w MCC	1.2968	4.3	6.1	
89	01	MED	Concussion w CC	0.9479	3.0	3.8	
90	01	MED	Concussion w/o CC/MCC	0.7405	2.0	2.5	
91	01	MED	Other disorders of nervous system w MCC	1.3242	4.7	6.6	
92	01	MED	Other disorders of nervous system w CC	0.9529	3.5	4.4	
93	01	MED	Other disorders of nervous system w/o CC/MCC	0.7710	2.6	3.2	
94	01	MED	Bacterial & tuberculous infections of nervous system w MCC	3.1499	9.7	12.5	
95	01	MED	Bacterial & tuberculous infections of nervous system w CC	2.5679	7.2	9.1	
96	01	MED	Bacterial & tuberculous infections of nervous system w/o CC/MCC	2.3482	4.9	6.2	
97	01	MED	Non-bacterial infect of nervous sys exc viral meningitis w MCC	2.6665	9.3	11.8	
98	01	MED	Non-bacterial infect of nervous sys exc viral meningitis w CC	2.0568	6.8	8.5	
99	01	MED	Non-bacterial infect of nervous sys exc viral meningitis w/o CC/MCC	1.8177	5.1	6.3	
100	01	MED	Seizures w MCC	1.2500	4.7	6.3	
101	01	MED	Seizures w/o MCC	0.8258	2.9	3.7	
102	01	MED	Headaches w MCC	0.8710	3.6	5.1	
103	01	MED	Headaches w/o MCC	0.6677	2.5	3.2	
113	02	SURG	Orbital procedures w CC/MCC	1.4141	3.8	5.5	
114	02	SURG	Orbital procedures w/o CC/MCC	1.0292	2.0	2.7	
115	02	SURG	Extraocular procedures except orbit	1.1185	3.3	4.5	
116	02	SURG	Intraocular procedures w CC/MCC	0.8891	2.2	3.4	
117	02	SURG	Intraocular procedures w/o CC/MCC	0.7094	1.5	1.9	
121	02	MED	Acute major eye infections w CC/MCC	0.8800	4.6	5.8	
122	02	MED	Acute major eye infections w/o CC/MCC	0.6608	3.3	4.1	
123	02	MED	Neurological eye disorders	0.7224	2.4	2.9	
124	02	MED	Other disorders of the eye w MCC	0.9308	3.9	5.3	
125	02	MED	Other disorders of the eye w/o MCC	0.6792	2.7	3.5	
129	03	SURG	Major head & neck procedures w CC/MCC or major device	1.7992	3.7	5.1	
130	03	SURG	Major head & neck procedures w/o CC/MCC	1.3987	2.4	3.2	
131	03	SURG	Cranial/facial procedures w CC/MCC	1.6300	4.0	5.8	
132	03	SURG	Cranial/facial procedures w/o CC/MCC	1.2054	2.1	2.6	
133	03	SURG	Other ear, nose, mouth & throat O.R. procedures w CC/MCC	1.4331	3.7	5.8	
134	03	SURG	Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC	0.9474	1.7	2.1	
135	03	SURG	Sinus & mastoid procedures w CC/MCC	1.5318	4.3	6.4	
136	03	SURG	Sinus & mastoid procedures w/o CC/MCC	1.1094	1.8	2.6	
137	03	SURG	Mouth procedures w CC/MCC	1.2677	3.7	5.4	
138	03	SURG	Mouth procedures w/o CC/MCC	0.8474	1.9	2.4	
139	03	SURG	Salivary gland procedures	0.8470	1.4	1.8	
146	03	MED	Ear, nose, mouth & throat malignancy w MCC	1.7734	7.1	10.3	
147	03	MED	Ear, nose, mouth & throat malignancy w CC	1.2182	4.2	5.8	
148	03	MED	Ear, nose, mouth & throat malignancy w/o CC/MCC	1.0070	2.5	3.5	
149	03	MED	Dysequilibrium	0.6154	2.2	2.7	
150	03	MED	Epistaxis w MCC	0.9916	4.0	5.5	
151	03	MED	Epistaxis w/o MCC	0.6227	2.3	2.9	
152	03	MED	Otitis media & URI w MCC	0.8160	3.7	4.7	
153	03	MED	Otitis media & URI w/o MCC	0.6207	2.8	3.4	
154	03	MED	Nasal trauma & deformity w MCC	1.1294	4.8	6.5	
155	03	MED	Nasal trauma & deformity w CC	0.8630	3.5	4.5	
156	03	MED	Nasal trauma & deformity w/o CC/MCC	0.7412	2.5	3.2	
157	03	MED	Dental & Oral Diseases w MCC	1.1909	5.0	6.9	
158	03	MED	Dental & Oral Diseases w CC	0.8653	3.4	4.4	
159	03	MED	Dental & Oral Diseases w/o CC/MCC	0.7361	2.4	3.1	
163	04	SURG	Major chest procedures w MCC	4.0452	12.2	15.0	
164	04	SURG	Major chest procedures w CC	2.8081	6.9	8.3	
165	04	SURG	Major chest procedures w/o CC/MCC	2.4106	4.5	5.4	
166	04	SURG	Other resp system O.R. procedures w MCC	3.2677	10.1	13.0	
167	04	SURG	Other resp system O.R. procedures w CC	2.4151	6.5	8.1	
168	04	SURG	Other resp system O.R. procedures w/o CC/MCC	1.8181	4.0	5.4	
175	04	MED	Pulmonary embolism w MCC	1.4152	6.1	7.4	
176	04	MED	Pulmonary embolism w/o MCC	1.1580	4.7	5.5	
177	04	MED	Respiratory infections & inflammations w MCC	1.8444	7.2	9.2	
178	04	MED	Respiratory infections & inflammations w CC	1.5636	6.0	7.4	
179	04	MED	Respiratory infections & inflammations w/o CC/MCC	1.2754	4.6	5.6	
180	04	MED	Respiratory neoplasms w MCC	1.5550	6.1	8.0	
181	04	MED	Respiratory neoplasms w CC	1.3126	4.5	6.0	
182	04	MED	Respiratory neoplasms w/o CC/MCC	1.1455	3.3	4.3	
183	04	MED	Major chest trauma w MCC	1.2664	5.7	7.2	
184	04	MED	Major chest trauma w CC	0.9611	3.8	4.6	
185	04	MED	Major chest trauma w/o CC/MCC	0.7298	2.7	3.3	
186	04	MED	Pleural effusion w MCC	1.4542	5.8	7.5	
187	04	MED	Pleural effusion w CC	1.1947	4.2	5.5	
188	04	MED	Pleural effusion w/o CC/MCC	0.9745	3.2	4.1	
189	04	MED	Pulmonary edema & respiratory failure	1.3660	4.8	6.2	
190	04	MED	Chronic obstructive pulmonary disease w MCC	1.1138	5.1	6.5	
191	04	MED	Chronic obstructive pulmonary disease w CC	0.9405	4.2	5.1	
192	04	MED	Chronic obstructive pulmonary disease w/o CC/MCC	0.8145	3.4	4.0	
193	04	MED	Simple pneumonia & pleurisy w MCC	1.2505	5.5	6.9	
194	04	MED	Simple pneumonia & pleurisy w CC	1.0235	4.5	5.3	
195	04	MED	Simple pneumonia & pleurisy w/o CC/MCC	0.8398	3.5	4.1	
196	04	MED	Interstitial lung disease w MCC	1.3781	5.8	7.3	
197	04	MED	Interstitial lung disease w CC	1.1458	4.4	5.4	
198	04	MED	Interstitial lung disease w/o CC/MCC	0.9654	3.5	4.3	
199	04	MED	Pneumothorax w MCC	1.4699	6.6	8.5	
200	04	MED	Pneumothorax w CC	1.0753	3.9	5.1	
201	04	MED	Pneumothorax w/o CC/MCC	0.8588	3.2	4.1	
202	04	MED	Bronchitis & asthma w CC/MCC	0.7841	3.6	4.5	
203	04	MED	Bronchitis & asthma w/o CC/MCC	0.6252	2.9	3.5	
204	04	MED	Respiratory signs & symptoms	0.6658	2.2	2.9	
205	04	MED	Other respiratory system diagnoses w MCC	1.0636	4.2	5.6	
206	04	MED	Other respiratory system diagnoses w/o MCC	0.7848	2.7	3.5	
207	04	MED	Respiratory system diagnosis w ventilator support 96+ hours	5.1231	12.6	15.0	
208	04	MED	Respiratory system diagnosis w ventilator support <96 hours	2.2463	5.2	7.3	
215	05	SURG	Other heart assist system implant	12.0016	6.3	12.0	
216	05	SURG	Cardiac valve & oth maj cardiothoracic proc w card cath w MCC	9.3040	15.9	18.7	
217	05	SURG	Cardiac valve & oth maj cardiothoracic proc w card cath w CC	7.5813	10.9	12.2	
218	05	SURG	Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC	6.8595	8.3	9.1	
219	05	SURG	Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC	7.2072	11.7	14.5	
220	05	SURG	Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC	5.7278	7.6	8.6	
221	05	SURG	Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC	5.2463	6.0	6.4	
222	05	SURG	Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC	8.0234	10.8	13.3	
223	05	SURG	Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC	6.8809	5.0	6.6	
224	05	SURG	Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC	7.3178	9.2	11.5	
225	05	SURG	Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC	6.2956	4.5	5.7	
226	05	SURG	Cardiac defibrillator implant w/o cardiac cath w MCC	5.9123	6.2	9.4	
227	05	SURG	Cardiac defibrillator implant w/o cardiac cath w/o MCC	5.0411	1.8	2.8	
228	05	SURG	Other cardiothoracic procedures w MCC	6.7400	12.0	14.6	
229	05	SURG	Other cardiothoracic procedures w CC	5.3191	7.9	9.0	
230	05	SURG	Other cardiothoracic procedures w/o CC/MCC	4.7847	5.6	6.6	
231	05	SURG	Coronary bypass w PTCA w MCC	7.2993	10.8	13.2	
232	05	SURG	Coronary bypass w PTCA w/o MCC	6.1947	8.0	9.0	
233	05	SURG	Coronary bypass w cardiac cath w MCC	6.4496	12.4	14.3	
234	05	SURG	Coronary bypass w cardiac cath w/o MCC	4.9216	8.2	8.9	
235	05	SURG	Coronary bypass w/o cardiac cath w MCC	5.1381	9.7	11.5	
236	05	SURG	Coronary bypass w/o cardiac cath w/o MCC	3.7307	6.1	6.6	
237	05	SURG	Major cardiovasc procedures w MCC or thoracic aortic anuerysm repair	4.4954	7.8	11.2	
238	05	SURG	Major cardiovasc procedures w/o MCC	3.1891	3.4	4.9	
239	05	SURG	Amputation for circ sys disorders exc upper limb & toe w MCC	3.9454	12.1	15.6	
240	05	SURG	Amputation for circ sys disorders exc upper limb & toe w CC	2.9983	8.4	10.5	
241	05	SURG	Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC	2.4709	5.7	6.9	
242	05	SURG	Permanent cardiac pacemaker implant w MCC	3.2586	6.9	8.9	
243	05	SURG	Permanent cardiac pacemaker implant w CC	2.5483	3.8	5.1	
244	05	SURG	Permanent cardiac pacemaker implant w/o CC/MCC	2.1367	2.2	2.9	
245	05	SURG	AICD lead & generator procedures	3.1073	2.1	3.3	
246	05	SURG	Perc cardiovasc proc w drug-eluting stent w MCC or 4+ vessels/stents	2.9046	3.7	5.5	
247	05	SURG	Perc cardiovasc proc w drug-eluting stent w/o MCC	2.1255	1.7	2.2	
248	05	SURG	Perc cardiovasc proc w non-drug-eluting stent w MCC or 4+ ves/stents	2.5180	4.3	6.2	
249	05	SURG	Perc cardiovasc proc w non-drug-eluting stent w/o MCC	1.8124	1.9	2.5	
250	05	SURG	Perc cardiovasc proc w/o coronary artery stent or AMI w MCC	2.4870	5.3	7.5	
251	05	SURG	Perc cardiovasc proc w/o coronary artery stent or AMI w/o MCC	1.7480	2.1	3.0	
252	05	SURG	Other vascular procedures w MCC	2.7564	5.6	8.8	
253	05	SURG	Other vascular procedures w CC	2.2536	4.1	6.0	
254	05	SURG	Other vascular procedures w/o CC/MCC	1.6786	2.0	2.8	
255	05	SURG	Upper limb & toe amputation for circ system disorders w MCC	2.1486	7.3	9.9	
256	05	SURG	Upper limb & toe amputation for circ system disorders w CC	1.6847	5.8	7.5	
257	05	SURG	Upper limb & toe amputation for circ system disorders w/o CC/MCC	1.3990	3.7	4.9	
258	05	SURG	Cardiac pacemaker device replacement w MCC	2.2926	5.5	7.6	
259	05	SURG	Cardiac pacemaker device replacement w/o MCC	1.6553	1.9	2.6	
260	05	SURG	Cardiac pacemaker revision except device replacement w MCC	2.1625	7.2	10.2	
261	05	SURG	Cardiac pacemaker revision except device replacement w CC	1.3212	2.8	3.9	
262	05	SURG	Cardiac pacemaker revision except device replacement w/o CC/MCC	1.1245	1.9	2.5	
263	05	SURG	Vein ligation & stripping	1.4977	3.5	5.5	
264	05	SURG	Other circulatory system O.R. procedures	2.4840	5.9	9.0	
280	05	MED	Acute myocardial infarction, discharged alive w MCC	1.7391	5.9	7.5	
281	05	MED	Acute myocardial infarction, discharged alive w CC	1.3126	4.0	4.9	
282	05	MED	Acute myocardia infarction, discharged alive w/o CC/MCC	1.0617	2.6	3.2	
283	05	MED	Acute myocardial infarction, expired w MCC	1.5787	3.4	5.5	
284	05	MED	Acute myocardial infarction, expired w CC	1.2074	2.3	3.5	
285	05	MED	Acute myocardial infarction, expired w/o CC/MCC	1.0421	1.6	2.2	
286	05	MED	Circulatory disorders except AMI, w card cath w MCC	1.6667	5.2	7.1	
287	05	MED	Circulatory disorders except AMI, w card cath w/o MCC	1.1412	2.5	3.2	
288	05	MED	Acute & subacute endocarditis w MCC	2.9143	9.6	12.2	
289	05	MED	Acute & subacute endocarditis w CC	2.3075	7.1	8.7	
290	05	MED	Acute & subacute endocarditis w/o CC/MCC	1.9733	5.2	6.6	
291	05	MED	Heart failure & shock w MCC	1.2585	5.1	6.6	
292	05	MED	Heart failure & shock w CC	1.0134	4.1	5.0	
293	05	MED	Heart failure & shock w/o CC/MCC	0.8765	3.1	3.7	
294	05	MED	Deep vein thrombophlebitis w CC/MCC	0.8665	4.6	5.5	
295	05	MED	Deep vein thrombophlebitis w/o CC/MCC	0.6950	3.8	4.4	
296	05	MED	Cardiac arrest, unexplained w MCC	1.1144	2.0	3.3	
297	05	MED	Cardiac arrest, unexplained w CC	0.8490	1.5	1.9	
298	05	MED	Cardiac arrest, unexplained w/o CC/MCC	0.7207	1.2	1.4	
299	05	MED	Peripheral vascular disorders w MCC	1.2220	5.2	6.9	
300	05	MED	Peripheral vascular disorders w CC	0.9451	4.1	5.1	
301	05	MED	Peripheral vascular disorders w/o CC/MCC	0.7183	3.1	3.8	
302	05	MED	Atherosclerosis w MCC	0.8236	3.3	4.4	
303	05	MED	Atherosclerosis w/o MCC	0.6055	2.1	2.6	
304	05	MED	Hypertension w MCC	0.8312	3.9	5.2	
305	05	MED	Hypertension w/o MCC	0.5942	2.3	2.9	
306	05	MED	Cardiac congenital & valvular disorders w MCC	1.2007	4.5	6.5	
307	05	MED	Cardiac congenital & valvular disorders w/o MCC	0.8224	2.7	3.5	
308	05	MED	Cardiac arrhythmia & conduction disorders w MCC	1.0841	4.3	5.8	
309	05	MED	Cardiac arrhythmia & conduction disorders w CC	0.8233	3.1	3.9	
310	05	MED	Cardiac arrhythmia & conduction disorders w/o CC/MCC	0.6439	2.3	2.8	
311	05	MED	Angina pectoris	0.5118	1.9	2.3	
312	05	MED	Syncope & collapse	0.7197	2.5	3.2	
313	05	MED	Chest pain	0.5489	1.7	2.1	
314	05	MED	Other circulatory system diagnoses w MCC	1.5606	5.1	7.1	
315	05	MED	Other circulatory system diagnoses w CC	1.1720	3.5	4.6	
316	05	MED	Other circulatory system diagnoses w/o CC/MCC	0.9075	2.4	3.0	
326	06	SURG	Stomach, esophageal & duodenal proc w MCC	5.1660	13.4	17.2	
327	06	SURG	Stomach, esophageal & duodenal proc w CC	3.2941	8.1	10.3	
328	06	SURG	Stomach, esophageal & duodenal proc w/o CC/MCC	1.8017	3.3	4.4	
329	06	SURG	Major small & large bowel procedures w MCC	4.5059	12.8	15.9	
330	06	SURG	Major small & large bowel procedures w CC	2.8935	8.4	9.8	
331	06	SURG	Major small & large bowel procedures w/o CC/MCC	1.8415	5.4	6.0	
332	06	SURG	Rectal resection w MCC	3.7139	12.2	14.7	
333	06	SURG	Rectal resection w CC	2.5787	7.8	8.9	
334	06	SURG	Rectal resection w/o CC/MCC	1.7856	4.9	5.6	
335	06	SURG	Peritoneal adhesiolysis w MCC	3.4785	11.8	14.4	
336	06	SURG	Peritoneal adhesiolysis w CC	2.4776	7.7	9.3	
337	06	SURG	Peritoneal adhesiolysis w/o CC/MCC	1.6984	4.4	5.7	
338	06	SURG	Appendectomy w complicated principal diag w MCC	2.7254	9.1	10.9	
339	06	SURG	Appendectomy w complicated principal diag w CC	1.9805	6.1	7.1	
340	06	SURG	Appendectomy w complicated principal diag w/o CC/MCC	1.3849	3.6	4.3	
341	06	SURG	Appendectomy w/o complicated principal diag w MCC	1.8824	5.3	7.3	
342	06	SURG	Appendectomy w/o complicated principal diag w CC	1.3562	3.4	4.3	
343	06	SURG	Appendectomy w/o complicated principal diag w/o CC/MCC	0.9887	1.9	2.3	
344	06	SURG	Minor small & large bowel procedures w MCC	2.5156	9.4	12.0	
345	06	SURG	Minor small & large bowel procedures w CC	1.7028	6.2	7.2	
346	06	SURG	Minor small & large bowel procedures w/o CC/MCC	1.2617	4.4	5.0	
347	06	SURG	Anal & stomal procedures w MCC	1.7658	6.2	8.4	
348	06	SURG	Anal & stomal procedures w CC	1.2781	4.1	5.5	
349	06	SURG	Anal & stomal procedures w/o CC/MCC	0.8629	2.4	3.0	
350	06	SURG	Inguinal & femoral hernia procedures w MCC	1.8330	5.9	8.1	
351	06	SURG	Inguinal & femoral hernia procedures w CC	1.2449	3.4	4.5	
352	06	SURG	Inguinal & femoral hernia procedures w/o CC/MCC	0.8967	1.9	2.4	
353	06	SURG	Hernia procedures except inguinal & femoral w MCC	2.0241	6.6	8.8	
354	06	SURG	Hernia procedures except inguinal & femoral w CC	1.4092	4.0	5.1	
355	06	SURG	Hernia procedures except inguinal & femoral w/o CC/MCC	1.0147	2.3	2.9	
356	06	SURG	Other digestive system O.R. procedures w MCC	3.3790	9.6	13.3	
357	06	SURG	Other digestive system O.R. procedures w CC	2.4946	6.1	8.0	
358	06	SURG	Other digestive system O.R. procedures w/o CC/MCC	1.7333	3.4	4.6	
368	06	MED	Major esophageal disorders w MCC	1.3788	5.1	6.6	
369	06	MED	Major esophageal disorders w CC	1.0839	3.7	4.6	
370	06	MED	Major esophageal disorders w/o CC/MCC	0.9558	2.8	3.4	
371	06	MED	Major gastrointestinal disorders & peritoneal infections w MCC	1.6263	6.6	8.8	
372	06	MED	Major gastrointestinal disorders & peritoneal infections w CC	1.3059	5.5	6.8	
373	06	MED	Major gastrointestinal disorders & peritoneal infections w/o CC/MCC	1.1109	4.2	5.0	
374	06	MED	Digestive malignancy w MCC	1.7229	6.5	8.8	
375	06	MED	Digestive malignancy w CC	1.3337	4.6	6.0	
376	06	MED	Digestive malignancy w/o CC/MCC	1.0268	3.1	4.1	
377	06	MED	G.I. hemorrhage w MCC	1.3367	5.0	6.5	
378	06	MED	G.I. hemorrhage w CC	1.0195	3.7	4.5	
379	06	MED	G.I. hemorrhage w/o CC/MCC	0.8476	2.9	3.4	
380	06	MED	Complicated peptic ulcer w MCC	1.4334	5.5	7.2	
381	06	MED	Complicated peptic ulcer w CC	1.1302	4.2	5.1	
382	06	MED	Complicated peptic ulcer w/o CC/MCC	0.9662	3.0	3.6	
383	06	MED	Uncomplicated peptic ulcer w MCC	1.1024	4.6	5.9	
384	06	MED	Uncomplicated peptic ulcer w/o MCC	0.8399	3.2	3.8	
385	06	MED	Inflammatory bowel disease w MCC	1.4936	6.7	9.0	
386	06	MED	Inflammatory bowel disease w CC	1.0766	4.6	5.7	
387	06	MED	Inflammatory bowel disease w/o CC/MCC	0.9488	3.6	4.4	
388	06	MED	G.I. obstruction w MCC	1.2860	5.5	7.4	
389	06	MED	G.I. obstruction w CC	0.9533	4.0	5.0	
390	06	MED	G.I. obstruction w/o CC/MCC	0.7260	3.0	3.6	
391	06	MED	Esophagitis, gastroent & misc digest disorders w MCC	0.9565	4.1	5.5	
392	06	MED	Esophagitis, gastroent & misc digest disorders w/o MCC	0.7121	2.8	3.5	
393	06	MED	Other digestive system diagnoses w MCC	1.3237	5.0	7.0	
394	06	MED	Other digestive system diagnoses w CC	1.0257	3.8	4.9	
395	06	MED	Other digestive system diagnoses w/o CC/MCC	0.7874	2.7	3.4	
405	07	SURG	Pancreas, liver & shunt procedures w MCC	4.8273	12.8	17.3	
406	07	SURG	Pancreas, liver & shunt procedures w CC	3.3149	7.1	9.5	
407	07	SURG	Pancreas, liver & shunt procedures w/o CC/MCC	2.2443	4.2	5.5	
408	07	SURG	Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC	3.8540	12.2	15.1	
409	07	SURG	Biliary tract proc except only cholecyst w or w/o c.d.e. w CC	2.9126	8.2	9.9	
410	07	SURG	Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC	2.0794	5.7	6.8	
411	07	SURG	Cholecystectomy w c.d.e. w MCC	3.4128	10.9	13.1	
412	07	SURG	Cholecystectomy w c.d.e. w CC	2.6382	7.6	8.8	
413	07	SURG	Cholecystectomy w c.d.e. w/o CC/MCC	1.9412	5.2	6.0	
414	07	SURG	Cholecystectomy except by laparoscope w/o c.d.e. w MCC	3.0942	9.7	11.9	
415	07	SURG	Cholecystectomy except by laparoscope w/o c.d.e. w CC	2.2749	6.6	7.7	
416	07	SURG	Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MCC	1.5398	4.1	4.9	
417	07	SURG	Laparoscopic cholecystectomy w/o c.d.e. w MCC	2.1361	6.6	8.4	
418	07	SURG	Laparoscopic cholecystectomy w/o c.d.e. w CC	1.7104	4.5	5.6	
419	07	SURG	Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC	1.2400	2.5	3.2	
420	07	SURG	Hepatobiliary diagnostic procedures w MCC	3.4851	10.1	14.2	
421	07	SURG	Hepatobiliary diagnostic procedures w CC	2.2557	5.6	7.8	
422	07	SURG	Hepatobiliary diagnostic procedures w/o CC/MCC	1.9432	3.4	4.5	
423	07	SURG	Other hepatobiliary or pancreas O.R. procedures w MCC	3.9593	11.4	15.5	
424	07	SURG	Other hepatobiliary or pancreas O.R. procedures w CC	3.0104	7.8	10.2	
425	07	SURG	Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC	2.5812	4.5	5.6	
432	07	MED	Cirrhosis & alcoholic hepatitis w MCC	1.5033	5.1	6.9	
433	07	MED	Cirrhosis & alcoholic hepatitis w CC	1.1431	3.8	4.9	
434	07	MED	Cirrhosis & alcoholic hepatitis w/o CC/MCC	1.0125	2.8	3.6	
435	07	MED	Malignancy of hepatobiliary system or pancreas w MCC	1.5661	5.8	7.7	
436	07	MED	Malignancy of hepatobiliary system or pancreas w CC	1.2906	4.5	5.9	
437	07	MED	Malignancy of hepatobiliary system or pancreas w/o CC/MCC	1.1709	3.3	4.4	
438	07	MED	Disorders of pancreas except malignancy w MCC	1.4201	5.6	7.7	
439	07	MED	Disorders of pancreas except malignancy w CC	1.0609	4.3	5.4	
440	07	MED	Disorders of pancreas except malignancy w/o CC/MCC	0.8912	3.2	3.9	
441	07	MED	Disorders of liver except malig,cirr,alc hepa w MCC	1.3973	5.1	7.0	
442	07	MED	Disorders of liver except malig,cirr,alc hepa w CC	1.0935	4.0	5.1	
443	07	MED	Disorders of liver except malig,cirr,alc hepa w/o CC/MCC	0.9079	3.1	3.8	
444	07	MED	Disorders of the biliary tract w MCC	1.3744	5.0	6.6	
445	07	MED	Disorders of the biliary tract w CC	1.1030	3.8	4.8	
446	07	MED	Disorders of the biliary tract w/o CC/MCC	0.8521	2.6	3.3	
453	08	SURG	Combined anterior/posterior spinal fusion w MCC	8.4313	12.7	15.9	
454	08	SURG	Combined anterior/posterior spinal fusion w CC	6.5810	6.8	8.4	
455	08	SURG	Combined anterior/posterior spinal fusion w/o CC/MCC	5.7023	4.1	4.7	
456	08	SURG	Spinal fus exc cerv w spinal curv/malig/infec or 9+ fus w MCC	6.7669	12.1	15.9	
457	08	SURG	Spinal fus exc cerv w spinal curv/malig/infec or 9+ fus w CC	5.4650	6.4	7.8	
458	08	SURG	Spinal fus exc cerv w spinal curv/malig/infec or 9+ fus w/o CC/MCC	4.9437	4.1	4.6	
459	08	SURG	Spinal fusion except cervical w MCC	4.8679	7.8	9.6	
460	08	SURG	Spinal fusion except cervical w/o MCC	3.4870	3.8	4.3	
461	08	SURG	Bilateral or multiple major joint procs of lower extremity w MCC	3.8345	6.9	8.5	
462	08	SURG	Bilateral or multiple major joint procs of lower extremity w/o MCC	3.0993	3.9	4.3	
463	08	SURG	Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w MCC	3.9615	12.3	16.9	
464	08	SURG	Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w CC	2.8821	7.8	10.4	
465	08	SURG	Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w/o CC/MCC	2.3417	4.6	6.2	
466	08	SURG	Revision of hip or knee replacement w MCC	3.5408	7.6	9.5	
467	08	SURG	Revision of hip or knee replacement w CC	2.7523	4.8	5.6	
468	08	SURG	Revision of hip or knee replacement w/o CC/MCC	2.4545	3.7	4.0	
469	08	SURG	Major joint replacement or reattachment of lower extremity w MCC	2.6664	7.1	8.4	
470	08	SURG	Major joint replacement or reattachment of lower extremity w/o MCC	1.9871	3.7	4.0	
471	08	SURG	Cervical spinal fusion w MCC	3.4723	7.0	10.1	
472	08	SURG	Cervical spinal fusion w CC	2.4819	2.9	4.3	
473	08	SURG	Cervical spinal fusion w/o CC/MCC	1.9446	1.6	2.0	
474	08	SURG	Amputation for musculoskeletal sys & conn tissue dis w MCC	2.8432	9.5	12.5	
475	08	SURG	Amputation for musculoskeletal sys & conn tissue dis w CC	2.1308	6.6	8.6	
476	08	SURG	Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC	1.6799	3.8	5.0	
477	08	SURG	Biopsies of musculoskeletal system & connective tissue w MCC	2.6555	9.6	12.5	
478	08	SURG	Biopsies of musculoskeletal system & connective tissue w CC	1.9836	4.8	6.8	
479	08	SURG	Biopsies of musculoskeletal system & connective tissue w/o CC/MCC	1.6784	1.9	2.8	
480	08	SURG	Hip & femur procedures except major joint w MCC	2.4027	8.0	9.5	
481	08	SURG	Hip & femur procedures except major joint w CC	1.8485	5.4	6.0	
482	08	SURG	Hip & femur procedures except major joint w/o CC/MCC	1.5644	4.5	4.9	
483	08	SURG	Major joint & limb reattachment proc of upper extremity w CC/MCC	1.9905	3.5	4.4	
484	08	SURG	Major joint & limb reattachment proc of upper extremity w/o CC/MCC	1.7376	2.2	2.5	
485	08	SURG	Knee procedures w pdx of infection w MCC	2.9362	10.2	12.4	
486	08	SURG	Knee procedures w pdx of infection w CC	2.3382	6.8	8.1	
487	08	SURG	Knee procedures w pdx of infection w/o CC/MCC	1.7771	5.0	5.8	
488	08	SURG	Knee procedures w/o pdx of infection w CC/MCC	1.6584	4.1	5.1	
489	08	SURG	Knee procedures w/o pdx of infection w/o CC/MCC	1.4512	2.7	3.1	
490	08	SURG	Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim	1.4912	3.3	4.7	
491	08	SURG	Back & neck proc exc spinal fusion w/o CC/MCC	1.0066	1.8	2.3	
492	08	SURG	Lower extrem & humer proc except hip,foot,femur w MCC	2.2413	6.9	8.7	
493	08	SURG	Lower extrem & humer proc except hip,foot,femur w CC	1.7186	4.4	5.3	
494	08	SURG	Lower extrem & humer proc except hip,foot,femur w/o CC/MCC	1.2752	2.8	3.4	
495	08	SURG	Local excision & removal int fix devices exc hip & femur w MCC	2.5765	8.3	11.1	
496	08	SURG	Local excision & removal int fix devices exc hip & femur w CC	1.7792	4.6	6.0	
497	08	SURG	Local excision & removal int fix devices exc hip & femur w/o CC/MCC	1.2301	2.3	3.1	
498	08	SURG	Local excision & removal int fix devices of hip & femur w CC/MCC	1.7563	5.8	8.2	
499	08	SURG	Local excision & removal int fix devices of hip & femur w/o CC/MCC	1.1887	2.3	3.1	
500	08	SURG	Soft tissue procedures w MCC	2.4096	8.1	11.3	
501	08	SURG	Soft tissue procedures w CC	1.5598	4.4	5.9	
502	08	SURG	Soft tissue procedures w/o CC/MCC	1.0342	2.3	2.9	
503	08	SURG	Foot procedures w MCC	1.7538	6.9	8.9	
504	08	SURG	Foot procedures w CC	1.4058	5.0	6.4	
505	08	SURG	Foot procedures w/o CC/MCC	1.1584	2.6	3.4	
506	08	SURG	Major thumb or joint procedures	1.0877	2.3	3.2	
507	08	SURG	Major shoulder or elbow joint procedures w CC/MCC	1.4296	3.6	5.2	
508	08	SURG	Major shoulder or elbow joint procedures w/o CC/MCC	1.1330	1.7	2.0	
509	08	SURG	Arthroscopy	1.0769	1.9	2.8	
510	08	SURG	Shoulder,elbow or forearm proc,exc major joint proc w MCC	1.6616	5.0	6.6	
511	08	SURG	Shoulder,elbow or forearm proc,exc major joint proc w CC	1.2512	3.1	3.9	
512	08	SURG	Shoulder,elbow or forearm proc,exc major joint proc w/o CC/MCC	0.9602	1.7	2.1	
513	08	SURG	Hand or wrist proc, except major thumb or joint proc w CC/MCC	1.1748	3.7	5.1	
514	08	SURG	Hand or wrist proc, except major thumb or joint proc w/o CC/MCC	0.8313	2.0	2.6	
515	08	SURG	Other musculoskelet sys & conn tiss O.R. proc w MCC	2.4858	8.1	10.9	
516	08	SURG	Other musculoskelet sys & conn tiss O.R. proc w CC	1.8307	4.4	6.0	
517	08	SURG	Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC	1.4192	2.0	2.9	
533	08	MED	Fractures of femur w MCC	1.1294	5.1	6.9	
534	08	MED	Fractures of femur w/o MCC	0.7560	3.2	4.0	
535	08	MED	Fractures of hip & pelvis w MCC	1.0836	4.8	6.4	
536	08	MED	Fractures of hip & pelvis w/o MCC	0.7340	3.4	4.0	
537	08	MED	Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MCC	0.7528	3.8	4.7	
538	08	MED	Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC	0.5986	2.6	3.1	
539	08	MED	Osteomyelitis w MCC	1.7648	7.7	10.2	
540	08	MED	Osteomyelitis w CC	1.4026	5.8	7.2	
541	08	MED	Osteomyelitis w/o CC/MCC	1.2101	4.4	5.7	
542	08	MED	Pathological fractures & musculoskelet & conn tiss malig w MCC	1.4877	6.8	8.7	
543	08	MED	Pathological fractures & musculoskelet & conn tiss malig w CC	1.1151	4.8	6.0	
544	08	MED	Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC	0.9395	3.7	4.5	
545	08	MED	Connective tissue disorders w MCC	1.8330	6.5	9.0	
546	08	MED	Connective tissue disorders w CC	1.2092	4.3	5.5	
547	08	MED	Connective tissue disorders w/o CC/MCC	0.9054	3.2	3.9	
548	08	MED	Septic arthritis w MCC	1.5372	7.0	9.3	
549	08	MED	Septic arthritis w CC	1.1522	5.0	6.2	
550	08	MED	Septic arthritis w/o CC/MCC	0.9567	3.6	4.5	
551	08	MED	Medical back problems w MCC	1.1632	5.5	7.2	
552	08	MED	Medical back problems w/o MCC	0.7839	3.4	4.2	
553	08	MED	Bone diseases & arthropathies w MCC	0.9199	4.8	6.1	
554	08	MED	Bone diseases & arthropathies w/o MCC	0.6475	3.0	3.7	
555	08	MED	Signs & symptoms of musculoskeletal system & conn tissue w MCC	0.7886	3.6	4.9	
556	08	MED	Signs & symptoms of musculoskeletal system & conn tissue w/o MCC	0.5958	2.5	3.2	
557	08	MED	Tendonitis, myositis & bursitis w MCC	1.2171	5.4	6.9	
558	08	MED	Tendonitis, myositis & bursitis w/o MCC	0.8480	3.5	4.3	
559	08	MED	Aftercare, musculoskeletal system & connective tissue w MCC	1.2104	5.1	7.3	
560	08	MED	Aftercare, musculoskeletal system & connective tissue w CC	0.8521	3.6	4.7	
561	08	MED	Aftercare, musculoskeletal system & connective tissue w/o CC/MCC	0.6753	2.1	2.7	
562	08	MED	Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC	1.1163	5.0	6.5	
563	08	MED	Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC	0.6981	3.1	3.7	
564	08	MED	Other musculoskeletal sys & connective tissue diagnoses w MCC	1.1606	5.3	7.1	
565	08	MED	Other musculoskeletal sys & connective tissue diagnoses w CC	0.9003	4.0	5.1	
566	08	MED	Other musculoskeletal sys & connective tissue diagnoses w/o CC/MCC	0.7790	2.9	3.7	
573	09	SURG	Skin graft &/or debrid for skn ulcer or cellulitis w MCC	2.7483	10.1	13.8	
574	09	SURG	Skin graft &/or debrid for skn ulcer or cellulitis w CC	2.0177	7.2	9.5	
575	09	SURG	Skin graft &/or debrid for skn ulcer or cellulitis w/o CC/MCC	1.4216	4.7	5.9	
576	09	SURG	Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC	2.4766	7.8	12.1	
577	09	SURG	Skin graft &/or debrid exc for skin ulcer or cellulitis w CC	1.6262	4.1	6.0	
578	09	SURG	Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC	1.0742	2.5	3.4	
579	09	SURG	Other skin, subcut tiss & breast proc w MCC	2.3093	8.1	11.1	
580	09	SURG	Other skin, subcut tiss & breast proc w CC	1.4256	3.6	5.5	
581	09	SURG	Other skin, subcut tiss & breast proc w/o CC/MCC	0.9124	1.9	2.6	
582	09	SURG	Mastectomy for malignancy w CC/MCC	0.9432	2.1	2.9	
583	09	SURG	Mastectomy for malignancy w/o CC/MCC	0.7523	1.6	1.8	
584	09	SURG	Breast biopsy, local excision & other breast procedures w CC/MCC	1.2484	3.7	5.7	
585	09	SURG	Breast biopsy, local excision & other breast procedures w/o CC/MCC	0.9066	1.7	2.2	
592	09	MED	Skin ulcers w MCC	1.4555	6.6	8.9	
593	09	MED	Skin ulcers w CC	1.1060	5.2	6.5	
594	09	MED	Skin ulcers w/o CC/MCC	0.9335	3.9	4.9	
595	09	MED	Major skin disorders w MCC	1.3997	6.0	8.2	
596	09	MED	Major skin disorders w/o MCC	0.8766	3.8	4.8	
597	09	MED	Malignant breast disorders w MCC	1.4034	5.9	8.2	
598	09	MED	Malignant breast disorders w CC	1.0695	4.2	5.6	
599	09	MED	Malignant breast disorders w/o CC/MCC	0.7232	2.6	3.6	
600	09	MED	Non-malignant breast disorders w CC/MCC	0.8471	4.1	5.4	
601	09	MED	Non-malignant breast disorders w/o CC/MCC	0.6715	3.1	3.8	
602	09	MED	Cellulitis w MCC	1.1522	5.5	7.0	
603	09	MED	Cellulitis w/o MCC	0.8087	3.9	4.7	
604	09	MED	Trauma to the skin, subcut tiss & breast w MCC	0.9681	4.1	5.4	
605	09	MED	Trauma to the skin, subcut tiss & breast w/o MCC	0.6863	2.8	3.5	
606	09	MED	Minor skin disorders w MCC	0.9223	4.2	5.9	
607	09	MED	Minor skin disorders w/o MCC	0.6505	2.9	3.8	
614	10	SURG	Adrenal & pituitary procedures w CC/MCC	2.1978	5.2	7.3	
615	10	SURG	Adrenal & pituitary procedures w/o CC/MCC	1.6502	2.8	3.4	
616	10	SURG	Amputat of lower limb for endocrine,nutrit,& metabol dis w MCC	3.1449	12.6	15.6	
617	10	SURG	Amputat of lower limb for endocrine,nutrit,& metabol dis w CC	2.2071	7.2	9.0	
618	10	SURG	Amputat of lower limb for endocrine,nutrit,& metabol dis w/o CC/MCC	1.7554	4.9	6.1	
619	10	SURG	O.R. procedures for obesity w MCC	2.7625	6.4	9.3	
620	10	SURG	O.R. procedures for obesity w CC	1.9294	3.4	4.2	
621	10	SURG	O.R. procedures for obesity w/o CC/MCC	1.6876	2.1	2.4	
622	10	SURG	Skin grafts & wound debrid for endoc, nutrit & metab dis w MCC	2.7257	9.7	13.2	
623	10	SURG	Skin grafts & wound debrid for endoc, nutrit & metab dis w CC	2.0065	6.8	8.7	
624	10	SURG	Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC	1.6056	4.6	5.9	
625	10	SURG	Thyroid, parathyroid & thyroglossal procedures w MCC	1.5928	5.0	7.5	
626	10	SURG	Thyroid, parathyroid & thyroglossal procedures w CC	1.0183	2.2	3.3	
627	10	SURG	Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC	0.8169	1.3	1.5	
628	10	SURG	Other endocrine, nutrit & metab O.R. proc w MCC	3.0602	7.8	11.8	
629	10	SURG	Other endocrine, nutrit & metab O.R. proc w CC	2.4730	7.0	8.8	
630	10	SURG	Other endocrine, nutrit & metab O.R. proc w/o CC/MCC	1.7767	3.7	5.1	
637	10	MED	Diabetes w MCC	1.0891	4.6	6.2	
638	10	MED	Diabetes w CC	0.8021	3.4	4.3	
639	10	MED	Diabetes w/o CC/MCC	0.6742	2.5	3.1	
640	10	MED	Nutritional & misc metabolic disorders w MCC	0.9793	4.1	5.6	
641	10	MED	Nutritional & misc metabolic disorders w/o MCC	0.7248	3.1	3.9	
642	10	MED	Inborn errors of metabolism	1.0616	3.8	5.3	
643	10	MED	Endocrine disorders w MCC	1.3926	6.0	7.8	
644	10	MED	Endocrine disorders w CC	1.0638	4.3	5.4	
645	10	MED	Endocrine disorders w/o CC/MCC	0.8310	3.2	3.9	
652	11	SURG	Kidney transplant	3.0654	6.6	7.9	
653	11	SURG	Major bladder procedures w MCC	4.5710	13.3	16.8	
654	11	SURG	Major bladder procedures w CC	3.1860	8.8	10.1	
655	11	SURG	Major bladder procedures w/o CC/MCC	2.7075	5.8	6.6	
656	11	SURG	Kidney & ureter procedures for neoplasm w MCC	2.6603	8.4	10.8	
657	11	SURG	Kidney & ureter procedures for neoplasm w CC	1.8997	5.1	6.1	
658	11	SURG	Kidney & ureter procedures for neoplasm w/o CC/MCC	1.6556	3.3	3.8	
659	11	SURG	Kidney & ureter procedures for non-neoplasm w MCC	2.8119	8.2	11.3	
660	11	SURG	Kidney & ureter procedures for non-neoplasm w CC	2.0605	4.8	6.5	
661	11	SURG	Kidney & ureter procedures for non-neoplasm w/o CC/MCC	1.4004	2.6	3.3	
662	11	SURG	Minor bladder procedures w MCC	2.0375	7.3	10.5	
663	11	SURG	Minor bladder procedures w CC	1.4254	3.6	5.3	
664	11	SURG	Minor bladder procedures w/o CC/MCC	1.0388	1.6	2.1	
665	11	SURG	Prostatectomy w MCC	2.1393	9.3	12.2	
666	11	SURG	Prostatectomy w CC	1.4691	4.3	6.3	
667	11	SURG	Prostatectomy w/o CC/MCC	0.9335	2.0	2.7	
668	11	SURG	Transurethral procedures w MCC	1.7208	6.3	8.6	
669	11	SURG	Transurethral procedures w CC	1.2079	3.1	4.4	
670	11	SURG	Transurethral procedures w/o CC/MCC	0.8838	1.9	2.5	
671	11	SURG	Urethral procedures w CC/MCC	1.2808	3.9	5.8	
672	11	SURG	Urethral procedures w/o CC/MCC	0.8422	1.9	2.5	
673	11	SURG	Other kidney & urinary tract procedures w MCC	2.5235	6.0	10.2	
674	11	SURG	Other kidney & urinary tract procedures w CC	2.1024	4.0	6.6	
675	11	SURG	Other kidney & urinary tract procedures w/o CC/MCC	1.7196	1.4	1.9	
682	11	MED	Renal failure w MCC	1.4664	5.3	7.3	
683	11	MED	Renal failure w CC	1.1942	4.5	5.7	
684	11	MED	Renal failure w/o CC/MCC	0.9835	3.1	3.8	
685	11	MED	Admit for renal dialysis	0.8599	2.4	3.5	
686	11	MED	Kidney & urinary tract neoplasms w MCC	1.4513	6.0	8.1	
687	11	MED	Kidney & urinary tract neoplasms w CC	1.1147	4.0	5.3	
688	11	MED	Kidney & urinary tract neoplasms w/o CC/MCC	0.8577	2.5	3.2	
689	11	MED	Kidney & urinary tract infections w MCC	1.0587	5.0	6.4	
690	11	MED	Kidney & urinary tract infections w/o MCC	0.8000	3.6	4.3	
691	11	MED	Urinary stones w esw lithotripsy w CC/MCC	1.1508	3.0	4.2	
692	11	MED	Urinary stones w esw lithotripsy w/o CC/MCC	0.9457	1.8	2.3	
693	11	MED	Urinary stones w/o esw lithotripsy w MCC	1.0459	3.9	5.2	
694	11	MED	Urinary stones w/o esw lithotripsy w/o MCC	0.7110	2.0	2.6	
695	11	MED	Kidney & urinary tract signs & symptoms w MCC	0.9422	4.3	5.7	
696	11	MED	Kidney & urinary tract signs & symptoms w/o MCC	0.6276	2.6	3.2	
697	11	MED	Urethral stricture	0.7223	2.4	3.3	
698	11	MED	Other kidney & urinary tract diagnoses w MCC	1.3017	5.1	6.8	
699	11	MED	Other kidney & urinary tract diagnoses w CC	1.0352	3.8	4.9	
700	11	MED	Other kidney & urinary tract diagnoses w/o CC/MCC	0.8232	2.7	3.5	
707	12	SURG	Major male pelvic procedures w CC/MCC	1.5521	3.5	4.5	
708	12	SURG	Major male pelvic procedures w/o CC/MCC	1.1858	2.0	2.4	
709	12	SURG	Penis procedures w CC/MCC	1.6134	3.6	6.5	
710	12	SURG	Penis procedures w/o CC/MCC	1.2986	1.5	1.9	
711	12	SURG	Testes procedures w CC/MCC	1.6051	5.3	7.8	
712	12	SURG	Testes procedures w/o CC/MCC	1.0842	2.1	3.0	
713	12	SURG	Transurethral prostatectomy w CC/MCC	0.9850	2.9	4.2	
714	12	SURG	Transurethral prostatectomy w/o CC/MCC	0.6710	1.7	2.0	
715	12	SURG	Other male reproductive system O.R. proc for malignancy w CC/MCC	1.5300	3.8	6.1	
716	12	SURG	Other male reproductive system O.R. proc for malignancy w/o CC/MCC	1.1310	1.3	1.5	
717	12	SURG	Other male reproductive system O.R. proc exc malignancy w CC/MCC	1.5653	5.0	7.5	
718	12	SURG	Other male reproductive system O.R. proc exc malignancy w/o CC/MCC	1.0329	2.1	2.7	
722	12	MED	Malignancy, male reproductive system w MCC	1.2827	5.6	7.4	
723	12	MED	Malignancy, male reproductive system w CC	1.0603	4.2	5.4	
724	12	MED	Malignancy, male reproductive system w/o CC/MCC	0.7677	2.5	3.3	
725	12	MED	Benign prostatic hypertrophy w MCC	0.9071	4.4	5.7	
726	12	MED	Benign prostatic hypertrophy w/o MCC	0.6886	2.8	3.5	
727	12	MED	Inflammation of the male reproductive system w MCC	1.0083	5.1	6.5	
728	12	MED	Inflammation of the male reproductive system w/o MCC	0.7241	3.3	4.0	
729	12	MED	Other male reproductive system diagnoses w CC/MCC	0.9542	3.7	5.1	
730	12	MED	Other male reproductive system diagnoses w/o CC/MCC	0.7058	2.4	3.2	
734	13	SURG	Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC	2.0185	5.8	7.6	
735	13	SURG	Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC	1.3798	3.0	3.5	
736	13	SURG	Uterine & adnexa proc for ovarian or adnexal malignancy w MCC	3.2108	11.5	13.9	
737	13	SURG	Uterine & adnexa proc for ovarian or adnexal malignancy w CC	2.1022	6.2	7.4	
738	13	SURG	Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC	1.6754	3.5	3.9	
739	13	SURG	Uterine,adnexa proc for non-ovarian/adnexal malig w MCC	2.2081	7.9	10.2	
740	13	SURG	Uterine,adnexa proc for non-ovarian/adnexal malig w CC	1.4577	4.4	5.2	
741	13	SURG	Uterine,adnexa proc for non-ovarian/adnexal malig w/o CC/MCC	1.0308	2.8	3.1	
742	13	SURG	Uterine & adnexa proc for non-malignancy w CC/MCC	1.2422	3.5	4.6	
743	13	SURG	Uterine & adnexa proc for non-malignancy w/o CC/MCC	0.8672	2.1	2.3	
744	13	SURG	D&C, conization, laparascopy & tubal interruption w CC/MCC	1.1896	4.0	5.8	
745	13	SURG	D&C, conization, laparascopy & tubal interruption w/o CC/MCC	0.8660	2.1	2.5	
746	13	SURG	Vagina, cervix & vulva procedures w CC/MCC	1.0488	3.0	4.1	
747	13	SURG	Vagina, cervix & vulva procedures w/o CC/MCC	0.8499	1.7	1.9	
748	13	SURG	Female reproductive system reconstructive procedures	0.7916	1.5	1.8	
749	13	SURG	Other female reproductive system O.R. procedures w CC/MCC	2.2813	7.1	9.8	
750	13	SURG	Other female reproductive system O.R. procedures w/o CC/MCC	1.4993	2.6	3.3	
754	13	MED	Malignancy, female reproductive system w MCC	1.5596	6.4	8.9	
755	13	MED	Malignancy, female reproductive system w CC	1.1608	4.2	5.6	
756	13	MED	Malignancy, female reproductive system w/o CC/MCC	0.7702	2.5	3.3	
757	13	MED	Infections, female reproductive system w MCC	1.4328	6.8	8.9	
758	13	MED	Infections, female reproductive system w CC	1.1147	4.9	6.1	
759	13	MED	Infections, female reproductive system w/o CC/MCC	0.9609	3.7	4.6	
760	13	MED	Menstrual & other female reproductive system disorders w CC/MCC	0.6910	2.9	3.8	
761	13	MED	Menstrual & other female reproductive system disorders w/o CC/MCC	0.5569	2.0	2.5	
765	14	SURG	Cesarean section w CC/MCC	0.9943	4.1	5.3	
766	14	SURG	Cesarean section w/o CC/MCC	0.7664	3.0	3.2	
767	14	SURG	Vaginal delivery w sterilization &/or D&C	0.7246	2.5	2.9	
768	14	SURG	Vaginal delivery w O.R. proc except steril &/or D&C	1.7348	4.7	5.8	
769	14	SURG	Postpartum & post abortion diagnoses w O.R. procedure	1.9114	3.2	5.7	
770	14	SURG	Abortion w D&C, aspiration curettage or hysterotomy	0.7336	1.6	2.6	
774	14	MED	Vaginal delivery w complicating diagnoses	0.5914	2.6	3.2	
775	14	MED	Vaginal delivery w/o complicating diagnoses	0.4461	2.1	2.3	
776	14	MED	Postpartum & post abortion diagnoses w/o O.R. procedure	0.6460	2.6	3.5	
777	14	MED	Ectopic pregnancy	0.7087	1.8	2.1	
778	14	MED	Threatened abortion	0.3744	2.0	2.8	
779	14	MED	Abortion w/o D&C	0.6013	1.7	2.6	
780	14	MED	False labor	0.2845	1.3	2.7	
781	14	MED	Other antepartum diagnoses w medical complications	0.5689	2.7	3.9	
782	14	MED	Other antepartum diagnoses w/o medical complications	0.4297	1.7	2.8	
789	15	MED	Neonates, died or transferred to another acute care facility	1.4250	*	*	
790	15	MED	Extreme immaturity or respiratory distress syndrome, neonate	4.6990	*	*	
791	15	MED	Prematurity w major problems	3.2093	*	*	
792	15	MED	Prematurity w/o major problems	1.9364	*	*	
793	15	MED	Full term neonate w major problems	3.2966	*	*	
794	15	MED	Neonate w other significant problems	1.1668	*	*	
795	15	MED	Normal newborn	0.1580	*	*	
799	16	SURG	Splenectomy w MCC	3.9513	10.7	14.3	
800	16	SURG	Splenectomy w CC	2.7617	6.4	8.2	
801	16	SURG	Splenectomy w/o CC/MCC	2.3252	3.7	4.8	
802	16	SURG	Other O.R. proc of the blood & blood forming organs w MCC	2.7940	9.1	12.8	
803	16	SURG	Other O.R. proc of the blood & blood forming organs w CC	1.8259	4.7	6.5	
804	16	SURG	Other O.R. proc of the blood & blood forming organs w/o CC/MCC	1.4754	2.4	3.2	
808	16	MED	Major hematol/immun diag exc sickle cell crisis & coagul w MCC	1.6171	6.0	8.0	
809	16	MED	Major hematol/immun diag exc sickle cell crisis & coagul w CC	1.2031	3.9	5.0	
810	16	MED	Major hematol/immun diag exc sickle cell crisis & coagul w/o CC/MCC	1.0741	3.1	3.9	
811	16	MED	Red blood cell disorders w MCC	1.0006	4.0	5.5	
812	16	MED	Red blood cell disorders w/o MCC	0.7780	2.8	3.7	
813	16	MED	Coagulation disorders	1.3426	3.8	5.2	
814	16	MED	Reticuloendothelial & immunity disorders w MCC	1.3226	5.3	7.2	
815	16	MED	Reticuloendothelial & immunity disorders w CC	1.0233	3.9	4.9	
816	16	MED	Reticuloendothelial & immunity disorders w/o CC/MCC	0.7990	2.7	3.4	
820	17	SURG	Lymphoma & leukemia w major O.R. procedure w MCC	4.4970	13.8	18.4	
821	17	SURG	Lymphoma & leukemia w major O.R. procedure w CC	2.6847	5.4	7.8	
822	17	SURG	Lymphoma & leukemia w major O.R. procedure w/o CC/MCC	1.5989	2.7	3.7	
823	17	SURG	Lymphoma & non-acute leukemia w other O.R. proc w MCC	3.5188	12.0	15.4	
824	17	SURG	Lymphoma & non-acute leukemia w other O.R. proc w CC	2.5164	6.6	8.8	
825	17	SURG	Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC	1.6201	3.3	4.7	
826	17	SURG	Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC	3.9780	13.0	17.4	
827	17	SURG	Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC	2.4230	5.7	7.5	
828	17	SURG	Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC	1.5109	2.9	3.7	
829	17	SURG	Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC	2.4894	6.9	10.5	
830	17	SURG	Myeloprolif disord or poorly diff neopl w other O.R. proc w/o CC/MCC	1.6396	2.5	3.5	
834	17	MED	Acute leukemia w/o major O.R. procedure w MCC	3.6361	8.9	14.7	
835	17	MED	Acute leukemia w/o major O.R. procedure w CC	2.5626	5.3	8.2	
836	17	MED	Acute leukemia w/o major O.R. procedure w/o CC/MCC	2.1785	3.4	5.1	
837	17	MED	Chemo w acute leukemia as sdx or w high dose chemo agent w MCC	4.7788	17.2	22.7	
838	17	MED	Chemo w acute leukemia as sdx w CC or high dose chemo agent	2.9919	6.2	9.0	
839	17	MED	Chemo w acute leukemia as sdx w/o CC/MCC	2.3980	4.9	6.1	
840	17	MED	Lymphoma & non-acute leukemia w MCC	2.1454	6.8	9.6	
841	17	MED	Lymphoma & non-acute leukemia w CC	1.6444	5.0	6.6	
842	17	MED	Lymphoma & non-acute leukemia w/o CC/MCC	1.2188	3.2	4.3	
843	17	MED	Other myeloprolif dis or poorly diff neopl diag w MCC	1.6341	6.3	8.7	
844	17	MED	Other myeloprolif dis or poorly diff neopl diag w CC	1.2403	4.5	6.0	
845	17	MED	Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC	0.9664	3.3	4.3	
846	17	MED	Chemotherapy w/o acute leukemia as secondary diagnosis w MCC	1.6523	5.8	8.5	
847	17	MED	Chemotherapy w/o acute leukemia as secondary diagnosis w CC	1.0296	2.7	3.3	
848	17	MED	Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC	0.9116	2.3	2.9	
849	17	MED	Radiotherapy	1.2663	4.3	6.0	
853	18	SURG	Infectious & parasitic diseases w O.R. procedure w MCC	5.1840	12.8	16.8	
854	18	SURG	Infectious & parasitic diseases w O.R. procedure w CC	3.9291	9.1	11.2	
855	18	SURG	Infectious & parasitic diseases w O.R. procedure w/o CC/MCC	3.3662	5.6	7.3	
856	18	SURG	Postoperative or post-traumatic infections w O.R. proc w MCC	3.9257	12.1	16.2	
857	18	SURG	Postoperative or post-traumatic infections w O.R. proc w CC	2.4919	6.8	8.9	
858	18	SURG	Postoperative or post-traumatic infections w O.R. proc w/o CC/MCC	2.0996	4.7	6.0	
862	18	MED	Postoperative & post-traumatic infections w MCC	1.5454	6.2	8.3	
863	18	MED	Postoperative & post-traumatic infections w/o MCC	1.0560	4.2	5.2	
864	18	MED	Fever of unknown origin	0.8240	3.2	4.1	
865	18	MED	Viral illness w MCC	1.2074	4.9	6.8	
866	18	MED	Viral illness w/o MCC	0.7527	2.8	3.5	
867	18	MED	Other infectious & parasitic diseases diagnoses w MCC	2.1971	7.2	9.9	
868	18	MED	Other infectious & parasitic diseases diagnoses w CC	1.5258	4.6	5.9	
869	18	MED	Other infectious & parasitic diseases diagnoses w/o CC/MCC	1.3611	3.5	4.4	
870	18	MED	Septicemia w MV 96+ hours	5.7579	12.6	15.3	
871	18	MED	Septicemia w/o MV 96+ hours w MCC	1.7484	5.6	7.7	
872	18	MED	Septicemia w/o MV 96+ hours w/o MCC	1.3783	4.7	5.8	
876	19	SURG	O.R. procedure w principal diagnoses of mental illness	2.4632	6.9	11.4	
880	19	MED	Acute adjustment reaction & psychosocial dysfunction	0.6085	2.4	3.2	
881	19	MED	Depressive neuroses	0.5198	3.1	4.2	
882	19	MED	Neuroses except depressive	0.5685	3.1	4.4	
883	19	MED	Disorders of personality & impulse control	0.8999	4.6	7.4	
884	19	MED	Organic disturbances & mental retardation	0.8431	4.0	5.4	
885	19	MED	Psychoses	0.7783	5.5	7.6	
886	19	MED	Behavioral & developmental disorders	0.6983	4.0	5.9	
887	19	MED	Other mental disorder diagnoses	0.8341	3.1	4.6	
894	20	MED	Alcohol/drug abuse or dependence, left ama	0.3571	2.1	3.0	
895	20	MED	Alcohol/drug abuse or dependence w rehabilitation therapy	0.7557	8.2	10.5	
896	20	MED	Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC	1.0419	4.8	6.6	
897	20	MED	Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC	0.6145	3.3	4.1	
901	21	SURG	Wound debridements for injuries w MCC	2.8534	9.3	14.4	
902	21	SURG	Wound debridements for injuries w CC	1.8611	5.7	7.9	
903	21	SURG	Wound debridements for injuries w/o CC/MCC	1.4966	3.5	4.9	
904	21	SURG	Skin grafts for injuries w CC/MCC	2.5246	7.2	12.2	
905	21	SURG	Skin grafts for injuries w/o CC/MCC	1.5926	3.5	4.7	
906	21	SURG	Hand procedures for injuries	0.9803	2.2	3.3	
907	21	SURG	Other O.R. procedures for injuries w MCC	3.1030	8.1	11.7	
908	21	SURG	Other O.R. procedures for injuries w CC	2.1865	5.0	6.9	
909	21	SURG	Other O.R. procedures for injuries w/o CC/MCC	1.4112	2.7	3.6	
913	21	MED	Traumatic injury w MCC	1.0631	4.6	6.2	
914	21	MED	Traumatic injury w/o MCC	0.6890	2.7	3.4	
915	21	MED	Allergic reactions w MCC	0.8660	3.3	4.7	
916	21	MED	Allergic reactions w/o MCC	0.4986	1.7	2.1	
917	21	MED	Poisoning & toxic effects of drugs w MCC	1.1717	3.7	5.2	
918	21	MED	Poisoning & toxic effects of drugs w/o MCC	0.6886	2.1	2.7	
919	21	MED	Complications of treatment w MCC	1.2830	4.4	6.2	
920	21	MED	Complications of treatment w CC	0.9797	3.2	4.3	
921	21	MED	Complications of treatment w/o CC/MCC	0.7101	2.3	2.9	
922	21	MED	Other injury, poisoning & toxic effect diag w MCC	1.1338	4.1	6.0	
923	21	MED	Other injury, poisoning & toxic effect diag w/o MCC	0.7071	2.4	3.3	
927	22	SURG	Extensive burns or full thickness burns w MV 96+ hrs w skin graft	12.3042	23.0	28.8	
928	22	SURG	Full thickness burn w skin graft or inhal inj w CC/MCC	4.3956	12.1	16.2	
929	22	SURG	Full thickness burn w skin graft or inhal inj w/o CC/MCC	2.3533	5.6	7.7	
933	22	MED	Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft	2.6626	2.7	5.9	
934	22	MED	Full thickness burn w/o skin grft or inhal inj	1.3745	4.7	6.8	
935	22	MED	Non-extensive burns	1.1605	3.7	5.5	
939	23	SURG	O.R. proc w diagnoses of other contact w health services w MCC	2.1672	7.5	10.9	
940	23	SURG	O.R. proc w diagnoses of other contact w health services w CC	1.6823	4.4	6.4	
941	23	SURG	O.R. proc w diagnoses of other contact w health services w/o CC/MCC	1.3531	2.3	3.0	
945	23	MED	Rehabilitation w CC/MCC	1.1005	8.4	10.3	
946	23	MED	Rehabilitation w/o CC/MCC	1.0143	7.0	7.9	
947	23	MED	Signs & symptoms w MCC	0.8767	3.8	5.0	
948	23	MED	Signs & symptoms w/o MCC	0.6542	2.7	3.4	
949	23	MED	Aftercare w CC/MCC	0.7323	2.5	4.1	
950	23	MED	Aftercare w/o CC/MCC	0.5948	2.4	3.4	
951	23	MED	Other factors influencing health status	0.6109	2.1	3.8	
955	24	SURG	Craniotomy for multiple significant trauma	5.1028	8.5	12.2	
956	24	SURG	Limb reattachment, hip & femur proc for multiple significant trauma	3.4854	7.6	9.5	
957	24	SURG	Other O.R. procedures for multiple significant trauma w MCC	5.7960	10.5	16.0	
958	24	SURG	Other O.R. procedures for multiple significant trauma w CC	4.4786	7.9	10.5	
959	24	SURG	Other O.R. procedures for multiple significant trauma w/o CC/MCC	3.6988	4.9	6.1	
963	24	MED	Other multiple significant trauma w MCC	2.2985	6.3	9.3	
964	24	MED	Other multiple significant trauma w CC	1.7015	5.0	6.3	
965	24	MED	Other multiple significant trauma w/o CC/MCC	1.4108	3.3	4.1	
969	25	SURG	HIV w extensive O.R. procedure w MCC	5.1395	13.5	18.7	
970	25	SURG	HIV w extensive O.R. procedure w/o MCC	3.6849	6.6	9.5	
974	25	MED	HIV w major related condition w MCC	2.1382	7.4	10.4	
975	25	MED	HIV w major related condition w CC	1.5918	5.3	7.3	
976	25	MED	HIV w major related condition w/o CC/MCC	1.3357	3.8	4.9	
977	25	MED	HIV w or w/o other related condition	1.0387	3.8	5.3	
981		SURG	Extensive O.R. procedure unrelated to principal diagnosis w MCC	4.5168	11.9	15.3	
982		SURG	Extensive O.R. procedure unrelated to principal diagnosis w CC	3.5417	7.8	10.0	
983		SURG	Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC	2.9737	3.9	5.4	
984		SURG	Prostatic O.R. procedure unrelated to principal diagnosis w MCC	2.7217	11.7	14.6	
985		SURG	Prostatic O.R. procedure unrelated to principal diagnosis w CC	2.0865	7.4	9.7	
986		SURG	Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC	1.6706	3.5	5.1	
987		SURG	Non-extensive O.R. proc unrelated to principal diagnosis w MCC	2.8500	9.9	13.2	
988		SURG	Non-extensive O.R. proc unrelated to principal diagnosis w CC	2.0134	5.9	8.0	
989		SURG	Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC	1.6310	2.9	4.1	
998		**	Principal diagnosis invalid as discharge diagnosis	#N/A	*	*	
999		**	Ungroupable	#N/A	*	*	
MS-DRGs 998 and 999 contain cases that could not be assigned to valid DRGs.
	
Note: If there is no value or asterisk in either the geometric mean length of stay or the arithmetic mean length of stay columns, the volume of cases is insufficient to determine a meaningful computation of these statistics. 

Exhibit 2
Base Rates and Cost-to-Charge Ratios

Medicare # 	Hospital Name 	08 Total Cost-To-Charge Ratio (CCR)	08 Base Rates	
60001	North Colo Med Ctr	0.3340	$6,163.74	
60003	Longmont	0.4000	$5,669.50	
60004	Platte Valley	0.3730	$6,060.56	
60006	Montrose	0.4740	$5,971.15	
60008	San Luis Valley Reg. Med.	0.4430	$5,671.89	
60009	Lutheran	0.2630	$5,470.96	
60010	Poudre Valley	0.4000	$5,414.57	
60011	Denver Health	0.4300	$8,948.54	
60012	St. Mary Corwin	0.2970	$5,652.72	
60013	Mercy-Durango	0.4070	$6,004.76	
60014	Pres/St. Luke	0.2910	$6,707.33	
60015	St. Anthony Cent	0.2220	$6,160.35	
60016	St. Thomas More	0.3360	$5,366.73	
60018	Southwest	0.5130	$6,116.97	
60020	Parkview	0.2480	$5,674.21	
60022	Memorial	0.3290	$5,720.47	
60023	St. Mary's Hosp.	0.3970	$7,032.89	
60024	University	0.2680	$8,092.45	
60027	Boulder Comm	0.4270	$5,467.93	
60028	St. Joseph	0.2470	$6,167.73	
60030	McKee Med Ctr	0.4880	$5,424.40	
60031	Penrose	0.2800	$5,167.28	
60032	Rose	0.2670	$6,215.05	
60034	Swedish	0.2520	$5,629.45	
60036	Arkansas Valley	0.5700	$5,669.26	
60041	Pioneer	0.7670	$11,602.49	
60043	Keefe Memorial	0.5690	$16,664.47	
60044	Colo.Plains Med Ctr	0.3820	$6,837.04	
60049	Yampa Valley	0.6880	$6,382.32	
60054	Community - GJ	0.5460	$5,340.59	
60064	Portercare	0.2800	$5,467.53	
60065	North Suburban	0.2650	$6,364.90	
60071	Delta County	0.5690	$5,374.48	
60075	Valley View	0.5500	$6,981.59	
60076	Sterling Reg Med Ctr	0.5470	$6,822.18	
60096	Vail Valley Med Ctr	0.5930	$7,674.60	
60100	Med Ctr Aurora	0.2630	$5,947.13	
60103	Porter - J. Avista	0.3250	$6,060.56	
60104	St. Anthony Nor	0.2920	$5,812.87	
60107	National Jewish	0.3370	$6,060.56	
60112	Sky Ridge	0.2770	$5,461.21	
60113	Porter -Littleton	0.2380	$5,462.85	
60114	Parker Adventist 	0.3590	$5,457.98	
60116	Exempla Good Samaritian	0.8360	$5,462.41	
60117	Animas Surgical Hospital	0.5580	$5,107.82	
60118	St Anthony's - Summit Cty – Frisco, CO	0.4509	$5,315.02	
60119	Medical Center of the Rockies 	0.5050	$4,786.66	
60120	Any New Hospital 	0.5050	$5,021.57	

Exhibit 3
Critical Access Hospitals
Name	Location in Colorado 	
Aspen Valley Hospital	Aspen 	
Conejos County Hospital	La Jara 	
East Morgan County Hospital 	Brush 	
Estes Park Medical Center	Estes Park	
Family Health West Hospital 	Fruita 	
Grand River Medical Center	Rifle	
Gunnison Valley Hospital	Gunnison	
Haxtun Hospital District	Haxtun	
Heart of the Rockies Regional Medical Center	Salida	
Kit Carson County Memeorial Hospital	Burlington	
Kremmling Memorial Hospital 	Kremmling	
Lincoln Community Hospital	Hugo	
Melissa Memorial Hospital	Holyoke	
The Memorial Hospital	Craig	
Mt. San Rafael Hospital	Trinidad	
Prowers Medical Center	Lamar	
Rangeley District Hospital	Rangely	
Rio Grande Hospital	Del Norte	
Sedgwick County Memorial Hospital	Julesburg	
Southeast Colorado Hospital	Springfield	
Spanish Peaks Regional Helath Center	Walsenburg	
St. Vincent General Hospital	Leadville	
Weisbrod Memorial County Hospital	Eads	
Wray Community District Hospital	Wray	
Yuma District Hospital	Yuma	

Exhibit 4

Outpatient Surgery Facility Groupers and Fees

APC Grouper	Group Description	Dollar Value 	
1	Level I Photochemotherapy	$0.00	
2	Level I Fine Needle Biopsy/Aspiration	$0.00	
3	Bone Marrow Biopsy/Aspiration	$0.00	
4	Level I Needle Biopsy/ Aspiration Except Bone Marrow	$0.00	
5	Level II Needle Biopsy/Aspiration Except Bone Marrow	$0.00	
6	Level I Incision & Drainage	$0.00	
7	Level II Incision & Drainage	$1,234.04	
8	Level III Incision and Drainage	$1,937.20	
9	Nail Procedures	$0.00	
10	Level I Destruction of Lesion	$0.00	
11	Level II Destruction of Lesion	$0.00	
12	Level I Debridement & Destruction	$0.00	
13	Level II Debridement & Destruction	$0.00	
15	Level III Debridement & Destruction	$0.00	
16	Level IV Debridement & Destruction	$295.96	
17	Level VI Debridement & Destruction	$1,929.85	
18	Biopsy of Skin/Puncture of Lesion	$0.00	
19	Level I Excision/ Biopsy	$0.00	
20	Level II Excision/ Biopsy	$753.28	
21	Level III Excision/ Biopsy	$1,670.96	
22	Level IV Excision/ Biopsy	$2,220.10	
23	Exploration Penetrating Wound	$0.00	
24	Level I Skin Repair	$0.00	
25	Level II Skin Repair	$581.90	
27	Level IV Skin Repair	$2,371.09	
28	Level I Breast Surgery	$2,133.05	
29	Level II Breast Surgery	$3,099.82	
30	Level III Breast Surgery	$4,189.93	
31	Smoking Cessation Services	$0.00	
33	Partial Hospitalization	$0.00	
35	Arterial/Venous Puncture	$0.00	
36	Level II Fine Needle Biopsy/Aspiration	$0.00	
37	Level IV Needle Biopsy/Aspiration Except Bone Marrow	$1,135.80	
38	Spontaneous MEG	$0.00	
39	Level I Implantation of Neurostimulator	$4,384.91	
40	Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve	$2,875.43	
41	Level I Arthroscopy	$3,167.08	
42	Level II Arthroscopy	$5,034.53	
43	Closed Treatment Fracture Finger/Toe/Trunk	$0.00	
45	Bone/Joint Manipulation Under Anesthesia	$1,614.80	
47	Arthroplasty without Prosthesis	$3,701.05	
48	Level I Arthroplasty with Prosthesis	$5,248.64	
49	Level I Musculoskeletal Procedures Except Hand and Foot	$2,309.17	
50	Level II Musculoskeletal Procedures Except Hand and Foot	$2,780.41	
51	Level III Musculoskeletal Procedures Except Hand and Foot	$4,546.22	
52	Level IV Musculoskeletal Procedures Except Hand and Foot	$7,366.57	
53	Level I Hand Musculoskeletal Procedures	$1,787.31	
54	Level II Hand Musculoskeletal Procedures	$2,862.95	
55	Level I Foot Musculoskeletal Procedures	$2,260.01	
56	Level II Foot Musculoskeletal Procedures	$4,520.39	
57	Bunion Procedures	$3,123.97	
58	Level I Strapping and Cast Application	$0.00	
60	Manipulation Therapy	$0.00	
61	Laminectomy or Incision for Implantation of Neurostimulator Electrodes, Excludin	$3,720.69	
62	Level I Treatment Fracture/Dislocation	$2,824.31	
63	Level II Treatment Fracture/Dislocation	$4,153.32	
64	Level III Treatment Fracture/Dislocation	$6,330.65	
65	Level I Stereotactic Radiosurgery	$0.00	
66	Level II Stereotactic Radiosurgery	$0.00	
67	Level III Stereotactic Radiosurgery	$0.00	
68	CPAP Initiation	$0.00	
69	Thoracoscopy	$3,534.39	
70	Thoracentesis/Lavage Procedures	$0.00	
71	Level I Endoscopy Upper Airway	$0.00	
72	Level II Endoscopy Upper Airway	$0.00	
73	Level III Endoscopy Upper Airway	$0.00	
74	Level IV Endoscopy Upper Airway	$1,636.70	
75	Level V Endoscopy Upper Airway	$2,428.74	
76	Level I Endoscopy Lower Airway	$1,053.63	
77	Level I Pulmonary Treatment	$0.00	
78	Level II Pulmonary Treatment	$0.00	
79	Ventilation Initiation and Management	$0.00	
80	Diagnostic Cardiac Catheterization	$4,100.58	
81	Non-Coronary Angioplasty or Atherectomy	$4,750.54	
82	Coronary Atherectomy	$7,988.18	
83	Coronary Angioplasty and Percutaneous Valvuloplasty	$6,504.71	
84	Level I Electrophysiologic Evaluation	$0.00	
85	Level II Electrophysiologic Evaluation	$0.00	
86	Ablate Heart Dysrhythm Focus	$0.00	
87	Cardiac Electrophysiologic Recording/Mapping	$0.00	
88	Thrombectomy	$4,175.55	
89	Insertion/Replacement of Permanent Pacemaker and Electrodes	$3,132.05	
90	Insertion/Replacement of Pacemaker Pulse Generator	$2,747.38	
91	Level II Vascular Ligation	$3,842.48	
92	Level I Vascular Ligation	$2,752.88	
93	Vascular Reconstruction/Fistula Repair without Device	$2,529.86	
94	Level I Resuscitation and Cardioversion	$0.00	
95	Cardiac Rehabilitation	$0.00	
96	Non-Invasive Vascular Studies	$0.00	
97	Cardiac and Ambulatory Blood Pressure Monitoring	$0.00	
98	Injection of Sclerosing Solution	$0.00	
99	Electrocardiograms	$0.00	
100	Cardiac Stress Tests	$0.00	
101	Tilt Table Evaluation	$0.00	
103	Miscellaneous Vascular Procedures	$1,796.56	
104	Transcatheter Placement of Intracoronary Stents	$9,705.37	
105	Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices	$2,834.01	
106	Insertion/Replacement of Pacemaker Leads and/or Electrodes	$3,784.97	
107	Insertion of Cardioverter-Defibrillator	$3,220.70	
108	Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads	$4,453.56	
109	Removal of Implanted Devices	$0.00	
110	Transfusion	$0.00	
111	Blood Product Exchange	$0.00	
112	Apheresis, Photopheresis, and Plasmapheresis	$3,343.95	
113	Excision Lymphatic System	$2,352.49	
114	Thyroid/Lymphadenectomy Procedures	$4,173.70	
115	Cannula/Access Device Procedures	$3,232.22	
121	Level I Tube changes and Repositioning	$0.00	
122	Level II Tube changes and Repositioning	$0.00	
123	Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant	$2,252.48	
125	Refilling of Infusion Pump	$0.00	
126	Level I Urinary and Anal Procedures	$0.00	
127	Level IV Stereotactic Radiosurgery	$0.00	
130	Level I Laparoscopy	$3,554.28	
131	Level II Laparoscopy	$4,818.35	
132	Level III Laparoscopy	$7,801.02	
140	Esophageal Dilation without Endoscopy	$603.74	
141	Level I Upper GI Procedures	$920.27	
142	Small Intestine Endoscopy	$1,050.50	
143	Lower GI Endoscopy	$970.18	
146	Level I Sigmoidoscopy and Anoscopy	$538.63	
147	Level II Sigmoidoscopy and Anoscopy	$945.74	
148	Level I Anal/Rectal Procedures	$0.00	
149	Level III Anal/Rectal Procedures	$2,463.80	
150	Level IV Anal/Rectal Procedures	$3,277.10	
151	Endoscopic Retrograde Cholangio-Pancreatography (ERCP)	$2,194.94	
152	Level I Percutaneous Abdominal and Biliary Procedures	$2,242.53	
153	Peritoneal and Abdominal Procedures	$2,443.34	
154	Hernia/Hydrocele Procedures	$3,232.76	
155	Level II Anal/Rectal Procedures	$1,409.45	
156	Level III Urinary and Anal Procedures	$0.00	
157	Colorectal Cancer Screening: Barium Enema	$0.00	
158	Colorectal Cancer Screening: Colonoscopy	$0.00	
159	Colorectal Cancer Screening: Flexible Sigmoidoscopy	$0.00	
160	Level I Cystourethroscopy and other Genitourinary Procedures	$718.63	
161	Level II Cystourethroscopy and other Genitourinary Procedures	$2,127.11	
162	Level III Cystourethroscopy and other Genitourinary Procedures	$2,641.03	
163	Level IV Cystourethroscopy and other Genitourinary Procedures	$3,864.31	
164	Level II Urinary and Anal Procedures	$0.00	
165	Level IV Urinary and Anal Procedures	$2,010.13	
166	Level I Urethral Procedures	$2,035.39	
168	Level II Urethral Procedures	$3,211.43	
169	Lithotripsy	$4,817.34	
170	Dialysis	$0.00	
171	Level V Anal/Rectal Procedures	$4,193.24	
180	Circumcision	$2,273.85	
181	Penile Procedures	$3,649.79	
183	Testes/Epididymis Procedures	$2,603.52	
184	Prostate Biopsy	$0.00	
188	Level II Female Reproductive Proc	$0.00	
189	Level III Female Reproductive Proc	$0.00	
190	Level I Hysteroscopy	$2,363.17	
191	Level I Female Reproductive Proc	$0.00	
192	Level IV Female Reproductive Proc	$0.00	
193	Level V Female Reproductive Proc	$0.00	
194	Level VIII Female Reproductive Proc	$2,269.06	
195	Level IX Female Reproductive Proc	$3,154.36	
196	Dilation and Curettage	$1,963.89	
197	Infertility Procedures	$0.00	
198	Pregnancy and Neonatal Care Procedures	$0.00	
200	Level VII Female Reproductive Proc	$1,873.49	
201	Level VI Female Reproductive Proc	$2,049.10	
202	Level X Female Reproductive Proc	$4,756.46	
203	Level IV Nerve Injections	$1,346.54	
204	Level I Nerve Injections	$0.00	
206	Level II Nerve Injections	$633.46	
207	Level III Nerve Injections	$703.71	
208	Laminotomies and Laminectomies	$4,884.73	
209	Level II MEG, Extended EEG Studies and Sleep Studies	$0.00	
210	Spinal Fusions	$330.89	
212	Nervous System Injections	$0.00	
213	Level I MEG, Extended EEG Studies and Sleep Studies	$0.00	
214	Electroencephalogram	$0.00	
215	Level I Nerve and Muscle Tests	$0.00	
216	Level III Nerve and Muscle Tests	$0.00	
218	Level II Nerve and Muscle Tests	$0.00	
220	Level I Nerve Procedures	$1,974.96	
221	Level II Nerve Procedures	$3,668.02	
222	Implantation of Neurological Device	$4,491.32	
223	Implantation or Revision of Pain Management Catheter	$3,412.15	
224	Implantation of Reservoir/Pump/Shunt	$5,203.98	
225	Implantation of Neurostimulator Electrodes, Cranial Nerve	$5,128.63	
226	Implantation of Drug Infusion Reservoir	$12,461.90	
227	Implantation of Drug Infusion Device	$3,807.23	
228	Creation of Lumbar Subarachnoid Shunt	$4,344.19	
229	Transcatherter Placement of Intravascular Shunts	$4,077.97	
230	Level I Eye Tests & Treatments	$0.00	
231	Level III Eye Tests & Treatments	$0.00	
232	Level I Anterior Segment Eye Procedures	$671.29	
233	Level II Anterior Segment Eye Procedures	$1,684.64	
234	Level III Anterior Segment Eye Procedures	$2,544.44	
235	Level I Posterior Segment Eye Procedures	$0.00	
236	Level II Posterior Segment Eye Procedures	$1,828.24	
237	Level III Posterior Segment Eye Procedures	$3,053.95	
238	Level I Repair and Plastic Eye Procedures	$0.00	
239	Level II Repair and Plastic Eye Procedures	$805.68	
240	Level III Repair and Plastic Eye Procedures	$1,894.68	
241	Level IV Repair and Plastic Eye Procedures	$2,794.27	
242	Level V Repair and Plastic Eye Procedures	$3,897.85	
243	Strabismus/Muscle Procedures	$2,354.49	
244	Corneal Transplant	$4,234.36	
245	Level I Cataract Procedures without IOL Insert	$1,645.27	
246	Cataract Procedures with IOL Insert	$2,614.63	
247	Laser Eye Procedures Except Retinal	$562.50	
248	Laser Retinal Procedures	$0.00	
249	Level II Cataract Procedures without IOL Insert	$3,233.86	
250	Nasal Cauterization/Packing	$0.00	
251	Level I ENT Procedures	$0.00	
252	Level II ENT Procedures	$835.47	
253	Level III ENT Procedures	$1,817.48	
254	Level IV ENT Procedures	$2,581.27	
256	Level V ENT Procedures	$4,226.44	
257	Level I Therapeutic Radiologic Procedures	$0.00	
258	Tonsil and Adenoid Procedures	$2,447.03	
259	Level VI ENT Procedures	$7,063.94	
260	Level I Plain Film Except Teeth	$0.00	
261	Level II Plain Film Except Teeth Including Bone Density Measurement	$0.00	
262	Plain Film of Teeth	$0.00	
263	Level I Miscellaneous Radiology Procedures	$0.00	
264	Level II Miscellaneous Radiology Procedures	$0.00	
265	Level I Diagnostic and Screening Ultrasound	$0.00	
266	Level II Diagnostic and Screening Ultrasound	$0.00	
267	Level III Diagnostic and Screening Ultrasound	$0.00	
268	Level I Ultrasound Guidance Procedures	$0.00	
269	Level II Echocardiogram Except Transesophageal	$0.00	
270	Transesophageal Echocardiogram	$0.00	
272	Fluoroscopy	$0.00	
274	Myelography	$0.00	
275	Arthrography	$0.00	
276	Level I Digestive Radiology	$0.00	
277	Level II Digestive Radiology	$0.00	
278	Diagnostic Urography	$0.00	
279	Level II Angiography and Venography	$0.00	
280	Level III Angiography and Venography	$0.00	
282	Miscellaneous Computerized Axial Tomography	$0.00	
283	Computed Tomography with Contrast	$0.00	
284	Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast	$0.00	
288	Bone Density:Axial Skeleton	$0.00	
293	Level V Anterior Segment Eye Procedures	$0.00	
296	Level II Therapeutic Radiologic Procedures	$0.00	
297	Level III Therapeutic Radiologic Procedures	$0.00	
298	Level IV Therapeutic Radiologic Procedures	$0.00	
299	Miscellaneous Radiation Treatment	$0.00	
300	Level I Radiation Therapy	$0.00	
301	Level II Radiation Therapy	$0.00	
302	Computer Assisted Navigational Procedures	$0.00	
303	Treatment Device Construction	$0.00	
304	Level I Therapeutic Radiation Treatment Preparation	$0.00	
305	Level II Therapeutic Radiation Treatment Preparation	$0.00	
307	Myocardial Positron Emission Tomography (PET) imaging	$0.00	
308	Non-Myocardial Positron Emission Tomography (PET) imaging	$0.00	
309	Level II Ultrasound Guidance Procedures	$0.00	
310	Level III Therapeutic Radiation Treatment Preparation	$0.00	
312	Radioelement Applications	$0.00	
313	Brachytherapy	$0.00	
314	Hyperthermic Therapies	$0.00	
315	Level II Implantation of Neurostimulator	$6,442.90	
320	Electroconvulsive Therapy	$0.00	
321	Biofeedback and Other Training	$0.00	
322	Brief Individual Psychotherapy	$0.00	
323	Extended Individual Psychotherapy	$0.00	
324	Family Psychotherapy	$0.00	
325	Group Psychotherapy	$0.00	
330	Dental Procedures	$0.00	
332	Computed Tomography without Contrast	$0.00	
333	Computed Tomography without Contrast followed by Contrast)	$0.00	
335	Magnetic Resonance Imaging, Miscellaneous	$0.00	
336	Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast	$0.00	
337	Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast 	$0.00	
339	Observation	$0.00	
340	Minor Ancillary Procedures	$0.00	
341	Skin Tests	$0.00	
342	Level I Pathology	$0.00	
343	Level III Pathology	$0.00	
344	Level IV Pathology	$0.00	
345	Level I Transfusion Laboratory Procedures	$0.00	
346	Level II Transfusion Laboratory Procedures	$0.00	
347	Level III Transfusion Laboratory Procedures	$0.00	
348	Fertility Laboratory Procedures	$0.00	
350	Administration of flu and PPV vaccine	$0.00	
360	Level I Alimentary Tests	$0.00	
361	Level II Alimentary Tests	$0.00	
362	Contact Lens and Spectacle Services	$0.00	
363	Level I Otorhinolaryngologic Function Tests	$0.00	
364	Level I Audiometry	$0.00	
365	Level II Audiometry	$0.00	
366	Level III Audiometry	$0.00	
367	Level I Pulmonary Test	$0.00	
368	Level II Pulmonary Tests	$0.00	
369	Level III Pulmonary Tests	$0.00	
370	Allergy Tests	$0.00	
372	Therapeutic Phlebotomy	$0.00	
373	Level I Neuropsychological Testing	$0.00	
374	Monitoring Psychiatric Drugs	$0.00	
376	Level II Cardiac Imaging	$0.00	
377	Level III Cardiac Imaging	$0.00	
378	Level II Pulmonary Imaging	$0.00	
379	Injection adenosine 6 MG	$0.00	
381	Single Allergy Tests	$0.00	
382	Level II Neuropsychological Testing	$0.00	
384	GI Procedures with Stents	$2,538.97	
385	Level I Prosthetic Urological Procedures	$1,473.21	
386	Level II Prosthetic Urological Procedures	$5,904.13	
387	Level II Hysteroscopy	$3,763.55	
388	Discography	$1,767.60	
389	Level I Non-imaging Nuclear Medicine	$0.00	
390	Level I Endocrine Imaging	$0.00	
391	Level II Endocrine Imaging	$0.00	
392	Level II Non-imaging Nuclear Medicine	$0.00	
393	Red Cell/Plasma Studies	$0.00	
394	Hepatobiliary Imaging	$0.00	
395	GI Tract Imaging	$0.00	
396	Bone Imaging	$0.00	
397	Vascular Imaging	$0.00	
398	Level I Cardiac Imaging	$0.00	
399	Nuclear Medicine Add-on Imaging	$0.00	
400	Hematopoietic Imaging	$0.00	
401	Level I Pulmonary Imaging	$0.00	
402	Brain Imaging	$0.00	
403	CSF Imaging	$0.00	
404	Renal and Genitourinary Studies Level I	$0.00	
405	Renal and Genitourinary Studies Level II	$0.00	
406	Level I Tumor/Infection Imaging	$0.00	
407	Level I Radionuclide Therapy	$0.00	
408	Level II Tumor/Infection Imaging	$0.00	
409	Red Blood Cell Tests	$0.00	
411	Respiratory Procedures	$0.00	
412	IMRT Treatment Delivery	$0.00	
413	Level II Radionuclide Therapy	$0.00	
415	Level II Endoscopy Lower Airway	$2,435.22	
416	Level I Intravascular and Intracardiac Ultrasound and Flow Reserve	$3,601.10	
417	Computerized Reconstruction	$0.00	
418	Insertion of Left Ventricular Pacing Elect.	$4,311.02	
421	Prolonged Physiologic Monitoring	$0.00	
422	Level II Upper GI Procedures	$2,849.62	
423	Level II Percutaneous Abdominal and Biliary Procedures	$4,133.65	
425	Level II Arthroplasty with Prosthesis	$11,860.22	
426	Level II Strapping and Cast Application	$0.00	
427	Level III Tube Changes and Repositioning	$1,289.81	
428	Level III Sigmoidoscopy and Anoscopy	$2,283.39	
429	Level V Cystourethroscopy and other Genitourinary Procedures	$4,768.74	
432	Health and Behavior Services	$0.00	
433	Level II Pathology	$0.00	
434	Cardiac Defect Repair	$9,744.59	
436	Level I Drug Administration	$0.00	
437	Level II Drug Administration	$0.00	
438	Level III Drug Administration	$0.00	
439	Level IV Drug Administration	$0.00	
440	Level V Drug Administration	$0.00	
441	Level VI Drug Administration	$0.00	
442	Dosimetric Drug Administration	$0.00	
443	Overnight Pulse Oximetry	$0.00	
604	Level 1 Hospital Clinic Visits	$0.00	
605	Level 2 Hospital Clinic Visits	$0.00	
606	Level 3 Hospital Clinic Visits	$0.00	
607	Level 4 Hospital Clinic Visits	$0.00	
608	Level 5 Hospital Clinic Visits	$0.00	
609	Level 1 Emergency Visits	$0.00	
613	Level 2 Emergency Visits	$0.00	
614	Level 3 Emergency Visits	$0.00	
615	Level 4 Emergency Visits	$0.00	
616	Level 5 Emergency Visits	$0.00	
617	Critical Care	$0.00	
618	Trauma Response with Critical Care	$0.00	
621	Level I Vascular Access Procedures	$0.00	
622	Level II Vascular Access Procedures	$2,507.87	
623	Level III Vascular Access Procedures	$3,153.65	
624	Minor Vascular Access Device Procedures	$0.00	
625	Level IV Vascular Access Procedures	$9,234.31	
648	Level IV Breast Surgery	$5,667.88	
651	Complex Interstitial Radiation Source Application	$0.00	
652	Insertion of Intraperitoneal and Pleural Catheters	$3,268.55	
653	Vascular Reconstruction/Fistula Repair with Device	$3,582.79	
654	Insertion/Replacement of a permanent dual chamber pacemaker	$2,826.13	
655	Insertion/Replacement/Conversion of a permanent dual chamber pacemaker	$3,953.57	
656	Transcatheter Placement of Intracoronary Drug-Eluting Stents	$0.00	
657	Placement of Tissue Clips	$0.00	
658	Percutaneous Breast Biopsies	$0.00	
659	Hyperbaric Oxygen	$0.00	
660	Level II Otorhinolaryngologic Function Tests	$0.00	
661	Level V Pathology	$0.00	
662	CT Angiography	$0.00	
663	Level I Electronic Analysis of Neurostimulator Pulse Generators	$0.00	
664	Level I Proton Beam Radiation Therapy	$0.00	
665	Bone Density:AppendicularSkeleton	$0.00	
667	Level II Proton Beam Radiation Therapy	$0.00	
668	Level I Angiography and Venography	$0.00	
670	Level II Intravascular and Intracardiac Ultrasound and Flow Reserve	$3,572.14	
672	Level IV Posterior Segment Eye Procedures	$4,141.24	
673	Level IV Anterior Segment Eye Procedures	$4,192.97	
674	Prostate Cryoablation	$12,033.09	
675	Prostatic Thermotherapy	$4,551.55	
676	Thrombolysis and Thrombectomy	$0.00	
678	External Counterpulsation	$0.00	
679	Level II Resuscitation and Cardioversion	$0.00	
680	Insertion of Patient Activated Event Recorders	$1,895.76	
681	Knee Arthroplasty	$6,060.22	
682	Level V Debridement & Destruction	$761.58	
683	Level II Photochemotherapy	$0.00	
685	Level III Needle Biopsy/Aspiration Except Bone Marrow	$679.18	
686	Level III Skin Repair	$1,552.82	
687	Revision/Removal of Neurostimulator Electrodes	$1,973.12	
688	Revision/Removal of Neurostimulator Pulse Generator Receiver	$3,935.57	
689	Electronic Analysis of Cardioverter-defibrillators	$0.00	
690	Electronic Analysis of Pacemakers and other Cardiac Devices	$0.00	
691	Electronic Analysis of Programmable Shunts/Pumps	$0.00	
692	Level II Electronic Analysis of Neurostimulator Pulse Generators	$0.00	
693	Breast Reconstruction	$4,093.63	
694	Mohs Surgery	$0.00	
695	Level VII Debridement & Destruction	$2,260.15	
697	Level I Echocardiogram Except Transesophageal	$0.00	
698	Level II Eye Tests & Treatments	$0.00	
699	Level IV Eye Tests & Treatments	$0.00	

Exhibit 5
Rural Health Facilities

Bent County Nursing Service Women’s Health Clinic	
215 Maple Avenue 	
Las Animas, Co 81054 - Bent County	
Telephone: (719) 456-1243, Fax: (719) 456-1246 	
	
Brush Family Clinic	
2400 W Edison	
Brush, Co 80723 - Morgan County	
Telephone: (970) 842-2833, Fax: (970) 842-6241	
	
Buena Vista Family Practice Clinic	
836 U.S. Hwy 24 So	
Buena Vista, Co 81211 - Chaffee County	
Telephone: (719) 395-9048, Fax: (719) 395-9064	
	
Button Family Practice	
1335 Phay Avenue Suite D	
Cannon City, Co 81212 – Fremont County	
Telephone:  (719) 269-8820, Fax:  (719) 204-0230	
	
Centennial Family Health Clenter	
319 Main Street	
Ordway, Co 81063 – Crowley County	
Telephone:  (719) 267-3503, Fax:  (719) 267-4153	
	
Colorado Plains Clinic – Wiggins	
226 Main Street	
Wiggins, Co 80654 – Morgan County	
Telephone:  (970) 483-7283	
	
Conejos Medical Clinic	
19021 State Hwy 285	
La Jara, Co 81140 - Conejos County	
Telephone: (719) 274-5121, Fax: (719) 274-6003	
	
Creed Family Practice Of Rio Grande Hospital	
802 Rio Grande Avenue	
Creed, Co 81130 – Mineral County	
Telephone:  (719) 658-0929, Fax: (719) 657-2851	

Custer County Medical Clinic	
704 Edwards	
Westcliffe, Co 81252 - Custer County	
Telephone: (719) 783-2380, Fax: (719) 783-2377	
	
Dolores Medical Center	
507 Central Avenue	
Dolores, Co 81323 - Montezuma County	
Telephone: (970) 882-7221, Fax: (970) 882-4243	
	
Eads Medical Clinic	
1211 Luther Street	
Eads, Co 81036 - Kiowa County	
Telephone: (719) 438-2251, Fax: (719) 438-2254	
	
Eastern Plains Medical Clinic Of Calhan	
555 Colorado Avenue	
Calhan, Co 80808 - El Paso County	
Telephone: (719) 347-0100, Fax: (719) 347-0551	
	
Family Care Clinic	
615 Fairhurst	
Sterling, Co 80751 - Logan County	
Telephone: (970) 521-3223	
	
Family Practice Of Holyoke	
520 South Interocean	
Holyoke, Co 80734 - Phillips County	
Telephone: (970) 854-2500, Fax: (970) 854-3440	
	
Fleming Family Health Center	
104 W Larimer St	
Fleming, Co 80728 - Logan County	
Telephone: (970) 774-6123, Fax: (970) 774-6158	
	
Florence Medical Center	
501 W 5th St	
Florence, Co 81226 - Fremont County	
Telephone: (719) 784-4816, Fax: (719) 784-6014	
	
Grand River Primary Care	
501 Airport Road	
Rifle, Co 81650 - Garfield County	
Telephone: (970) 625-1100, Fax: (970) 625-0725	

Grand River Primary Care - Battlement Mesa	
73 Sipperelle Drive, Suite K	
Parachute, Co 81635 - Garfield County	
Telephone: (970) 285-7046, Fax: (970) 285-6064	
	
Havens Family Clinic	
109 Latigo Ln Ste C	
Canon City, Co 81212 - Fremont County	
Telephone: (719) 276-3211, Fax: (719) 276-3011	
	
Kit Carson Clinic	
102 East 2nd Avenue	
Kit Carson, Co 80825 - Cheyenne County	
Telephone: (719) 962-3501, Fax: (719) 962-3403	
	
La Clinica Inc	
24850 N St Hwy 69	
Gardner, Co 81040 - Huerfano County	
Telephone: (719) 746-2244	
	
Lake City Area Medical Center	
700 N Henson Street	
Lake City, Co 81235 - Hinsdale County	
Telephone: (970) 944-2331, Fax: (970) 944-2320	
	
Meeker Family Health Center	
345 Cleveland	
Meeker, Co 81641 - Rio Blanco County	
Telephone: (970) 878-4014, Fax: (970) 878-3285	
	
Mountain Medical Center Of Buena Vista, P.C	
36 Oak St	
Buena Vista, Co 81211 - Chaffee County	
Telephone: (719) 395-8632, Fax: (719) 395-4971	
	
Mt San Rafael Hospital Health Clinic	
400 Benedicta Ste A	
Trinidad, Co 81082 – Las Animas County	
Telephone:  (719) 846-2206, Fax:  (719) 846-7823	
	
North Park Medical Clinic	
521 5th St	
Walden, Co 80480 - Jackson County	
Telephone: (970) 723-4255, Fax: (970) 723-4268	

Olathe Medical Clinic	
308 Main St	
Olathe, Co 81425 - Montrose County	
Telephone: (970) 323-6141, Fax: (970) 323-6117	
	
Parke Health Clinic	
182 16th St	
Burlington, Co 80807 - Kit Carson County	
Telephone: (719) 346-9481, Fax: (719) 346-9485	
	
Pediatric Associates, The	
947 South 5th Street	
Montrose, Co 81401 – Montrose County	
Telephone:  (970) 249-2421, Fax:  (970) 249-8897	
	
Pediatric Association Of Canon City	
1335 Phay Avenue	
Canon City, Co 81212 - Fremont County	
Telephone: (719) 269-1727, Fax: (719) 269-1730	
	
Prairie View Rural Health Clinic	
560 N 6 W Street	
Cheyenne Wells, Co 80810 - Cheyenne County	
Telephone: (719) 767-5669, Fax: (719) 767-8042	
	
Rio Grande Hospital Clinic	
1280 Grand Avenue	
Del Norte Co 81132 – Rio Grande County	
Telephone:  (719) 657-2418, Fax:  (719) 658-3001	
	
River Valley Pediatrics	
1335 Phay Avenue	
Canon City, Co 81212 – Fremont County	
Telephone:  (719) 276-2222	
	
Rocky Ford Family Health Center	
1014 Elm Avenue	
Rocky Ford, Co 81067 - Otero County	
Telephone: (719) 254-7421, Fax: (719) 254-6966	
	
Santa Fe Trail Medical Center	
111 Waverly Ave	
Trinidad, Co 81082 - Las Animas County	
Telephone: (719) 846-0123, Fax: (719) 846-0121	

Southeast Colorado Physician's Clinic	
210 E Tenth Ave	
Springfield, Co 81073 - Baca County	
Telephone: (719) 523-6628, Fax: (719) 523-4513	
	
Stratton Medical Clinic	
500 Nebraska Avenue	
Stratton, Co 80836 - Kit Carson County	
Telephone: (719) 348-4650, Fax: (719) 348-4653	
	
Surface Creek Family Practice	
255 Sw 8th Ave	
Cedaredge, Co 81413 - Delta County	
Telephone: (970) 856-3146, Fax: (970) 856-4385	
	
Telluride Medical Center	
500 W Pacific	
Telluride, Co 81435 - San Miguel County	
Telephone: (970) 728-3840, Fax: (970) 728-3404	
	
Trinidad Family Medical Center	
1502 E Main St	
Trinidad, Co 81082 - Las Animas County	
Telephone: (719) 846-3305, Fax: (719) 846-4922	
	
Trinidad Medical Associates	
400 Benedicta #E	
Trinidad, Co 81082 - Las Animas County	
Telephone: (719) 845-0627, Fax: (719) 845-0663	
	
United Medical Center Of Berthoud	
549 Mountain Avenue	
Berthoud, Co 80513 - Larimer County	
Telephone: (970) 532-4644, Fax: (970) 532-0608	
	
Valley Medical Clinic	
116 E Ninth Street	
Julesburg, Co 80737 - Sedgwick County	
Telephone: (970) 474-3376, Fax: (970) 474-2461	
	
Washington County Clinic	
482 Adams Avenue	
Akron, Co 80720 - Washington County	
Telephone: (970) 345-2262, Fax: (970) 345-2265	

Wiley Medical Clinic	
302 Main Street	
Wiley, Co 81092 - Prowers County	
Telephone: (719) 829-4627, Fax: (719) 829-4269	
	
Yuma Rural Health Clinic	
910 S Main St	
Yuma, Co 80759 - Yuma County	
Telephone: (970) 848-4700, Fax: (970) 848-0809	

Exhibit 6
Dental Fee Schedule
Code	Fees	
D0120	$43.37	
D0140	$59.48	
D0145	BR	
D0150	$81.78	
D0160	$105.33	
D0170	$52.05	
D0180	BR	
D0210	$129.78	
D0220	$22.31	
D0230	$18.58	
D0240	$37.18	
D0250	$50.81	
D0260	$49.57	
D0270	$27.26	
D0272	$41.10	
D0273	$50.83	
D0274	$60.56	
D0277	$89.21	
D0290	$171.00	
D0310	$436.19	
D0320	$747.21	
D0321	BR	
D0322	$599.76	
D0330	$92.94	
D0340	$126.39	
D0350	$55.76	
D0360	BR	
D0362	BR	
D0363	BR	
D0415	$49.58	
D0416	BR	
D0421	BR	
D0425	$32.22	
D0431	BR	
D0460	$55.76	
D0470	$92.94	
D0472	$84.26	
D0473	$163.57	
D0474	$197.02	
D0480	$118.97	
D0486	$118.97	
D0475	BR	
D0476	BR	
D0477	BR	
D0478	BR	
D0479	BR	
D0481	BR	
D0482	BR	
D0483	BR	
D0484	BR	
D0485	BR	
D0502	BR	
D0999	BR	
D1110	$80.55	
D1120	$55.76	
D1203	$37.18	
D1204	$37.18	
D1206	$97.60	
D1310	$47.08	
D1320	$49.58	
D1330	$63.20	
D1351	$43.37	
D1510	$278.81	
D1515	$358.12	
D1520	$380.43	
D1525	$521.68	
D1550	$66.91	
D1555	$66.92	
D2140	$105.33	
D2150	$136.31	
D2160	$175.96	
D2161	$204.46	
D2330	$123.92	
D2331	$171.00	
D2332	$215.62	
D2335	$254.02	
D2390	$323.41	
D2391	$168.52	
D2392	$195.78	
D2393	$268.90	
D2394	$340.77	
D2410	$268.90	
D2420	$448.57	
D2430	$776.94	
D2510	$743.49	
D2520	$758.36	
D2530	$930.61	
D2542	$912.02	
D2543	$877.32	
D2544	$992.56	
D2610	$837.67	
D2620	$774.46	
D2630	$883.51	
D2642	$967.77	
D2643	$967.77	
D2644	$1,047.09	
D2650	$812.89	
D2651	$812.89	
D2652	$688.97	
D2662	$598.50	
D2663	$703.84	
D2664	$753.41	
D2710	$425.03	
D2712	BR	
D2720	$1,047.09	
D2721	$980.16	
D2722	$1,002.47	
D2740	$967.77	
D2750	$976.45	
D2751	$780.67	
D2752	$836.43	
D2780	$1,016.11	
D2781	$956.62	
D2782	$987.60	
D2783	$1,045.84	
D2790	$877.32	
D2791	$969.01	
D2792	$986.37	
D2794	BR	
D2799	$425.03	
D2910	$104.09	
D2915	BR	
D2920	$92.94	
D2930	$249.07	
D2931	$293.67	
D2932	$365.56	
D2933	$410.16	
D2934	BR	
D2940	$111.52	
D2950	$229.25	
D2951	$59.47	
D2952	$418.83	
D2953	$215.62	
D2954	$358.12	
D2955	$268.90	
D2957	$178.44	
D2960	$662.95	
D2961	$981.41	
D2962	$1,064.20	
D2970	BR	
D2971	BR	
D2975	BR	
D2980	BR	
D2999	BR	
D3110	$89.21	
D3120	$85.50	
D3220	$183.39	
D3221	$184.63	
D3230	$177.20	
D3240	$190.83	
D3310	$557.62	
D3320	$667.91	
D3330	$1,029.59	
D3331	$239.15	
D3332	$614.63	
D3333	$204.46	
D3346	$956.62	
D3347	$1,127.63	
D3348	$1,355.63	
D3351	$402.72	
D3352	$175.96	
D3353	$594.79	
D3410	$501.85	
D3421	$888.47	
D3425	$1,004.95	
D3426	$334.57	
D3430	$246.59	
D3450	$499.37	
D3460	$2,395.28	
D3470	$995.03	
D3910	$130.10	
D3920	$389.09	
D3950	$177.20	
D3999	BR	
D4210	$510.53	
D4211	$292.01	
D4230	BR	
D4231	BR	
D4240	$935.56	
D4241	$935.56	
D4245	$672.87	
D4249	$1,066.90	
D4260	$991.32	
D4261	$991.32	
D4263	$456.00	
D4264	$228.01	
D4265	BR	
D4266	$550.18	
D4267	$707.55	
D4268	BR	
D4270	$1,116.48	
D4271	$1,147.45	
D4273	$1,224.28	
D4274	$345.72	
D4275	BR	
D4276	BR	
D4320	$447.33	
D4321	$552.66	
D4341	$229.25	
D4342	$229.25	
D4355	$161.09	
D4381	BR	
D4910	$144.99	
D4920	$123.92	
D4999	BR	
D5110	$1,486.99	
D5120	$1,486.99	
D5130	$1,418.83	
D5140	$1,418.83	
D5211	$1,214.36	
D5212	$1,322.51	
D5213	$1,486.99	
D5214	$1,486.99	
D5225	BR	
D5226	BR	
D5281	$961.58	
D5410	$81.78	
D5411	$81.78	
D5421	$81.78	
D5422	$81.78	
D5510	$235.44	
D5520	$130.10	
D5610	$185.88	
D5620	$247.83	
D5630	$229.25	
D5640	$130.10	
D5650	$185.88	
D5660	$241.64	
D5670	BR	
D5671	BR	
D5710	$452.29	
D5711	$578.69	
D5720	$571.25	
D5721	$571.25	
D5730	$309.80	
D5731	$309.80	
D5740	$313.51	
D5741	$313.51	
D5750	$371.74	
D5751	$371.74	
D5760	$449.82	
D5761	$449.82	
D5810	$721.19	
D5811	$775.71	
D5820	$557.62	
D5821	$592.32	
D5850	$142.50	
D5851	$142.50	
D5860	BR	
D5861	BR	
D5862	BR	
D5867	BR	
D5875	BR	
D5899	BR	
D5911	$377.94	
D5912	$377.94	
D5913	$7,970.23	
D5914	$7,970.23	
D5915	$10,785.58	
D5916	$2,875.60	
D5919	BR	
D5922	BR	
D5923	$2,821.55	
D5924	BR	
D5925	BR	
D5926	BR	
D5927	BR	
D5928	BR	
D5929	BR	
D5931	$4,291.19	
D5932	$8,026.00	
D5933	BR	
D5934	$7,314.71	
D5935	$6,364.28	
D5936	$7,148.67	
D5937	$898.38	
D5951	$1,168.52	
D5952	$3,793.04	
D5953	$7,203.19	
D5954	$6,675.32	
D5955	$6,173.45	
D5958	BR	
D5959	BR	
D5960	BR	
D5982	$742.26	
D5983	$1,796.77	
D5984	$1,796.77	
D5985	$1,796.77	
D5986	$152.42	
D5987	$2,696.40	
D5988	BR	
D5999	BR	
D6010	$2,493.17	
D6012	BR	
D6040	$11,465.88	
D6050	$7,116.45	
D6053	BR	
D6054	BR	
D6055	$633.21	
D6056	BR	
D6057	BR	
D6058	$1,434.93	
D6059	$1,416.35	
D6060	$1,338.28	
D6061	$1,365.55	
D6062	$1,360.59	
D6063	$1,161.08	
D6064	$1,237.92	
D6094	BR	
D6065	$1,411.40	
D6066	$1,375.46	
D6067	$1,334.57	
D6068	$1,434.93	
D6069	$1,416.35	
D6070	$1,338.28	
D6071	$1,365.55	
D6072	$1,394.04	
D6073	$1,261.46	
D6074	$1,360.59	
D6194	BR	
D6075	$1,411.40	
D6076	$1,375.46	
D6077	$1,334.57	
D6078	BR	
D6079	BR	
D6080	BR	
D6090	BR	
D6091	BR	
D6092	BR	
D6093	BR	
D6094	BR	
D6095	BR	
D6100	BR	
D6190	BR	
D6199	BR	
D6205	BR	
D6210	$877.32	
D6211	$941.75	
D6212	$980.16	
D6214	BR	
D6240	$898.38	
D6241	$805.46	
D6242	$967.77	
D6245	$1,024.78	
D6250	$980.16	
D6251	$904.59	
D6252	$933.44	
D6253	BR	
D6545	$898.38	
D6548	$458.48	
D6600	$929.37	
D6601	$992.56	
D6602	$866.17	
D6603	$1,061.96	
D6604	$866.17	
D6605	$992.56	
D6606	$866.17	
D6607	$1,061.96	
D6624	BR	
D6608	$929.37	
D6609	$1,061.96	
D6610	$866.17	
D6611	$992.56	
D6612	$866.17	
D6613	$992.56	
D6614	$1,017.35	
D6615	$1,017.35	
D6634	BR	
D6710	BR	
D6720	$842.62	
D6721	$1,049.56	
D6722	$1,068.15	
D6740	$1,163.58	
D6750	$898.38	
D6751	$836.43	
D6752	$1,083.02	
D6780	$836.43	
D6781	$1,068.15	
D6782	$992.56	
D6783	$1,100.37	
D6790	$855.01	
D6791	$1,037.17	
D6792	$1,074.34	
D6793	BR	
D6794	BR	
D6920	$189.60	
D6930	$154.89	
D6940	$301.11	
D6950	$588.60	
D6970	$366.79	
D6972	$298.63	
D6973	$240.39	
D6975	$658.00	
D6976	$156.13	
D6977	$148.70	
D6980	BR	
D6985	BR	
D6999	BR	
D7111	BR	
D7140	BR	
D7210	$223.05	
D7220	$249.07	
D7230	$292.44	
D7240	$344.48	
D7241	$483.27	
D7250	$247.83	
D7260	$2,493.17	
D7261	BR	
D7270	$516.73	
D7272	$734.81	
D7280	$566.30	
D7282	BR	
D7283	BR	
D7285	$1,002.47	
D7286	$411.40	
D7287	BR	
D7288	BR	
D7290	$467.13	
D7291	$70.63	
D7292	BR	
D7293	BR	
D7294	BR	
D7310	$272.61	
D7311	BR	
D7320	$371.74	
D7321	BR	
D7340	$2,234.18	
D7350	$7,006.17	
D7410	$1,557.61	
D7411	BR	
D7412	BR	
D7413	BR	
D7414	BR	
D7415	BR	
D7465	BR	
D7440	$1,577.44	
D7441	$2,451.05	
D7450	$893.43	
D7451	$1,402.73	
D7460	$893.43	
D7461	$1,438.65	
D7471	$925.65	
D7472	BR	
D7473	BR	
D7485	BR	
D7490	$7,473.33	
D7510	$267.65	
D7511	BR	
D7520	$1,275.09	
D7521	BR	
D7530	$459.72	
D7540	$509.29	
D7550	$317.23	
D7560	$2,522.91	
D7610	$4,079.29	
D7620	$3,059.47	
D7630	$5,303.57	
D7640	$3,365.53	
D7650	$2,550.18	
D7660	$1,503.09	
D7670	$1,173.47	
D7671	BR	
D7680	$7,649.30	
D7710	$4,794.28	
D7720	$3,365.53	
D7730	$6,935.54	
D7740	$3,431.21	
D7750	$4,364.30	
D7760	$1,750.92	
D7770	$2,372.97	
D7771	BR	
D7780	$10,199.46	
D7810	$4,486.97	
D7820	$734.81	
D7830	$421.32	
D7840	$6,116.46	
D7850	$5,281.27	
D7852	$6,047.07	
D7854	$6,240.37	
D7856	$4,428.73	
D7858	$12,622.01	
D7860	$5,380.40	
D7865	$8,669.11	
D7870	$286.25	
D7871	$572.49	
D7872	$3,058.22	
D7873	$3,681.51	
D7874	$5,281.27	
D7875	$5,785.60	
D7876	$6,237.90	
D7877	$5,505.56	
D7880	$1,734.81	
D7899	BR	
D7910	$247.83	
D7911	$1,019.82	
D7912	$1,836.42	
D7920	$3,008.67	
D7940	$9,006.16	
D7941	$9,006.16	
D7943	$9,379.15	
D7944	$8,363.03	
D7945	$9,280.02	
D7946	$11,467.12	
D7947	$9,660.43	
D7948	$15,043.32	
D7949	$21,163.48	
D7950	BR	
D7951	BR	
D7953	BR	
D7955	BR	
D7960	$343.25	
D7963	BR	
D7970	$510.53	
D7971	$193.31	
D7972	BR	
D7980	$865.20	
D7981	BR	
D7982	$2,329.61	
D7983	$2,223.03	
D7990	$2,039.64	
D7991	$5,048.31	
D7995	BR	
D7996	BR	
D7997	$312.27	
D7998	BR	
D7999	BR	
D8010	BR	
D8020	BR	
D8030	BR	
D8040	BR	
D8050	BR	
D8060	BR	
D8070	BR	
D8080	BR	
D8090	BR	
D8210	BR	
D8220	BR	
D8660	$85.50	
D8670	$411.40	
D8680	$904.59	
D8690	$427.51	
D8691	$224.28	
D8692	$447.33	
D8693	$224.28	
D8999	BR	
D9110	$137.55	
D9120	BR	
D9210	$68.16	
D9211	$55.76	
D9212	$102.84	
D9215	$55.76	
D9220	$456.00	
D9221	$192.07	
D9230	$89.21	
D9241	$359.35	
D9242	$149.94	
D9248	$76.83	
D9310	$240.39	
D9410	$317.23	
D9420	$436.19	
D9430	$80.55	
D9440	$123.92	
D9450	BR	
D9610	BR	
D9612	BR	
D9630	BR	
D9910	$52.04	
D9911	$80.55	
D9920	BR	
D9930	BR	
D9940	$737.30	
D9941	$340.77	
D9942	BR	
D9950	$318.46	
D9951	$247.83	
D9952	$876.08	
D9970	$55.76	
D9971	$78.07	
D9972	$358.12	
D9973	$39.66	
D9974	$304.83	
D9999	BR