Rule 18 Changes Document 2009 to 2010

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 2009 2008 edition of the Relative Values for Physicians (RVP©), developed by Relative Value Studies, Inc., published by Ingenixâ St. Anthony Publishing, the Current Procedural Terminology CPT®  2009 2008, Professional Edition, published by the American Medical Association (AMA) and Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 27.0  26.0 (DRGs Definitions Manual) developed and published by 3M Health Information Systems using MS-DRGs effective after October 1, 2009 October 1, 2008.  The incorporation is limited to the specific editions named and does not include later revisions or additions.  For information about inspecting or obtaining copies of the incorporated materials, contact the Medical Fee Schedule Administrator, 633 17th Street, Suite 400, Denver, Colorado 80202-3626 3660.  These materials may be examined at any state publications depository library.  All guidelines and instructions are adopted as set forth in the RVP©, CPT® and MS-DRGs: Definitions Manual, unless otherwise specified in this rule.
This rule applies to all services rendered on or after January 1, 2010 2009.  All other bills shall be reimbursed in accordance with the fee schedule in effect at the time service was rendered.
18-2      STANDARD TERMINOLOGY FOR THIS RULE
(A)        CPTâ - Current Procedural Terminology CPTâ 2009 2008, copyrighted and distributed by the AMA and incorporated by reference in Rule 18-1.
(B)        DoWC Zxxx – Colorado Division of Workers’ Compensation created codes.
(C)        MS-DRGs Definitions Manual – version 27.0 26.0 incorporated by reference in Rule 18-1.
(D)        RVP© – the 2009 2008 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 Ingenixâ St. Anthony Publishing, the Current Procedural Terminology, 2009 2008 Edition may be purchased from the AMA, 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/NumericalCCRDocList.do?deptID=10&deptName=1100%20Department%20of%20Labor%20and%20Employment&agencyID=135&agencyName=1101%20Division%20of%20Workers'%20Compensation .(Last accessed September 1, 2009) 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                                                        $ 50.87 49.87/RVU
Surgery                                                             $ 94.64 92.79/RVU
Surgery X Procedures                                      $ 38.07/RVU
(see Rule 18-5(D)(1)( d))
Radiology                                                          $ 17.43/RVU
Pathology                                                          $ 12.99 /RVU
Medicine                                                            $  7.56 /RVU
Physical Medicine                                              $  5.73 5.57 /RVU
            Physical Medicine and Rehabilitation, Medical Nutrition Therapy and Acupuncture
Evaluation & Management (E&M)                        $ 9.16 8.81/RVU
18-5      INSTRUCTIONS AND/OR MODIFICATIONS TO THE DOCUMENTS INCORPORATED BY REFERENCE IN RULE 18-1 
(B)        Unless modified herein, the RVP© is adopted for RVUs and reimbursement.  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® 2009 2008 is adopted for codes, descriptions, parenthetical notes and coding guidelines, unless modified in this rule. 
(C)        CPT® Category III 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:
(b)        Anesthesia physical status modifiers and qualifying circumstances add-on codes are reimbursed using the anesthesia CF and unit values found in the RVP©, Anesthesia section’s Guidelines XI “Physical Status Modifiers” and XII, “Qualifying Circumstances.”  (Not under the Medicine section.)
(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 September 1, 2009 September 27, 2008).  The incorporation is limited to the edition named and does not include later revisions or additions.  Copies of the material incorporated by reference may be inspected at any State publications depository library.  For information about inspecting or obtaining copies of the incorporated material, contact the Medical Fee Schedule Administrator, 633 17th Street, Suite 400, Denver, Colorado, 80202-3626 60.  
	Where the publication restricts use of such assistants to "almost never" or a procedure is not referenced in the publication, prior authorization for payment (see Rule 16-9 and 16-10) is required shall be obtained from the payer.
(c)        No payment shall be made for more than one assistant surgeon or minimum assistant surgeon without prior authorization for payment (see Rule 16-9 and 16-10) unless a trauma team was activated due to the emergency nature of the injury(ies).
(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:
¨         If a patient is seen for the first time or an established patient is seen for a new problem and the “decision for surgery” is made the day of the procedure or the day before the procedure is performed, then the surgeon can bill both the procedure code and an E&M code, using a 57 modifier or 25 modifier on the the E&M code.
(E)        Radiology Section: 
(1)        General
(d)	In billing  radiology services, the applicable radiology  procedure code may be billed using the total component or the appropriate modifier to bill either the professional component or the technical component.  If a physician bills the total or professional component, a separate written interpretive report is required.  
If a physician interprets the same radiological image more than once, or if multiple physicians interpret the same radiological image, only one interpretation shall be reimbursed.
The time a physician spends reviewing and/or interpreting an existing radiological image is considered a part of the physician’s evaluation and management service code.
(2)        Thermography
(b)        Indications for diagnostic thermographic evaluation must be one of the following:
 (e)       Prior authorization for payment (see Rule 16-9 and 16-10) 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). Reimbursement for billed pathology procedures includes either a technical and professional component, or a total component.  If an automated clinical lab procedure does not have a separate written interpretive report beyond the computer generated values, the biller may receive the total component value as long as no other provider seeks reimbursement for the professional component. The physician ordering the automated laboratory tests may seek verbal consultation with the pathologist in charge of the laboratory’s policy, procedures and staff qualifications.  The consultation with the ordering physician is not payable unless the ordering physician requested additional medical interpretation and judgment and requested a separate written report.  Upon such a request, the pathologist may bill using the proper CPT® code and values from the RVP©, not DoWC Z755.
(G)        Medicine Section: 
(2)        Anesthesia qualifying circumstance add-on values are reimbursed in accordance with the anesthesia section of Rule 18.
(3)        Biofeedback
Prior authorization for payment (see Rule 16-9 and 16-10) shall be required from the payer for any treatment exceeding the treatment guidelines.  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 or psychologist 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 2008 2009 CPTâ identifies mixed, motor and sensory nerve conduction studies and their appropriate billing.  
(5)        Manipulation -- Chiropractic (DC), Medical (MD) and Osteopathic (DO):
(a)        Prior authorization  for payment (see Rule 16-9 and 16-10) 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 (see Rule 16-9 and 16-10) if treatment exceeds these limitations.
(6)        Psychiatric/Psychological CNS Tests and Assessment Services:
(b)        Most initial evaluations for delayed recovery can be completed in two (2) hours.  Prior authorization for payment (see Rule 16-9 and 16-10) is required any time the following limitations are exceeded on a single day:
Evaluation Procedures                                        limit:  4 hours
Testing Procedures                                            limit:  6 hours
Most initial evaluations for delayed recovery can be completed in two (2) hours.
(c)        Psychotherapy services                          limit:  50 mins per visit
	Prior authorization for payment (see Rule 16-9 and 16-10) is required any time the 50 minutes per visit 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 for payment (see Rule 16-9 and 16-10) from the payer except where specifically addressed in the treatment guidelines.
(H)        Physical Medicine and Rehabilitation: 
Restorative services are an integral part of the healing process for a variety of injured workers.
(1)        Prior authorization for payment (see Rule 16-9 and 16-10) is required for medical nutrition therapy.  See Rule 18-6(O)(10).
(3)        Special Note to All Physical Medicine and Rehabilitation Providers:
Prior authorization for payment (see Rule 16-9 and 16-10) 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 (see Rule 16-9 and 16-10) shall be required for treatment of a condition not covered under the medical treatment guidelines and exceeding sixty (60) calendar days from the initiation of treatment.  
(4)        Interdisciplinary Rehabilitation Programs – (Requires Prior Authorization for Payment (see Rule 16-9 and 16-10)
If the individual interdisciplinary rehabilitation professionals bill separately for their participation in an interdisciplinary rehabilitation program, the applicable CPT® codes shall be used to bill for their services.  Demonstrated participation in an interdisciplinary rehabilitation program allows the use of the frequencies and durations listed in the relevant medical treatment guidelines guildelines recommendations.
(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 (see Rule 16-9 and 16-10) 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) per visit, per discipline, per day.
NOTE:  Instruction and application of a transcutaneous electric nerve stimulation (TENS)TENS unit for the patient's independent use shall be billed using the education code in the Medicine section of the RVP© timed e-stim RVP© code.  Rental or purchase of a TENS unit requires prior authorization for payment (see Rule 16-9 and 16-10). For maximum fee allowance, see Rule 18-6(H).
Dry Needling of Trigger Points DoWC Codes:
Bill only one of the dry needling modality codes.  (s See relevant treatment guidelines for limitations on frequencies. frequency)
(7)        Evaluation Services for Therapists:  Physical Therapy (PT), Occupational Therapy (OT) and Athletic Trainers (ATC) (cf. §12-36-106 C.R.S.) 
(b)        Payers are only required to pay for evaluation services directly performed by a PT, OT, or ATC 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©.
 (8)        Special Tests 
(a)        Billing Restrictions:
(1)        Job Site Evaluations require prior authorization for payment (see Rule 16-9 and 16-10) if exceeding 2 hours. Computer-Enhanced Evaluations, and Work Tolerance Screenings require prior authorization for payment for more than 4 hours or more than 6 tests per claim.  Functional Capacity Evaluations require prior authorization for payment for more than 4 hours or 2 tests per claim.
(12)       Non-Medical Facility
Fees, such as gyms, pools, etc., and training or supervision by non-medical providers require prior authorization for payment (see Rule 16-9 and 16-10) from the payer and a written negotiated fee.
(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 for payment (see Rule 16-9 and 16-10).
(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 for payment (see Rule 16-9 and 16-10).
(d)        For Work Conditioning, Work Hardening, or Work Simulation, the following apply.
(2)	If the frequency and duration is expected to exceed the medical treatment guidelines’ recommendation, prior authorization for payment (see Rule 16-9 and 16-10) is required.
(I)         Evaluation and Management Section (E&M)
(3)        Number of Office Visits
All providers, as defined in Rule 16-5 (A-B), are limited to one office visit per patient, per day, per workers’ compensation claim unless prior authorization for payment (see Rule 16-9 and 16-10) 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.
18-6      DIVISION ESTABLISHED CODES AND VALUES 
(A)       	Face-to-face or telephonic meeting by a treating physician with the employer, claim representatives, or any attorney, and with or without the injured worker.  Claim representatives may include physicians or qualified medical personnel performing payer-initiated medical treatment reviews, but this code does not apply to requests initiated by a provider for prior authorization for payment (see Rule 16-9 and 16-10).
	Before the meeting is separately payable the following must be met:
(2 b)	A report or written record signed by the physician is required and shall include the following:
(b 2)	Purpose of the meeting
(d 4)	Documented time Time documented (both start and end times)
(D)        Deposition and Testimony Fees
(2)        By prior agreement, the provider 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 Provider Physician:
                                                DoWC Z730	                 $325.00 per hour
(3)       Deposition
Payment for a treating or non-treating provider’s physician's testimony at a deposition shall not exceed $325.00 per hour billed in half-hour increments.  Calculation of the provider’s physician's time shall be "portal to portal."
If requested, the provider physician is entitled to a full hour deposit in advance in order to schedule the deposition.
If the provider 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. Bill using code DoWC Z731.
Deposition:                                
Treating or Non-treating  provider physician:
                        DoWC Z734		$325.00 per hr.
                                                Billed in half-hour increments
(4)        Testimony:
Calculation of the provider’s physician's time shall be "portal to portal (includes travel time and mileage in both directions)."
For testifying at a hearing, if requested the provider physician is entitled to a four (4) hour deposit in advance in order to schedule the testimony.
If the provider 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. Bill using code DoWC Z735.
Testimony:                    
Treating or Non-treating  provider physician:
                        DoWC Z738  
                        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 52 55 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.  
(F)        Permanent Impairment Rating
 (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 The authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient should complete 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
(b)        Use the appropriate DoWC RVP© code:
(1)        Fee for the Level II Accredited Authorized Treating Physician Providing Primary Care:
 Bill DoWC Z759 $355.00 Reimbursed for 1.5 hours with a maximum not to exceed $343.59.                                   
(2)        Fee for the Referral, Level II Accredited Authorized Physician:
 Bill DoWC Z760 $575.00  Reimbursed for 2.5 hours with a maximum not to exceed $ 660.75.                                 
(3)        A return visit for a range of motion (ROM) validation shall be reimbursed using the appropriate separate procedure CPT© code in the medicine section of the RVP©.
(G)        Report Preparation
(1)        Routine Reports
Diagnostic testing Testing
Procedure reports Reports
(2)        Completion of the Physician’s Report of Workers’ Compensation Injury (WC164) 
(a)        Initial Report
	The designated or selected authorized treating physician (generally the designated or selected physician)  managing the total workers’ compensation claim of the patient for this workers’ compensation injury completes the initial WC 164 and submits it to the payer and to the injured worker after the first visit with the injured worker.  When applicable, the emergency room or urgent care authorized treating physician for this workers’ compensation injury may also create a WC 164 initial report.  Unless requested or prior authorized by the payer in a specific workers’ compensation claim, no other authorized physician should complete and bill for the initial WC 164 form. This form shall include completion of items 1-7 and 10.  Note that certain information in Item 2 (such as Insurer Claim #) may be omitted if not known by the provider.
(b)        Closing Report
	The WC164 closing report is required from the authorized treating physician (generally the designated or selected physician)  managing the total workers’ compensation claim of the patient when the an injured worker is at maximum medical improvement for all injuries or diseases covered under this workers’ compensation claim, 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 (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is Level II Accredited, or
(2)        The name of the Level II Accredited physician requested designated to perform the permanent impairment rating when a rating is necessary and the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is not determining the permanent impairment rating.
(c)        Payer Requested WC164 Report 
	If the payer requests a 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 a 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.
(3)	Request for physicians to complete additional forms sent to them by a payer or employer shall be paid by the requesting party.  A form requiring 15 minutes or less of a physician’s time shall be billed pursuant to a & b A & B below.  Forms requiring more than 15 minutes shall be paid as a special report.
(4)        Special Reports
Description:  The term special reports includes reports not otherwise addressed under Rule 16, Utilization Standards, Rule 17, Medical Treatment Guidelines and Rule 18, including any form, questionnaire or letter with variable content.  This includes, but is not limited to, independent medical evaluations 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.  Special reports also include payment for meeting, reviewing another’s written record, and amending or signing that record (see Rule 18-5(I)(7)).  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.
Cancellation:
Written Reports Only:  In cases of cancellation for those special reports not requiring a scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation up to the date of cancellation.  Bill cancellation using code DoWC Z 761.
IME/report with patient exam:  In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation at least seven (7) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and shall refund to the party requesting the special report any portion of an advance payment in excess of time actually spent preparing.  . Bill cancellation using code DoWC Z762.
In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation at least  five (5) business days but less than seven (7) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and one-half the time scheduled for the patient exam.  Any portion of a deposit in excess of this amount shall be refunded.  Bill cancellation using code DoWC Z763.
In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation less than five (5) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and has scheduled for the patient exam. Bill cancellation  using code DoWC Z764.
Billing Codes:  Billed in half hour increments
	Written Report Only 		DoWC Code:	Z755
	IME/Report with patient exam	DoWC Code:	Z756
	Lengthy Form Completion	DoWC Code:	Z757

18-5(I)(7) Face-to-face/telephonic meeting and report with
Non-treating Physician		DoWC Code:	Z758
Special Report Maximum Fees: 	$325.00 per hour.
	Billed in half hour increments.
CRS 8-43-404 IME Audio Recording	DoWC Code:	Z766
					$30.00 per exam

CRS 8-43-404 IME Audio copying fee	DoWC Code:	Z767
					$20.00 per copy

(5) 	Chronic Opioid Management Report 
(a)	When the authorized treating physician prescribes long-term opioid treatment, s/he shall use the Division of Workers’ Compensation Chronic Pain Disorder Medical Treatment Guidelines and also review  the Colorado State Board of Medical Examiners’  Policy # 10-14, “Guidelines for the Use of Controlled Substances for the Treatment of Pain.”  Urine Drug Tests for chronic opioid management shall employ testing methodologies that meet or exceed industry standards for sensitivity, specificity and accuracy.  The test methodology must be capable of identifying and quantifying the parent compound and relevant metabolites of the opioid prescribed.  In-office screening tests designed to screen for drugs of abuse are not appropriate for chronic opioid compliance monitoring.  
(1)	Drug testing shall be done prior to the initial long-term drug prescription being implemented and randomly repeated at least annually.
(2)	When drug screen tests are ordered, the authorized treating physician shall utilize the Colorado Prescription Drug Monitoring (PDMP) program.
(3)	While the injured worker is receiving chronic opioid management, additional drug screens with documented justification may be conducted.  Examples of documented justification include the following:
(i)	Concern regarding the functional status of the patient
(ii)	Abnormal results on previous testing
(iii)	Change in management of dosage or pain
(iv) chronic daily opioid dosage above 150 mg of morphine or equivalent
(4)	The opioids prescribed for long-term treatment shall be provided through a pharmacy.
 (5)	The prescribing authorized treating physician shall review  and integrate the screening results, PDMP, and the injured worker’s past and current functional status on the prescribed levels of medications.  A written report will document the treating physician’s assessment of the patient’s past and current functional status of work, leisure activities and activities of daily living competencies.
(b)	Codes and maximum fees for the authorized treating physician for a written report with all the following review services completed and documented:
(1)	ordering and reviewing drug tests
(2)	ordering and reviewing PDMP results
(3)	Reviewing the medical records,
(4)	Reviewing the injured workers’ current functional status
(5)	determining what actions, if any, need to be taken.
	Bill using code DoWC Z765	$75.00 per 15 minutes
	 – maximum of 30 minutes per report
(H)       Supplies, Durable Medical Equipment (DME), Orthotics and Prostheses 
(1)        Unless otherwise indicated in this rule, minimum payment for supplies shall reflect the provider’s actual cost with plus a 20% markup and.  Cost includes shipping and handling charges.
(2)	Providers may bill supplies, including “Supply et al.,” orthotics, prostheses, DMEs or drugs, including injectables, using Medicare’s HCPCS Level II codes at the Colorado rate.  The billing provider is responsible for identifying their cost for the items they wish to be paid at their cost plus 20% instead of Medicare’s Colorado HCPCS Level II maximum fee.  This may be done using an advance agreement between the payer and provider or may be done by furnishing an invoice or their supplier’s published rate with their bill.
(3)	Payers may pay using Medicare’s Colorado HCPCS Level II maximum fee values for the codes billed unless the provider has indicated that the item(s) is to be paid at cost plus 20%.  The payer may request an invoice or published rate for any items to be paid at cost plus 20%.
(4)	If the provider failed to indicate that an item was to be paid at cost plus 20%, and their cost plus 20% is more than the Medicare Colorado HCPCS Level II value, the provider may submit cost information within 60 days following receipt of the Explanation of Benefits (EOB) and is entitled to at least their cost plus 20%.
(I)         Inpatient Hospital Facility Fees
(1)        Provider Restrictions
All non-emergency, inpatient admissions require prior authorization for payment (see Rule 16-9 and 16-10).
(3)        Inpatient Facility Reimbursement:  
(c)        All other inpatient facilities are reimbursed as follows:
(1)        (MS-DRG Relative Wt x Specific hospital base rate x 160% 175%) + (reimbursement for all “Supply et al.”) + (trauma center activation allowance)
(J)         Scheduled Outpatient Surgery Facility Fees
(1)        Provider Restrictions
(a)        All non-emergency outpatient surgeries require prior authorization for payment (see Rule 16-9 and 16-10) from the payer.
(3)        Outpatient Surgery Facility Reimbursement
(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 Addendum B.
	The surgical procedure codes are classified by APC code in Medicare’s April 2009 2008 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.
·         nursing services, including but not limited to,  IV insertion or other injections, drug administration, pulse ox, EKG ekg,
	The April 2009 2008 Addendum B can be accessed at Medicare’s Hospital Outpatient PPS website.  
(1)        The highest valued APC code per Exhibit 4 plus 50% of any lesser-valued APC code values.
The surgery discogram procedure (APC 388) value is for all each levels and includes conscious sedation and the technical component of the radiological procedure.
(3)        Diagnostic testing and preoperative labs may be are reimbursed by applying the appropriate CF to the unit values for the specific CPT® code as listed in the RVP.
However, diagnostic testing and preoperative labs shall be reimbursed according to Exhibit #4 when it lists a dollar value greater than zero.  Other services with non-zero Exhibit #4 values, such as cardiac and dialysis procedures, shall also be reimbursed according to Exhibit #4.  Use Medicare’s addendum B to link Exhibit #4 APC Grouper numbers to CPT® codes. http://www.cms.hhs.gov/apps/ama/license.asp?file=/hospitaloutpatientpps/downloads/2009_April_Addendum_B_040109.zip (last accessed September 1, 2009. [April 2009 APC list)
CPT® RVP© radiological procedure codes (not the injection codes) with an appropriate modifier are to be used for all venograms, arthrograms and myelograms; and 
(4)        Observation room maximum allowance is limited to 6 hours without prior authorization for payment (see Rule 16-9 and 16-10).  Documentation should support the medical necessity for observation or convalescent care.  Observation time begins when the patient is placed in a bed for the purpose of initiating observation care in accordance with the physician’s order.  Observation or daily outpatient convalescence time ends when the patient is actually discharged from the hospital or ASC or admitted into a licensed facility for an inpatient stay.  Observation time would not include the time patients remain in the observation area after treatment is finished for reasons such as waiting for transportation home.  Hospital or convalescence licensure is required for billing observation or convalescence time beyond 23 hours.
(5)        Additional reimbursement is payable for the following services not included in the values found in Exhibit 4 of Rule 18:
(d)        In rare cases, a reasonable facility fee may be paid when an outpatient surgical procedure poses a significant risk to the injured worker if performed in a lesser facility, even if the procedure:
	Once the risk to the injured worker has been provided in writing and the payer has agreed or it is ordered that this procedure may occur in the facility, a reasonable dollar value shall be determined by using a similar procedure code (if the exact code cannot be used) that can be assigned under Exhibit 4 or under Medicare’s Addendum B.  If a value does not exist in Exhibit 4, then the APC dollar value from Medicare’s Addendum B is multiplied by 158% 170%.   The services normally included in Exhibit 4 values shall be included in this reimbursement value, and the services allowed as additional reimbursement under Rule 18-6 (J)(3)(c)(2)-(5) would be allowed.
(g)         In compliance with r 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
(2)        Reimbursement
(c)        All other facilities:
(2)        No separate facility fee allowance for diagnostic testing.  Facility fees for diagnostic testing are considered part of the procedure’s technical component value except when there is a non-zero value listed in Exhibit 4 for the diagnostic test.  Outpatient diagnostic testing is reimbursed using the RVP© code unit value, except when there is a non-zero value listed in Exhibit 4, in which case that value is used.  Dyes and contrasts may be reimbursed at 80% of billed charges.
(L)        Outpatient Urgent Care Facility Fees
(3)        Urgent Care Reimbursement
(d)        The Observation Room allowance shall not exceed a rate of $45.00 per hour and is limited to a maximum of 3 hours without prior authorization for payment (see Rule 16-9 and 16-10).
(M)       Outpatient Emergency Room Department (ERD) Facility Fees
(3)        ERD Reimbursement
(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 CPT® E&M definitions and internal level of care guidelines developed by the hospital in compliance with Medicare regulations.  The hospital’s guidelines should establish an appropriate graduation of hospital resources (ERD staff and other resources) as the level of service increases. 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 level of care guidelines 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			$	200.00 240.00 
2			$350.00 390.00
3			$550.00 590.00
4			$800.00 840.00
5 			$1,500.00 1,540.00 
Critical Care			$1,500.00 1,540.00
(3)        The observation room allowance shall not exceed a rate of $45.00 per hour and is limited to a maximum of 3 hours without prior authorization for payment (see Rule 16-9 and 16-10).  The documentation should support the medical necessity for observation; and
(g)        Trauma Center fees are not paid for alerts.  Activation fees are as follows:
(3)	The level of trauma activation shall be determined by CDPHE’s assigned hospital trauma level designation.
(N)        Home Therapy
Prior authorization for payment (see Rule 16-9 and 16-10) is required for all home therapy.  The payer and the home health entity should agree in writing on the type of care, skill level of provider, frequency of care and duration of care at each visit, and any financial arrangements to prevent disputes. 
(2)        Nursing Services
DoWC Z770     Skilled Nursing (LPN & RN)
$95.79 per hour 
There is a limit of 2 hours without prior authorization for payment (see Rule 16-9 and 16-10).
(4)        Mileage 
Travel allowances should be agreed upon with the payer and the mileage rate should not exceed $0.52 0.55 per mile, portal to portal.
DoWC code:      Z772  
(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 for payment (see Rule 16-9 and 16-10) and shall not exceed $30.00 per hour.
DoWC code:      Z773 
(O)        Pharmacy Fees
(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 Z790       Materials, mailing, handling
DoWC Z791       Pharmacist			$50.00/hr
(9)        Injured Worker Reimbursement
In the event the injured worker has directly paid for authorized prescriptions, the payer shall reimburse the injured worker for the amounts actually paid within thirty (30) days after receipt of the bill.  See Rule 16-11(G).  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).
(P)        Complementary Alternative Medicine (CAM) (Requires prior authorization for payment (see Rule 16-9 and 16-10)
(Q)        Acupuncture 
(2)        Billing Restrictions
(a).       For treatments frequencies exceeding the maximum allowed in Rule 17 Medical Treatment Guidelines of more than fourteen (14) sessions, the provider must obtain prior authorization for payment (see Rule 16-9 and 16-10) from the payer.
(b)        Unless the provider’s medical records reflect medical necessity and the provider obtains prior authorization for payment (see Rule 16-9 and 16-10) 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
(b)        Non-Physician evaluation services
(2)        LAc new patient visit:
            DoWC Z800     Maximum value $91.68 89.12 
(3)        LAc established patient visit:
            DoWC Z801     Maximum value $61.88 60.16 
(c)        Herbs require prior authorization for payment (see Rule 16-9 and 16-10) and fee agreements as in this Rule 18-6(O)(10);
(R)	Use of an Interpreter
	Rates and terms shall be negotiated.  Prior authorization for payment (see Rule 16-9 and 16-10) is required except for emergency treatment.  Use DoWC Z722 to bill.
18-7      DENTAL FEE SCHEDULE
The dental schedule is adopted using the American Dental Association’s Current Dental Terminology, 2009-2010 2007-2008 (CDT-2009-2010 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-2009-2010 2007/2008 dental codes.

EXHIBITS 1 THROUGH 6 DELETED AND REPLACED