Table of Changes
For Effective Date January 1, 2012

Rule 16, Effective 01/01/2012	
Current Rule	New Rule	
16-1      STATEMENT OF PURPOSE
            In an effort to comply with its legislative charge to assure appropriate and timely medical care at a reasonable cost, the Director (Director) of the Division of Workers' Compensation (Division) has promulgated these utilization standards, effective January 1, 2011.  This rule defines the standard terminology, administrative procedures and dispute resolution procedures required to implement the Division's Medical Treatment Guidelines and Medical Fee Schedule.  With respect to any matter arising under the Colorado Workers' Compensation Act and/or the Workers' Compensation Rules of Procedure and to the extent not otherwise precluded by the laws of this state, all providers and payers shall use and comply with the provisions of the "Medical Treatment Guidelines," Rule 17, and the "Medical Fee Schedule," Rule 18, as incorporated and defined in the Workers' Compensation Rules of Procedure, 7 CCR 1101-3.
	16-1      STATEMENT OF PURPOSE
            In an effort to comply with its legislative charge to assure appropriate and timely medical care at a reasonable cost, the Director (Director) of the Division of Workers' Compensation (Division) has promulgated these utilization standards, effective January 1, 2012 2011.  This rule defines the standard terminology, administrative procedures and dispute resolution procedures required to implement the Division's Medical Treatment Guidelines and Medical Fee Schedule.  With respect to any matter arising under the Colorado Workers' Compensation Act and/or the Workers' Compensation Rules of Procedure and to the extent not otherwise precluded by the laws of this state, all providers and payers shall use and comply with the provisions of the "Medical Treatment Guidelines," Rule 17, and the "Medical Fee Schedule," Rule 18, as incorporated and defined in the Workers' Compensation Rules of Procedure, 7 CCR 1101-3.
	
16-2     STANDARD TERMINOLOGY FOR RULES 16 AND 18
 (I) Day – for the purpose of Rule 16, day is defined as a calendar day unless otherwise noted.	16-2     STANDARD TERMINOLOGY FOR RULES 16 AND 18
 (I)  Day – for the purpose of Rule 16, day is defined as a calendar day unless otherwise noted.	
16-2      STANDARD TERMINOLOGY FOR RULES 16 AND 18
(U)     	“Supply et al.” – any single supply, durable medical equipment (DME), orthotic, prosthesis, biologic, or single drug dose, for which the billed amount exceeds $500.00 and all implants.
	16-2      STANDARD TERMINOLOGY FOR RULES 16 AND 18
(U)     	“Supply et al.” – any single supply, durable medical equipment (DME), orthotic, prosthesis, biologic item, or single drug dose, for which the billed amount exceeds $500.00 and all implants.
	
16-5      RECOGNIZED HEALTH CARE PROVIDERS
(A)        Physician and Non-Physician Providers
(1)        For the purpose of this rule, recognized health care providers are divided into the major categories of "physician" and "non-physician".  Recognized providers are defined as follows:
(a)        "Physician providers" are those individuals who are licensed by the State of Colorado through one of the following state boards:
(3)        Colorado Podiatry Board; and
	16-5      RECOGNIZED HEALTH CARE PROVIDERS
(A)        Physician and Non-Physician Providers
(1)        For the purpose of this rule, recognized health care providers are divided into the major categories of "physician" and "non-physician".  Recognized providers are defined as follows:
(a)        "Physician providers" are those individuals who are licensed by the State of Colorado through one of the following state boards:
(3)        Colorado Podiatry Board; or and
	
16-5      RECOGNIZED HEALTH CARE PROVIDERS
(A)        Physician and Non-Physician Providers
(1)        For the purpose of this rule, recognized health care providers are divided into the major categories of "physician" and "non-physician".  Recognized providers are defined as follows:
(b)        "Non-physician providers" are those individuals who are registered or licensed by the State of Colorado Department of Regulatory Agencies, or certified by a national entity recognized by the State of Colorado as follows:
(18)      Respiratory Therapist (RTL) – certified by the National Board of Respiratory Care and licensed by the Colorado Department Of Regulatory Agencies;
	16-5      RECOGNIZED HEALTH CARE PROVIDERS
(A)        Physician and Non-Physician Providers
(1)        For the purpose of this rule, recognized health care providers are divided into the major categories of "physician" and "non-physician".  Recognized providers are defined as follows:
(b)        "Non-physician providers" are those individuals who are registered or licensed by the State of Colorado Department of Regulatory Agencies, or certified by a national entity recognized by the State of Colorado as follows:
(18)      Respiratory Therapist (RTL) – certified by the National Board of Respiratory Care and licensed by the Colorado Department O of Regulatory Agencies;
	
16-6      HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS 
(C)       Payment for billed services not identified or identified but without established value in the fee schedule shall require prior authorization from the payer as set forth in Rule 16-9 Prior Authorization and Rule 16-10 Contest of a Request for Prior Authorization.  Determination of the payment amount shall be made by the payer and reflect the complexity, time, level of training and expertise required to perform the service or procedure, but shall at no time exceed the amount billed.  The methodology for determination of payment used by the payer shall be made available to the provider upon request.  If the payer uses a usual and customary rate data base (UCR), the payer must specify the percentile used, the zip code used and the source of the data base.  Rule 16-11, Payment of Medical Benefits, sets forth the procedures for contesting any portion of a bill.  If there are no reasonable methods to determine a fee, the payer shall pay the billed charges.
	16-6      HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS 
(C)       Payment for billed services not identified or identified but without established value in the fee schedule shall require prior authorization from the payer as set forth in Rule 16-9 Prior Authorization and Rule 16-10 Contest of a Request for Prior Authorization.  The payer and provider shall negotiate a payment amount using a reasonable method that identifies a similar existing code with established RVUs and that justifies the difference in value.
	If no established RVUs are reasonably similar, then the payer and provider may agree to the amount to be paid.
	If no established similar CPT© exists and no agreement between the provider and payer exists, then the payer shall pay the billed amount. 
	Determination of the payment amount shall be made by the payer and reflect the complexity, time, level of training and expertise required to perform the service or procedure, but shall at no time exceed the amount billed.  The methodology for determination of payment used by the payer shall be made available to the provider upon request.  If the payer uses a usual and customary rate data base (UCR), the payer must specify the percentile used, the zip code used and the source of the data base.  Rule 16-11, Payment of Medical Benefits, sets forth the procedures for contesting any portion of a bill.  If there are no reasonable methods to determine a fee, the payer shall pay the billed charges.
	
16-6      HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS 
(D)	Any payer contesting a provider’s treatment shall follow the procedures as outlined under Rule 16-10 Contest of a Request For Prior Authorization or Rule 16-11 Payment of Medical Benefits.
	16-6      HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS 
(D)	Any payer contesting a provider’s treatment shall follow the procedures as outlined under Rule 16-10 Contest of a Request F for Prior Authorization, or Rule 16-11 Payment of Medical Benefits.
	
16-9      PRIOR AUTHORIZATION
(E)       To complete a prior authorization request, the provider shall concurrently explain the medical necessity of the services requested and provide relevant supporting medical documentation.  Supporting medical documentation is defined as documents used in the provider’s decision-making process to substantiate the need for the requested service or procedure.	16-9      PRIOR AUTHORIZATION
(E)       To complete a prior authorization request, the provider shall concurrently explain the medical necessity of the services requested and provide relevant supporting medical documentation.  Supporting medical documentation is defined as documents used in the provider’s decision-making process to substantiate the need for the requested service or procedure and include:
•	An accurate definition or description of the procedure
•	documentation of the relevant diagnostic or surgical indications as listed in the Medical Treatment Guidelines
•	Justification for any variance in an established procedure, when appropriate
•	A listing of any similar procedure and value, and
•	The justification for the difference in the value.
	
16-11    PAYMENT OF MEDICAL BENEFITS
(B)    	Process for Contesting Payment of Billed Services Based on Non-Medical Reasons
(5)        If the payer agrees a service or procedure was reasonable and necessary, the provider’s lack of prior authorization for payment does not warrant denial of liability for payment.
	16-11    PAYMENT OF MEDICAL BENEFITS
(B)    	Process for Contesting Payment of Billed Services Based on Non-Medical Reasons
(5)        If the payer agrees a service or procedure was reasonable and necessary, the provider’s l  Lack of prior authorization for payment does not warrant denial of liability for payment.

Rule 18 Effective 01/01/2012	
Current Rule 18	New Rule 18	
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 2010 edition of the Relative Values for Physicians (RVP©), developed by Relative Value Studies, Inc., published by Ingenix® St. Anthony Publishing, the Current Procedural Terminology CPT®  2010, Professional Edition, published by the American Medical Association (AMA) and Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 28.0 developed and published by 3M Health Information Systems using MS-DRGs effective after October 1, 2010.  The incorporation is limited to the specific editions named and does not include later revisions or additions.  For information about inspecting or obtaining copies of the incorporated materials, contact the Medical Fee Schedule Administrator, 633 17th Street, Suite 400, Denver, Colorado 80202-3626.  These materials may be examined at any state publications depository library.  All guidelines and instructions are adopted as set forth in the RVP©, CPT® and MS-DRGs, unless otherwise specified in this rule.
This rule applies to all services rendered on or after January 1, 2011.  All other bills shall be reimbursed in accordance with the fee schedule in effect at the time service was rendered.
	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 2011 2010 edition of the Relative Values for Physicians (RVP©), developed by Relative Value Studies, Inc., published by Ingenix® St. Anthony Publishing, the Current Procedural Terminology CPT®  2011 2010, Professional Edition, published by the American Medical Association (AMA) and Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 29.0 28.0 developed and published by 3M Health Information Systems using MS-DRGs effective after October 1, 2011 2010.  The incorporation is limited to the specific editions named and does not include later revisions or additions.  For information about inspecting or obtaining copies of the incorporated materials, contact the Medical Fee Schedule Administrator, 633 17th Street,Suite 400, Denver, Colorado 80202-3626.  These materials may be examined at any state publications depository library.  All guidelines and instructions are adopted as set forth in the RVP©, CPT® and MS-DRGs, unless otherwise specified in this rule.
This rule applies to all services rendered on or after January 1, 2012 2011.  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© - Current Procedural Terminology CPT© 2010, copyrighted and distributed by the AMA and incorporated by reference in Rule 18-1.
(C)        MS-DRGs – version 28.0 incorporated by reference in Rule 18-1.
(D)        RVP© – the 2010 edition incorporated by reference in Rule 18-1.	18-2      STANDARD TERMINOLOGY FOR THIS RULE
(A)        CPT© - Current Procedural Terminology CPT© 2011 2010, copyrighted and distributed by the AMA and incorporated by reference in Rule 18-1.
(C)        MS-DRGs – version 29.0 28.0 incorporated by reference in Rule 18-1.
(D)        RVP© – the 2011 2010 edition incorporated by reference in Rule 18-1.	
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 Current Procedural Terminology, 2010 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.  An official copy of the rules is available on the Secretary of State’s webpage.
	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 Current Procedural Terminology, 2011 2010 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.  An official copy of the rules is available on the Secretary of State’s webpage.	
18-4 CONVERSION FACTORS (CF)
RVP© SECTION                                  CF
Anesthesia                           $  50.87/RVU
Surgery                                $ 94.64/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                $  5.90/RVU
(Physical Medicine and Rehabilitation, 
Medical Nutrition Therapy and Acupuncture)
Evaluation & Management(E&M) $9.62/RVU
	18-4  CONVERSION FACTORS (CF)
RVP© SECTION                           CF
Anesthesia                  $ 51.89 50.87/RVU
Surgery                       $ 96.53 94.64/RVU
Surgery X Procedures $ 38.83 38.07/RVU
(See Rule 18-5(D)(1)( d))
Radiology                    $ 17.78 17.43/RVU
Pathology                    $ 13.25 12.99/RVU
Medicine                      $  7.71  7.56/RVU
Physical Medicine        $  6.02  5.90/RVU
(Physical Medicine and Rehabilitation, 
Medical Nutrition Therapy and Acupuncture)
Evaluation & Management (E&M) $9.81  9.62/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® 2010 is adopted for codes, descriptions, parenthetical notes and coding guidelines, unless modified in this rule.	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.  Those codes listed with RVUs of “BR” (by report) and “RNE” (relativity not established) require prior authorization as explained in Rule 16.  The CPT® 2011 2010 is adopted for codes, descriptions, parenthetical notes and coding guidelines, unless modified in this rule.	
18-5 (D)  Surgery/Anesthesia
               (1)  Anesthesia Section:
(d)  Surgery X Procedures 
(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 $38.07 CF.  No additional unit values are added for time when calculating the maximum values for reimbursement. 	18-5 (D) Surgery/Anesthesia
(1)  Anesthesia Section:
(d)  Surgery X Procedures 
(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 $38.83 38.07 CF.  No additional unit values are added for time when calculating the maximum values for reimbursement. 	
18-5 (D) Surgery/Anesthesia 
(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.  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.  
	18-5 (D) Surgery/Anesthesia 
(2) Surgical Section: 
(a) The use of assistant surgeons shall be limited according to the American College Of Surgeons'  Physicians as Assistants at Surgery:  2011 2007 Study (January 2007 2011), available from the American College of Surgeons, Chicago, IL, or from their web page.  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.  	
18-6  (F) Pathology Section: 
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.
	18-6 (F) Pathology Section: 
(1) 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.
(2)	Drug Testing Codes and Values
(a)	G0434 (Drug screen, other than chromatographic; any number of drug classes, by Clinical Laboratory Improvement Amendments [CLIA] waived test or moderate complexity test, per patient encounter) will be used to report very simple testing methods, such as dipsticks, cups, cassettes, and cards, that are interpreted visually, with the assistance of a scanner, or are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code is also used to report any other type of drug screen testing using test(s) that are classified as (CLIA) moderate complexity test(s), keeping the following points in mind: 
G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc. that are not CLIA waived. 
(b) Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver shall bill using the QW modifier. 
Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation do not append the QW modifier to claim lines. 
Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines. 
(c)	G0431 (Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter) will be used to report more complex testing methods, such as multi-channel chemistry analyzers, where a more complex instrumented device is required to perform some or all of the screening tests for the patient. Note that the descriptor has been revised for CY 2011. This code may only be reported if the drug screen test(s) is classified as CLIA high complexity test(s) with the following restrictions: 
G0431 may only be reported when tests are performed using instrumented systems (i.e., durable systems capable of withstanding repeated use). 
CLIA waived tests and comparable non-waived tests may not be reported under test code G0431; they must be reported under test code G0434. 
CLIA moderate complexity tests should be reported under test code G0434 with one (1) Unit of Service (UOS). 
G0431 may only be reported once per patient encounter. 
Laboratories billing G0431 must not append the QW modifier to claim lines. 
Reimbursement:
G0431     $138.28
G0434     $  27.66	
18-5 (G) Medicine Section: 
(6) Psychiatric/Psychological CNS Tests and Assessment Services:
(a) A licensed psychologist (PsyD, PhD, EdD) is reimbursed a maximum of 100% 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.  	18-5 (G) Medicine Section: 
(6) Psychiatric/Psychological CNS Tests and Assessment Services:
(a) A licensed psychologist (PsyD, PhD, EdD) is reimbursed a maximum of 100% 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.  	
New Text	18-5 (G) Medicine Section: 
(9)	Quantitative Autonomic Testing Battery (ATB) and Autonomic Nervous System Testing.
(a)	Quantitative Sudomotor Axon Reflex Test (QSART) is a diagnostic test used to diagnose CRPS.  This test is performed on a minimum of two extremities, and encompasses the following components:
(1)	Resting Sweat Test.
(2)	Stimulated Sweat Test
(3)	Resting Skin Temperature test
(4)	Interpretation of clinical laboratory scores.  Physician must evaluate the patient specific clinical information generated from the test and quantify it into a numerical scale.  The data from the test and a separate report interpreting the results of the test must be documented.
(b)	Maximum fee when all of the services outlined in 18-5(G)(9)(A) are completed and documented.
	QSART Billing Code 
	DoWC Z401	QSART		$1,007.00
Z401 is to be billed once per workers’ compensation claim, regardless of the number limbs tested.
 (10)	Intra-Operative Monitoring (IOM)
IOM is used to identify compromise to the nervous system during certain surgical procedures. Evoked responses are constantly monitored for changes that could imply damage to the nervous system. 
(a)	Clinical Services for IOM: Technical and Professional
(1)	Technical staff:  A qualified specifically trained technician shall setup the monitoring equipment in the operating room and is expected to be in constant attendance in the operating room with the physical or electronic capacity for real-time communication with the supervising neurologist or other physician trained in neurophysiology. The technician shall be specifically trained/registered with:
The American Society of Neurophysiologic Monitoring; or
The American Society of Electro diagnostic Technologists
(2)     Professional /Supervisory /Interpretive
A specifically neurophysiology trained Colorado licensed physician shall monitor the patient’s nervous system through out the surgical procedure. The monitoring physician’s time is billed based upon the actual time the physician devotes to the individual patient, even if the monitoring physician is monitoring more than one patient. The monitoring physician’s time does not have to be continuous for each patient and maybe cumulative. The monitoring physician shall not monitor more than three surgical patients at one time.  The monitoring physician shall provide constant neuromonitoring at critical points during the surgical procedure as indicated by the surgeon or any unanticipated testing responses. There must be a neurophysiology trained Colorado licensed physician backup available to continue monitoring the other two patients if one of the patients being monitored has complications and or requires the monitoring physician’s undivided attention for any reason.   There is no additional payment for the back-up neuromonitoring physician, unless he/she is utilized in a specific case.
(3)	Technical Electronic Capacity for Real-time Communication requirements
The electronic communication equipment shall use a 16-channel monitoring and minimum real-time auditory system, with the possible addition of video connectivity between monitoring staff, operating surgeon and anesthesia. The equipment must also provide for all of the monitoring modalities that may be applied with the IOM procedure code.
(b)  Procedures and time reporting
Physicians shall include an interpretive written report for all primary billed procedures. 
(11)  Central Nervous System Tests and Assessment Services
For CNS Tests and Assessment services, providers shall bill the appropriate code from the RVP©.
All CNS tests and assessments requiring more than six hours require prior authorization.	
18-5 (H) Physical Medicine and Rehabilitation: 
(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 Z505     fixed fee per day                        1.5 RVU
	18-5 (H) Physical Medicine and Rehabilitation: 
(11) Unattended Treatment
When a patient uses a facility or its equipment for but is performing unattended procedures, in either an individual or a group setting, bill:
DoWC Z505     fixed fee per day                        1.5 RVU
	
18-5 (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 for an E&M visit is disability counseling or coordination of care, then time can determine the level of E&M service.  Documented telephonic or on-line communication time with the patient or other healthcare providers one day prior or seven days following the scheduled E&M visit may be included in the calculation of total time.	18-5 (I) Evaluation and Management Section (E&M)
(1) Medical record documentation shall encompass the RVP© “E&M Documentation Guidelines” criteria as adopted in Exhibit #7 to this Rule 18 to justify the billed level of E&M service.  If 50% of the time spent for an E&M visit is disability counseling or coordination of care, then time can determine the level of E&M service.  Documented telephonic or on-line communication time with the patient or other healthcare providers one day prior or seven days following the scheduled E&M visit may be included in the calculation of total time.	
18-6  DIVISION ESTABLISHED CODES AND VALUES 
(F) Permanent Impairment Rating
(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.
	18-6  DIVISION ESTABLISHED CODES AND VALUES 
(F) Permanent Impairment Rating
(4) MMI Determined with a Calculated Permanent Impairment Rating
(a)  Calculated Impairment:  The total fee includes the office visit, a complete physical examination, complete history, review of all medical records except when the amount of medical records is extensive (see below), determining MMI, completing all required measurements, referencing all tables used to determine the rating, using all report forms from the AMA's Guide to the Evaluation of Permanent Impairment, Third Edition (Revised), (AMA Guides), and completing the Division form, titled Physician's Report of Workers’ Compensation Injury (Closing Report) WC164.
Extensive medical records take longer than 1 hour to review and a separate report is created.  The separate report must document each record reviewed, specific details of the record reviewed and the dates represented by the record(s) reviewed.  The separate record review can be billed under special reports for written report only and require prior authorization and agreement from the payer for the separate record review fees.	
(G) Report Preparation
(1) Routine Reports
Completion of routine reports or records are incorporated in all fees for service and include:
	(G) Report Preparation
(1) Routine Reports
Completion of r Routine reports or records are incorporated in all fees for service.  They and include:
	
(H) Supplies, Durable Medical Equipment (DME), Orthotics and Prostheses
(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%.
	(H) Supplies, Durable Medical Equipment (DME), Orthotics and Prostheses
(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%.
	
(I) Inpatient Hospital Facility Fees
(2) Bills for Services 
(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.
	(I) Inpatient Hospital Facility Fees
(2) Bills for Services 
(d) Any inpatient admission requiring the use of both an acute care hospital (admission/discharge) and its Medicare certified rehabilitation facility (admission/discharge) is considered as one admission and MS-DRG.  This does not apply to long term care and licensed rehabilitation facilities.	
(3) Inpatient Facility Reimbursement:  
(b) The following types of inpatient facilities are reimbursed at 80% of billed inpatient charges:
(3) Colorado Department of Public Health and Environment (CDPHE) licensed rehabilitation facility, and,
	(3) Inpatient Facility Reimbursement:  
(b) The following types of inpatient facilities are reimbursed at 80% of billed inpatient charges:
(3) Colorado Department of Public Health and Environment (CDPHE) licensed rehabilitation facility, and,
	
(c) All other inpatient facilities are reimbursed as follows:
(3) For trauma center activation allowance, (revenue codes 680-685) 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:
 (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
(g) To comply with Rule 16-6(B), the payer shall compare each billed charge type:
•	The MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier allowance),          "Supply et al." billed charges to the "Supply et al." allowance [cost + 20%], and	(c) All other inpatient facilities are reimbursed as follows:
(3) For trauma center activation allowance, (revenue codes 680-685) 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:
 (4)  If the “Difference” is greater than $23,375.00 25,800.00, additional reimbursement is warranted.  The additional reimbursement is determined by the following equation: 
“Difference” x .80 = additional fee allowance
(g) To comply with Rule 16-6(B), the payer shall compare each billed charge type:
•	The MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier allowance), and
          "Supply et al." billed charges to the "Supply et al." allowance [cost + 20%], and

(J)   Scheduled Outpatient Surgery Facility Fees
(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 Revised January 2010 Update to reflect Affordable Care Act 05/18/2010- Addendum B [PDF, 961KB]  (Revised Addendum B).

(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 
	(J)   Scheduled Outpatient Surgery Facility Fees
(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) and the Division’s rates for both hospitals and ASCs.  The Division’s hospital rate is listed in Column #4 of Exhibit 4.  The Division’s ASC rate is listed in Column #5 of Exhibit #4.  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 Revised January 2010 Update to reflect Affordable Care Act 05/18/2010- Addendum B [PDF, 961KB]  https://www.cms.gov/HospitalOutpatientPPS/AU/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1243097&intNumPerPage=10  (Revised Addendum B).
The APC Exhibit #4 values  include the following revenue codes, except as allowed by the applicable CPT© code that identifies the APC grouper code and may be aligned on the UB-04 with one of these revenue codes and any “Supply et al.” criteria that is met or agreed to by the parties:

25X-29X and drugs, biologicals and other pharmaceuticals; 
61X-63X pharmaceuticals; medical surgical supplies and
67X Surgical supplies and equipment; surgical dressings, 
splints, casts and other devices used for reduction of fractures or dislocations supplies, intravenous liquids and supplies,  drugs, sterile supplies, except when Medicare allows for a separate payment buy using an appropriate Medicare HCPCS Level II pass- through code
31X Pathology, except for surgical pathology
32X-35X radiology except as allowed by a separate APC value for the given CPT© code
36X-37X	operating room (or) and anesthesia supplies and equipment used for administering and monitoring anesthesia or sedation, except as allowed by a separate APC value for the given CPT© code
46X all pulseox readings and equipment
49X use of ASC for surgical procedures allowed, except as allowed by a separate APC value for the given CPT© code
51X-52X all clinics
71X recovery room (rr)
72X labor and delivery room
73X routine EKG, telemetry
76X all specialty and preventative care services treatment rooms, except observation (761 revenue code), except as allowed by a separate APC value for the given CPT© code.  (See 18-6(3)(c)(1).
(1)  The highest valued APC code per Exhibit 4 plus 50% of any lesser-valued APC code values.
When reported in conjunction with other knee arthroscopy codes, any combination of surgical knee arthroscopies for removal of loose body, foreign body, and/or debridement/shaving of articular cartilage shall be paid only if performed in a different compartment of the knee using G0289; and
(5)   Additional reimbursement is payable for the following services not included in the values found in Exhibit 4 of Rule 18:
•	ambulance services (Revenue Code 540)
•	blood, blood plasma, platelets (Revenue Codes 380X)
•	Physician or physician assistant services
•	Nurse practitioner services 
•	Licensed clinical psychologist
•	Licensed social workers
•	Rehabilitation services (PT, OT, Respiratory or Speech/Language, Revenue Codes 420, 430,440) are paid based upon the RVP unit value multiplied by the applicable conversion factor.
	
(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
(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 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 according to Rule 18-6(H).
	(K)  Outpatient Diagnostic Testing or Treatments Done at a Hospital 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 required billing form, either the UB-04 or CMS 1500 (08-05).
(2)  Reimbursement
(c) All other facilities:
(1) No separate allowance for clinic visit fees unless the facility is considered a rural health clinic as listed in Exhibit #5.  Supplies are reimbursed in accordance with Rule 18-6(H).
(2) The technical facility fee component of an outpatient diagnostic testing done at a free-standing facility or hospital is based upon the appropriate Exhibit #4 Total Hospital APC Outpatient Payment rate listed in Column #4.  The fees listed in Exhibit #4, Column #5, are the maximum facility fees for any diagnostic tests done in an ASC.  The limitations as listed under Rule 18-6(J)(3)(c) are effective for any multiple diagnositc testing performed on the same day unless a Medicare composite dollar value is agreed to in writing by the provider and the payer. 
The billing free-standing facility, hospital or ASC may bill the professional component of the diagnostic testing or treatment and the payer shall pay the billing provider the professional component at the RVP© relative value multiplied by the applicable Rule 18-4 conversion factor.  However, only one professional fee is payable for a single diagnostic test.
The maximum allowance for all diagnostic testing and treatments/services done in a physician’s office shall be based upon the appropriate RVP© unit value multiplied by the applicable Rule 18-4 conversion factor.
At no time shall any provider be paid under the RVP© technical component and Exhibit #4 APC dollar value for the same service.  Nor shall any tests or treatments/services be paid more than once for either the professional or technical components.
Hospitals who perform treatments in their facility may bill for their services and the maximum fee shall be determined by Exhibit #4 listed in Column #4.
ASCs that perform treatment in their facility may bill for their services, and the maximum fee shall be determined by Exhibit #4 in Column #5.
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 according to Rule 18-6(H).
	
(M) Outpatient Emergency Room Department (ERD) Facility Fees
(3) ERD Reimbursement
(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				$    160.00
2				$    360.00
3				$    620.00
4				$    870.00
5				$ 1,640.00
Critical Care			$ 1,640.00
(Only the higher one of any ERD Levels or critical care codes shall be paid)
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 $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
(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.

(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
	(M) Outpatient Emergency Room Department (ERD) Facility Fees
(3) ERD Reimbursement
(d) Total maximum value for an ERD episode of care includes the sum of the following:
(1) All hospital outpatient emergency room facility fees, including the ERD level, are reimbursed based on Exhibit 4 of this Rule 18.  Exhibit 4 lists Medicare’s outpatient hospital ambulatory prospective payment codes (APC) and rates.  The Division’s Outpatient Hospital ERD rate is equal to Medicare’s APC payment rate, as listed in Column #3 in Exhibit #4.  See Medicare’s January 2010 revision of Addendum B to reflect the Affordable Care Act 05/18/2010:    https://www.cms.gov/apps/ama/license.asp?file=/hospitaloutpatientpps/downloads/2010RevisedWebJanuary_AddB_05.17.10.zip https://www.cms.gov/HospitalOutpatientPPS/AU/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1243097&intNumPerPage=10

ERD reimbursement amount for “Level of Care” points:
ERD                                     Reimbursement
Level                                                              
1				$    160.00
2				$    360.00
3				$    620.00
4				$    870.00
5				$ 1,640.00
Critical Care			$ 1,640.00
(Only the higher one of any ERD Levels or critical care codes shall be paid)
and
(2) All diagnostic testing, laboratory services and therapeutic services not included in the hospital’s point system and not included in Exhibit #4 of this Rule 18 (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) All surgical procedures are paid according to Exhibit #4 as indicated in Rule 18-6(J); except the surgical code maximum allowances are using the Outpatient Hospital ERD column #3.  No supply et al. items are separately payable.
(3 4) 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
(4 5)  All “Supply et al.” items are included in the values of the APCs.  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.
(6)      The hospital shall be paid an outlier threshold payment if the hospital’s cost is greater than its maximum fee per billed line by $500.00.  The outlier calculation is as follows:
“Cost” is calculated by taking the individual hospital’s “CCR” rate listed in Exhibit #2 of this Rule 18 and multiplying it by the hospital’s line charge.
“Difference” is equal to the Hospital’s line cost subtracted from the line maximum fee.
If the line “difference” is greater than $500.00, then the maximum outlier dollar is 80% of the difference.  If the difference is equal to or less than $500.00 then no additional outlier dollars are warranted.
 (g) Trauma Center fees are not paid for alerts.  Activation fees are as follows:
Revenue Code 681 Level I              $3,000.00
Revenue Code 682 Level II             $2,500.00
Revenue Code 683 Level III            $1,000.00
Revenue Code 684 Level IV                $00.00
	
(N)  Home Therapy
(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)
DoWC Z771 Certified Nurse Assistant (CNA):
$31.67 per hour for the first hour per trip to injured worker;
$  9.46 for each additional half hour.  Service must be at least 15 minutes to bill an additional half hour charge.
	(N)  Home Therapy
(2)  Nursing Services
(a)	DoWC Z770 Skilled Nursing (LPN & RN)
DoWC Z770	$95.79 per hour 
There is a limit of 2 hours without prior authorization for payment (see Rule 16-9 and 16-10).
(b)	DoWC Z771Certified Nurse Assistant (CNA):
DoWC Z771	$31.67 per hour for the first hour per trip to injured worker;
DoWC Z774	$  9.46 for each additional half hour.  Service must be at least 15 minutes to bill an additional half hour charge.
	
(O) Pharmacy Fees  STRUCK AND REPLACED
(1) AWP (See Rule 18-6(O)(14)) + $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 (See Rule 18-6(O)(14)) for brand name and generic pharmaceuticals may be determined through the use of such monthly publications as Price Alert, First Databank, Inc., Red Book, Medispan.  In case of a dispute on AWP values, the parties should take the average of their referenced published values.
(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).
 (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 if specifically 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 (See Rule 18-6(O)(14)) 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.
(14) If average wholesale price (AWP) ceases, substitute Wholesale Acquisition Cost (WAC) + 20% for AWP everywhere it is found in this rule.	 (O) Drugs and Medications
(1) Drugs (brand name or generic) shall be reported on bills using the applicable identifier from the National Drug Code (NDC) Directory as published by the Food and Drug Administration (FDA) 
(2) Average Wholesale Price (AWP)
(a) AWP for brand name and generic pharmaceuticals may be determined through the use of such monthly publications as Price Alert, Red Book, or Medispan.  In case of a dispute on AWP values, the parties should take the average of their referenced published values.
	(b) If published AWP data becomes unavailable, substitute Wholesale Acquisition Cost (WAC) + 20% for AWP everywhere it is found in this rule.
(3) Reimbursement for Drugs & Medications (Except Compounded Drugs)
(a) For prescriptions written within 30 days from the date of injury, reimbursement shall be AWP + $4.00
(b) For prescriptions written after 30 days from the date of injury, reimbursement shall be AWP + $4.00.  If drugs have been repackaged, use the original AWP and NDC that was the source of the repackaged drugs to determine reimbursement. 
(c) Drugs administered in the course of the provider’s direct care shall be reimbursed at the provider’s actual cost incurred.
(4) Compounded Drugs
All compounds shall be billed using the DoWC Z code corresponding with the applicable category as follows:
Category i     Z790     Fee $ 75.00 per 30 day supply
Any anti-inflammatory medication or any local anesthetic single agent.
Category II     Z791    Fee $150.00 per 30 day supply
Any anti-inflammatory agent or agents in combination with any local anesthetic agent or agents.
Category III    Z792    Fee $250.00 per 30 day supply
Any single agent other than anti-inflammatory agent or local anesthetic, either alone, or in combination with anti-inflammatory or local anesthetic agents.
Category IV     Z793     Fee $350.00 per 30 day supply
Two or more agents that are not anti-inflammatory or local anesthetic agents, either alone or in combination with other anti-inflammatory or local anesthetic agents.
All ingredient materials must be listed by quantity used.  category fees include materials, shipping and handling and time.  Regardless of how many ingredients or what type, compounded drugs cannot be reimbursed higher than the Category IV fee.
 (5) Injured Worker Reimbursement
In the event the injured worker has directly paid for authorized prescriptions, the payer shall reimburse the injured worker for the amounts actually paid within thirty (30) days after receipt the injured worker’s receipt.  See Rule 16-11(G).
(6) Dietary Supplements, Vitamins and Herbal Medicines
Reimbursement for outpatient dietary supplements, vitamins and herbal medicines dispensed in conjunction with acupuncture and complementary alternative medicine are authorized only by prior agreement of the payer, except if specifically provided for in Rule 17.
(7) Prescription Writing
(a) Physicians shall indicate on the prescription form that the medication is related to a workers’ compensation claim.
	(b) All prescriptions shall be filled with bio-equivalent generic drugs unless the physician indicates "Dispense As Written" (DAW) on the prescription
(c) The provider shall prescribe no more than a 60-day supply per prescription
(8) Required Billing Forms
(a) All parties shall use one 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 (see Rule 18-6(H)).
(c) The payer may return any prescription billing form if the information is incomplete.
(d) A signature shall be kept on file indicating that the patient or his/her authorized representative has received the prescription.
(9) A line-by-line itemization of each drug billed and the payment for that drug shall be made on the payment voucher by the payer.

(Q) Acupuncture 
(3) Billing Codes:
(b) Non-Physician evaluation services
(1) New or established patient services are reimbursable only if the medical record specifies the appropriate history, physical examination, treatment plan or evaluation of the treatment plan.  Payers are only required to pay for evaluation services directly performed by an LAc.  All evaluation notes or reports must be written and signed by the LAc.  Without appropriate supporting documentation, the payer may deny payment.  (See Rule 16-11)
(2) LAc new patient visit:		DoWC Z800     
					Maximum value $94.40
(3) LAc established patient visit:	DoWC Z801    
Maximum value $63.72
	(Q) Acupuncture 
(3) Billing Codes:
(b) Non-Physician evaluation services
(1) New or established patient services are reimbursable only if the medical record specifies the appropriate history, physical examination, treatment plan or evaluation of the treatment plan.  Payers are only required to pay for evaluation services directly performed by an LAc.  All evaluation notes or reports must be written and signed by the LAc.  Without appropriate supporting documentation, the payer may deny payment.  (See Rule 16-11)
(2) LAc new patient visit:  DoWC Z800     
		Maximum value $96.32 94.40
(3) LAc established patient visit:	DoWC Z801    
		Maximum value $65.02 63.72
	
Exhibit 1	Exhibit 1 STRUCK AND REPLACED WITH 2011 FIGURES	
Exhibit 2	Exhibit 2 STRUCK AND REPLACED WITH 2011 FIGURES	
Exhibit 3	Exhibit 3 STRUCK AND REPLACED	
Exhibit 4	Exhibit 4 STRUCK AND REPLACED	
Exhibit 5	Exhibit 5 STRUCK AND REPLACED	
Exhibit 6	Exhibit 6 STRUCK AND REPLACED	
	Exhibit 7 NEW (see below)	

NEW
Exhibit 7
(Effective January 1, 2012)
Evaluation and Management (E&M) Guidelines for Colorado
Workers’ Compensation Claims
This E&M Guidelines for Colorado Workers’ Compensation Claims is intended for the physicians who manage injured workers’ medical and non-medical care.  Providers may use the “1997 Documentation Guidelines for Evaluation and Management Services” as developed by Medicare and available on Medicare’s web site when indicated in this exhibit.
1.	History (Hx),  2.  Examination (Exam), and 3.  Medical Decision Making (MDM) Determines the Level of Service:
New Patient/Office Consultations
Level of Service (Requires all three key components at the same level or higher)	1. Hx	2. Exam	3. MDM	Avg. time (minutes)	
99201/99241	Problem Focused (PF)	PF	Straight Forward (SF)	10	
99202/99242	Extended Problem Focused (EPF)	EPF	SF	20	
99203/99243	Detailed (D)	D	Low	30	
99204/99244	Comprehensive(C)	C	Moderate	45	
99205/99245	C	C	High	60	
Established Patient Office Visit
Level of Service (Requires at least two of the three key components at the same level or higher)	1. Hx	2. Exam	3. MDM	Avg. time (minutes)	
99211	N/A	N/A	N/A	5	
99212	PF	PF	SF	10	
99213	EPF	EPF	Low	15	
99214	D	D	Moderate	25	
99215	C	C	High	40	
NOTES:  Documentation of a chief complaint is required for any billed office visit.
CPT© criteria for a consultation is still required to bill a consultation code.
1.  History Component – To qualify for a given level of history all three elements in the table below must be met and documented in the record.  Documentation must be patient specific and pertain directly to the current visit.  Information copied directly from prior records without change is not considered current nor counted.
History Elements	Requirements for a Problem Focused (PF) History Level	Requirements for an Expanded Problem Focused (EPF) History Level	Requirements for a Detailed (D) History Level	Requirements for a Comprehensive (C) History Level	
History of Present Illness/Injury (HPI)	Brief 1-3 elements	Brief 1-3 elements	Extended 4+ elements (required a detailed patient specific description of the patient’s progress with the current TX plan, which should include objective functional gains/losses, ADLs)	Extended 4+ elements (requires a detailed patient specific description of the patient’s progress with the current TX plan, which should include objective functional gains/losses, ADLs)	
Review of Systems (ROS) is not required for established patient visits.	None	Problem pertinent – limited to injured body part	2 to 9 body parts or body systems	Complete 10+	
Past Medical, Family and Social/Work History (PMFSH)	None	None	Pertinent 1 of 4 types of histories	2 or more of the 4 types of histories	
A.	HPI Elements represents the injured worker relaying their condition to the physician and should include the following:
1.	Location (where?)
2.	Quality (sharp, dull)
3.	Severity (pain level 1-10 or pain diagram)
4.	Duration (how long?)
5.	Timing (how often?)
6.	Context (what ADLs or functions aggravates/relieves?)**
7.	Modifying factors (doing what?)
8.	Associated signs (nausea, when?)
For the provider to achieve an “extended” HPI in an established patient/injured worker visit it is necessary to document a detailed description of the patient’s progress since the last visit with current treatment plan that includes patient pertinent objective functional gains, such as ADLs, physical therapy goals and return to work. 
For the provider to achieve an “extended” HPI in an initial patient/injured worker’s visit it is necessary for the provider to discuss the causality of the patient/injured worker’s work related injury(s) to the patient/injured worker’s job duties.
B.	Review of Systems (ROS) each system/body part is counted once whether positive or negative:
1.	Constitutional symptoms (e.g., fever, weight loss)
2.	Eyes
3.	Ears, Nose, Mouth, Throat
4.	Cardiovascular
5.	Respiratory
6.	Gastrointestinal 
7.	Genitourinary
8.	Musculoskeletal
9.	Integumentary (skin and/or breast)
10.	Neurological
11.	Psychiatric
12.	Endocrine
13.	Hematologic/Lymphatic
14.	Allergic/Immunologic
Identify, perform and documentation of all pertinent ROS systems with either a “positive or negative” response is necessary to be counted.
C.	The PMFSH consists of a review of four areas (NOTE:  Employers should not have access to any patient’s or the family’s generic/hereditary diagnoses or testing information, etc.)
1.	Past history – the patient’s past experiences with illnesses, operations, injuries and treatments;
2.	Family history – a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk and any family situations that can interfere with or support the injured worker’s treatment plan and returning to work;
3.	Occupational/Social History – an age appropriate review of past and current work activities, occupational history, current work status, any work situations that support or interfere with return to work.  For established visits specific updates of progress must be discussed.
4.	Non-Occupational/Social History – Hobbies, current recreational physical activities and the patient’s support relationships, etc.  For established visits specific updates of progress must be discussed.
2.	Pertinent Physician’s Examination Component – Each bullet is counted only when it is pertinent and related to the workers’ compensation injury and the medical decision making process.
The 1997 Evaluation and Management (E&M) guidelines may be used for specialist examination.
Content and Documentation Requirements
Level of Examination
Performed and Documented	# of Bullets Required for each Level	
Problem Focused	1 to 5 elements identified by a bullet as indicated in this guideline	
Expanded Problem Focused	6 elements identified by a bullet as indicated in this guideline	
Detailed	7-12 elements identified by a bullet as indicated in this guideline	
Comprehensive	> 13 elements identified by a bullet as indicated in this guideline	
Constitutional Measurement
Vital signs (may be measured and recorded by ancillary staff) – any of three vital signs is counted as one bullet:
1.	sitting or standing blood pressure
2.	supine blood pressure
3.	pulse rate and regularity
4.	respiration
5.	temperature
6.	height
7.	weight or BMI
One bullet for commenting on the general appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
Musculoskeletal
Each of the six body areas with three (3) assessments is counted as one bullet.
1.	head and or neck
2.	spine or ribs and pelvis or all three
3.	right upper extremity (shoulder, elbow, wrist, entire hand)
4.	left upper extremity (shoulder, elbow, wrist, entire hand)
5.	right lower extremity (hip, knee, ankle, entire foot)
6.	left lower extremity (hip, knee, ankle, entire foot)
Assessment of a given body area includes:
1.	Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
2.	Assessment of range of motion with notation of any pain (e.g., straight leg raising), crepitation or contracture
3.	Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
4.	Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (fasciculation, tardive dyskinesia)
7.	Examination of gait and station
Neck – one bullet for both examinations
1.	Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
2.	Examination of thyroid (e.g., enlargement, tenderness, mass)
Neurological
	One bullet for each neurological examination/assessment(s) per extremity:
1.	Test coordination (e.g., finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities
2.	Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (e.g., Babinski)
3.	Examination of sensation (e.g., by touch, pin, vibration, proprioception)
4.	One bullet for all of the 12 cranial nerves assessments with notations of any deficits
Cardiovascular
1.	One bullet per extremity examination/assessment of peripheral vascular system by:
a.	Observation (e.g., swelling, varicosities); and
b.	Palpation (e.g., pulses, temperature, edema, tenderness)
2.	One bullet for palpation of heart (e.g., location, size, thrills)
3.	One bullet for auscultation of heart with notation of abnormal sounds and murmurs
4.	One bullet for examination of each one of the following:
a.	carotid arteries (e.g., pulse amplitude, bruits)
b.	abdominal aorta (e.g., size, bruits)
c.	femoral arteries (e.g., pulse amplitude, bruits)
Skin
One bullet for pertinent body part(s) inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes, lesions, cafeau-lait pots, ulcers)
Respiratory (one bullet for each examination/assessment)
1.	Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
2.	Percussion of chest (e.g., dullness, flatness, hyperresonance)
3.	Palpation of chest (e.g., tactile fremitus)
4.	Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)
Gastrointestinal (one bullet for each examination /assessment)
1.	Examination of abdomen with notation of presence of masses or tenderness and liver and spleen
2.	Examination of presence or absence of hernia
3.	Examination (when indicated0 of anus, perineum and rectum, including sphincter tone, present of hemorrhoids, rectal masses and/or obtain stool sample of occult blood test when indicated
Psychiatric
1.	One bullet for assessment of mood and affect (e.g., depression, anxiety, agitation) if not counted under the Neurological system
2.	One bullet for a mental status examination which includes:
a.	Attention span and concentration; and
b.	Language (e.g., naming objects, repeating phrases, spontaneous speech) orientation to time, place and person; and
c.	Recent and remote memory; and
d.	Fund of knowledge (e.g., awareness of current events, past history, vocabulary)
Eyes (one bullet for both eyes and all three examinations/assessments)
1.	Inspection of conjunctivae and lids; and
2.	Examination of pupils and irises (e.g., reaction of light and accommodation, size and symmetry); and
3.	Opthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)
Ears and Nose, Mouth and Throat
One bullet for all of the following examination/assessment:
1.	External inspection of ears and nose (e.g., overall appearance, scars, lesions, asses)
2.	Otoscopic examination of external auditory canals and tympanic membranes
3.	Assessment of hearing with tuning fork and clinical speech reception thresholds (e.g., whispered voice, finger rub, tuning fork)
One bullet for all of the following examinations/assessments:
1.	Inspection of nasal mucosa, septum and turbinates
2.	Inspection of lips, teeth and gums
3.	Examination of oropharynx:  oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx (e.g., asymmetry, lesions, hydration of mucosal surfaces)
Genitourinary
	MALE – 
	One bullet for each of the following examination of the male genitalia:
1.	The scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass)
2.	Epididymides (e.g., size, symmetry, masses)
3.	Testes (e.g., size symmetry, masses)
4.	Urethral meatus (e.g., size location, lesions, discharge)
5.	Examination of the penis (e.g., lesions, presence of absence of foreskin, foreskin retract ability, plaque, masses, scarring, deformities)
6.	Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness)
7.	Inspection of anus and perineum
	FEMALE –
	One bullet for each of the following female pelvic examination(s) (with or without specimen collection for smears and cultures):
1.	Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele rectocele)
2.	Examination of urethra (e.g., masses, tenderness, scarring)
3.	Examination of bladder (e.g., fullness, masses, tenderness)
4.	Cervix (e.g., general appearance, lesions, discharge)
5.	Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
6.	Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)
Chest (one bullet for both examinations/assessments of both breasts)
1.	Inspection of breasts (e.g., symmetry, nipple discharge); and
2.	Palpation of breasts and axillae (e.g., masses or lumps, tenderness)
Lymphatic palpation of lymph nodes -- two or more areas is counted as one bullet:
1.	Neck
2.	Axillae
3.	Groin
4.	Other
3.	Medical Decision Making (MDM) Component
Documentation must be patient specific and pertain directly to the current visit.  Information copied directly from prior records without change is not considered current nor counted.

Level of Risk	1.  # of Points for the # of Dxs and Management Options)	2.  # of Points for Amount and Complexity of Data)	3.  Level of Risk	
Straightforward	0-1	0-1	Minimal	
Low	2	2	Low	
Moderate	3	3	Moderate	
High	4+	4+	High	
Overall MDM is determined by the highest 2 out of the 3 above categories.

1.  Number of Diagnosis & Management Options	
Category of Problem(s)	Occurrence of Problem(s)		Value		TOTAL	
Self-limited or minor problem	(max 2)	X	1	=		
Established problem, stable or improved		X	1	=		
Established problem, minor worsening		X	2	=		
New problem with no additional workup planned or established patient with worsening of condition and no additional workup planned	(max1)	X	3	=		
New problem, additional workup planned or established patient with worsening of condition and additional workup planned.		X	4	=		

2.  Amount and/or Complexity of Data Reviewed		
Date Type:	Points	
Lab(s) ordered and/or reports reviewed	1	
X-ray(s) ordered and/or reports reviewed	1	
Discussion of test results with performing physician	1	
Decision to obtain old records and/or obtain history from someone other than the patient	1	
Medicine section (90701-99199) ordered and/or physical therapy reports reviewed and commented on progress (state whether the patient is progressing and how they are functionally progressing or not and document any planned changes to the plan of care)	2	
Review and summary of old records and/or discussion with other health provider	2	
Independent visualization of images, tracing or specimen	2	
TOTAL		

3.  Table of Risk (the highest one in any one category determines the overall risk for this portion)	
Level of Risk	Presenting Problem(s)	Diagnostic Procedure(s) Ordered	Management Option(s) Selected	
Minimal	One self-limited or minor problem, e.g., cold, insect bite, tinea corpori, minor non-sutured laceration	Lab tests requiring venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound
KOH prep	Rest
Gargles
Elastic bandages
Superficial dressings	
Low	Two or more self-limited or minor problems
One stable chronic illness, e.g., well-controlled HTN, NIDDM, cataract, BPH
Acute, uncomplicated illness or injury, e.g., allergic rhinitis or simple sprain cyctitis 
Acute laceration repair	Physiologic tests nor under stress, e.g., PFTs
Non-cardiovascular imaging studies w/contrast, e.g., barium enema
Superficial needle biopsies
Lab tests requiring arterial puncture
Skin biopsies	Over-the-counter drugs
Minor surgery w/no identified risk factors
PT/OT
IV fluids w/o additives
Simple or layered closure
Vaccine injection	
Moderate	One or more chronic illnesses with mild exacerbation, progression or side effects of treatment
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis, e.g., new extremity neurologic complaints
Acute illness with systemic symptoms, e.g., pyelonephritis, colitis
Acute complicated injury, e.g., head injury with brief loss of consciousness	Physiologic tests under stress, e.g., cardiac stress test
Diagnostic endoscopies w/ no identified risk factors
Deep needle or incisional biopsies
Cardiovascular imaging studies with contrast and no identified risk factors e.g., arteriogram, cardiac cath
Obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis, culdocentesis	Minor surgery with identified risk factors
Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
Prescription drug management
Therapeutic nuclear medicine IV fluids with additives
Closed Tx of Fx or dislocation w/o manipulation	
High	One or more chronic illness with severe exacerbation, progression or side effects of treatment
Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others;
An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss	Cardiovascular imaging studies with contrast with identified risk factors
Cardiac electrophysiological tests
Diagnostic endoscopies with identified risk factors	Elective major surgery with identified risk factors
Emergency major surgery
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate or to de-escalate care because of poor prognosis,
Potential for significant permanent work restrictions or total disability
Management of addiction behavior or other significant psychiatric condition
Treatment plan for patients with symptoms causing severe functional deficits without supporting physiological \findings or verified related medical diagnosis.	

If greater than fifty percent of a physician’s time at an E&M visit is spent either face-to-face with the patient counseling and/or coordination of care and there is detailed patient specific documentation of the counseling and/or coordination of care, then time can determine the level of service.
The total time spent face-to-face with the patient and/or coordination of care must be documented in the record and the total visit time.
If time is used to establish the level of visit and total amount of time falls in between two levels, then the provider’s time shall be more than half way to reaching the higher level.
Documentation must be patient specific and pertain directly to the current visit.  Information copied directly from prior records without change is not considered current nor counted.
 Counseling:
The physician’s time spent face-to-face with the patient and/or their family counseling him/her or them in one or more of the following:
1.	Injury/disease education that includes discussion of diagnostic tests results and a disease specific treatment plan.
2.	Return to work
3.	Temporary and/or permanent restrictions
4.	Self-management of symptoms while at home and/or work
5.	Correct posture/mechanics to perform work functions
6.	Job task exercises for muscle strengthening and stretching
7.	Appropriate tool and equipment use to prevent re-injury and/or worsening of the existing injury/condition
8.	Patient/injured worker expectations and specific goals
9.	Family and other interpersonal relationships and how they relate to psychological/social issues
10.	Discussion of pharmaceutical management (includes drug dosage, specific drug side effects and potential of addiction /problems
11.	Assessment of vocational plans (i.e., restrictions as they relate to current and future employment job requirements)
Coordination of Care:
Coordination of care requires the physician to either call another health care provider (outside of their own clinic) regarding the patient’s diagnosis and/or treatment or the physician telephones or visits the employer in person to safely return the patient to work.
The counseling or coordination of care activities must be done 24 hours prior to the actual patient encounter or within seven (7) business days after the actual patient encounter.  If these activities are done outside of the 24 hours prior to or 7 business days after the patient encounter, then Rule 18-5(I)(4) “Treating Physician Telephone or On-line Services” or Rule 18-6(A) “Face-to-Face or Telephonic meeting by a Treating Physician with the Employer … With or Without the Injured Workers” is applicable.