DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 ccr 1101-3
WORKERS’ COMPENSATION RULES OF PROCEDURE
Rule 16           UTILIZATION STANDARDS
 
16-1      STATEMENT OF PURPOSE
            In an effort to comply with its legislative charge to assure appropriate and timely medical care at a reasonable cost, the Director (Director) of the Division of Workers' Compensation (Division) has promulgated these utilization standards, effective January 1, 2011 2010.  This rule defines the standard terminology, administrative procedures and dispute resolution procedures required to implement the Division's Medical Treatment Guidelines and Medical Fee Schedule.  With respect to any matter arising under the Colorado Workers' Compensation Act and/or the Workers' Compensation Rules of Procedure and to the extent not otherwise precluded by the laws of this state, all providers and payers shall use and comply with the provisions of the "Medical Treatment Guidelines," Rule 17, and the "Medical Fee Schedule," Rule 18, as incorporated and defined in the Workers' Compensation Rules of Procedure, 7 CCR 1101-3.
16-2      STANDARD TERMINOLOGY FOR RULES 16 AND 18
(A)        Ambulatory Surgical Center (ASC) – licensed as an ambulatory surgery center by the Colorado Department of Public Health and Environment.
(B)        Authorized Treating Provider (ATP) – may be any of the following:
(1)        The treating physician designated by the employer and selected by the injured worker;
(2)        A health care provider to whom an authorized treating physician refers the injured worker for treatment, consultation, or impairment rating;
(3)        A health care provider selected by the injured worker when the injured worker has the right to select a provider;
(4)        A health care provider authorized by the employer when the employer has the right or obligation to make such an authorization;
(5)        A health care provider determined by the director or an administrative law judge to be an ATP;
(6)        A provider who is designated by the agreement of the injured worker and the payer.
(C)        Billed Service(s) – any billed service, procedure, equipment or supply provided to an injured worker by a provider.
(D)        Billing Party – a service provider or an injured worker who has incurred authorized medical costs.
(E)        Certificate of Mailing – a signed and dated statement containing the names and mailing addresses of all persons receiving copies of attached or referenced document(s), certifying the documents were placed in the U.S. Mail, postage pre-paid, to those persons.
(F)        Children’s Hospital – as identified and Medicare certified by the Colorado Department of Public Health and Environment.
(G)        Convalescent Center – as licensed by the Colorado Department of Public Health and Environment.
(H)        Critical Access Hospital (CAH) – as identified and Medicare certified by the Colorado Department of Public Health and Environment.
(I)         Day – for the purpose of Rule 16, day is defined as a calendar day unless otherwise noted.
(J)         Hospital – as identified and licensed by the Colorado Department of Public Health and Environment.
(K)        Long-Term Care Facility – as identified and Medicare certified by the Colorado Department of Public Health and Environment
(L)        Medical Fee Schedule – Division's Rule 18, its Exhibits,  and the documents incorporated by reference in that rule.
(M)       Medical Treatment Guidelines – the medical treatment guidelines as incorporated into Rule 17, "Medical Treatment Guidelines."
(N)        Payer – an insurer, employer, or their designated agent(s) who is responsible for payment of medical expenses.
(O)        Private Psychiatric Facilities – Licensed as a psychiatric hospital by the Colorado Department of Public Health and Environment.
(P)        Provider – a person or entity providing authorized health care service, whether involving treatment or not,  to a worker in connection with work-related injury or occupational disease.
(Q)       Rehabilitation Facilities – licensed as a rehabilitation hospital by the Colorado Department of Public Health and Environment.
(R)       Rural Health Facility – as identified and Medicare certified by the Colorado Department of Public Health and Environment.
(S)	Skilled Nursing Facility (SNF) – licensed as a skilled nursing facility by the Colorado Department of Public Health and Environment
(T)     	State Psychiatric Hospitals and State Mental Health Institutions – licensed as a psychiatric facility and operated by the state.
(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.
(V)      Veterans’ Administration Medical Facilities – all medical facilities overseen by the Federal Veterans’ Administration.
16-3      REQUIRED USE OF THE MEDICAL TREATMENT GUIDELINES AND PAYMENT FOR SERVICE
            When an injury or occupational disease falls within the purview of Rule 17 "Medical Treatment Guidelines" and the date of injury occurs on or after July 1, 1991, providers and payers shall use the medical treatment guidelines, in effect at the time of service, to prepare or review their treatment plan(s) for the injured worker.  A payer may not dictate the type or duration of medical treatment.  Nor may a payer rely solely on  its own internal guidelines or other standards for medical determination.  When treatment exceeds or is outside of the Medical Treatment Guidelines, prior authorization is required.  In all instances of contest appropriate processes to deny are required.  Refer to applicable sections of Rule 16-9, 16-10 and/or 16-11.
16-4      REQUIRED USE OF THE MEDICAL FEE SCHEDULE
(A)	When services provided to an injured worker fall within the purview of the medical fee schedule, all payers shall use the fee schedule to determine maximum allowable fees.
(B)	All providers are required to report services in accordance with codes and standards in Rule 18 Medical Fee Schedule that accurately represent the services provided.  The medical fee schedule sets the maximum allowable payment but the fee schedule does not limit the billing charges.
(C)	The provider may be subject to penalties under the Workers’ Compensation Act for inaccurate billing when the provider knew or should have known that the services billed were inaccurate, as determined by the Director or an administrative law judge..
16-5      RECOGNIZED HEALTH CARE PROVIDERS
(A)        Physician and Non-Physician Providers
(1)        For the purpose of this rule, recognized health care providers are divided into the major categories of "physician" and "non-physician".  Recognized providers are defined as follows:
(a)        "Physician providers" are those individuals who are licensed by the State of Colorado through one of the following state boards:
(1)        Colorado State Board of Medical Examiners;
(2)        Colorado State Board of Chiropractic Examiners;
(3)        Colorado Podiatry Board; and
(4)        Colorado State Board of Dental Examiners.
(b)        "Non-physician providers" are those individuals who are registered or licensed by the State of Colorado Department of Regulatory Agencies, or certified by a national entity recognized by the State of Colorado as follows:
(1)        Acupuncturist (LAc) – licensed by the Office of Acupuncturist Registration, Colorado Department of Regulatory Agencies;
(2)        Advanced Practice Nurse – licensed by the Colorado State Board of Nursing; Advanced Practice Nurse Registry;
(3)	Athletic Trainers (ATC) – certified by the Board of Certification, Inc. (BOC);
(4)	Audiologist (AU.D., CCC-A) – certified by the American Speech Language-Hearing Speech/Language and Hearing Association or board certified in audiology from the American Board of Audiology;
(5)        Clinical Social Worker (LCSW) – licensed by the Colorado State Board of Social Work Examiners;
(6)        Marriage and Family Therapist (LMFT) – licensed by the Colorado State Board of Marriage and Family Therapist Examiners;
(7)	Massage Therapist (RMT) – registered as a massage therapist by the Colorado Department of Regulatory Agencies;
(8)        Occupational Therapist (OTR) – registered by the Colorado Department of Regulatory Agencies  as an occupational therapist certified by the  National Board for Certification of Occupational Therapy;
(9)        Optometrist (OD) – licensed by the Colorado State Board of Optometric Examiners;
(10)      Orthopedic Technologist (OTC) – certified by the Board for Certification of Orthopedic Technologists, National Association of Orthopedic Technologists;
(11)	Pharmacist – licensed by the Colorado State Board of Pharmacy;
(12)      Physical Therapist (LPT) – licensed by the Colorado State Board of Physical Therapy;
(13)      Physician Assistant (PA) – licensed by the Colorado State Board of Medical Examiners;
(14)       Practical Nurse (LPN) – licensed by the Colorado State Board of Nursing;
(15)      Professional Counselor (LPC) – licensed by the Colorado State Board of Professional Counselor Examiners;
(16)      Psychologist (PsyD, PhD, EdD) – licensed by the Colorado State Board of Psychologist Examiners;
(17)      Registered Nurse (RN) – licensed by the Colorado State Board of Nursing;
(18)      Respiratory Therapist (RTL) – certified by the National Board of Respiratory Care and licensed by the Colorado Department Of Regulatory Agencies;
(19)       Speech Language Pathologist (CCC-SLP) – certified by the American Speech Language-Hearing and Hearing Association; and
(20)       Surgical Technologist (CST) – certified under direction of the Association of Surgical Technologists.
(2)        Upon request, health care providers must provide copies of license, registration, certification or evidence of health care training for billed services.
(3)	Any provider not listed in Rule 16-5(A)(1)(a) or (b) must comply with Rule 16-9, Prior Authorization when providing all services.
(4)	Referrals:
(a)	A payer or employer shall not redirect or alter the scope of an authorized treating provider’s referral to another provider for treatment or evaluation of a compensable injury.  Any party who has concerns regarding a referral or its scope shall advise the other parties and providers involved. 
(b)	All non-physician providers must have a referral from an authorized treating physician.  An authorized physician making the referral to any listed or unlisted non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care.
(c)	Any listed or non-listed non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care with the referring authorized treating physician.
(5)        Rule 18 Medical Fee Schedule applies to authorized services provided in relation to a specific workers’ compensation case.
 (B)        Out-of-State Provider
(1)        Injured Worker Relocated
(a)        Upon receipt of the "Employer's First Report of Injury" or the "Worker's Claim for Compensation” form, the payer shall notify the injured worker that the procedures for change-of-provider, should s/he relocate out-of-state, can be obtained from the payer.
(b)        A change of provider must be made:
(1)        Through referral by the injured worker's authorized provider; or
(2)        In accordance with § 8-43-404 (5)(a), C.R.S.
(2)        Injured Worker Referred
In the event an injured worker has not relocated out-of-state but is referred to an out-of-state provider for treatment or services not available within Colorado, the referring provider shall obtain prior authorization from the payer as set forth in Rule 16-9, Prior Authorization, and 16-10, Contest of a Request for Prior Authorization.  The referring provider's written request for out-of-state treatment shall include the following information:
(a)        Medical justification prepared by the referring provider;
(b)        Written explanation as to why the requested treatment/services cannot be obtained within Colorado;
(c)        Name, complete mailing address and telephone number of the out-of-state provider;
(d)        Description of the treatment/services requested, including the estimated length of time and frequency of the treatment/service, and all associated medical expenses; and
(e)        Out-of-state provider’s qualifications to provide the requested treatment or services.
(3)        The Colorado fee schedule should govern reimbursement for out-of-state providers.
16-6      HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS 
(A)       Use of agents, including but not limited to  PPO networks, bill review companies, third party administrators (TPAs) and case management companies, shall not relieve the employer or insurer from their legal responsibilities for compliance with these rules.  
(B)        Payment for billed services identified in the fee schedule shall not exceed those scheduled rates and fees, or the provider's actual billed charges, whichever is less.
(C)        Payment for billed services not identified or identified but without established value in the fee schedule shall require prior authorization from the payer as set forth in Rule 16-9 Prior Authorization and Rule 16-10 Contest of a Request for Prior Authorization.  Determination of the payment amount shall be made by the payer and reflect the complexity, time, level of training and expertise required to perform the service or procedure, but shall at no time exceed the amount billed.  The methodology for determination of payment used by the payer shall be made available to the provider upon request.  If the payer uses a usual and customary rate data base (UCR), the payer must specify the percentile used, the zip code used and the source of the data base.  Rule 16-11, Payment of Medical Benefits, sets forth the procedures for contesting any portion of a bill.  If there are no reasonable methods to determine a fee, the payer shall pay the billed charges.
(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.
(E)	The payer should note that ICD-9 Supplementary Classification of External Causes of Injury and Poisoning codes (E-codes), when submitted, shall not be used to establish the work relatedness of an injury or treatment.  
16-7      REQUIRED BILLING FORMS AND ACCOMPANYING DOCUMENTATION
(A)        Providers may use electronic reproductions of any required form(s) referenced in this section; however, any such reproduction shall be an exact duplication of such form(s) in content and appearance.  With the agreement of the payer, identifying information may be placed in the margin of the form.
(B)        Required Billing Forms
All health care providers shall use only the following billing forms or electronically produced formats when billing for services:
(1)        CMS (Centers for Medicare & Medicaid Services) 1500 (08-05) - shall be used by all providers billing for professional services, durable medical equipment (DME) and ambulance with the exception of those providers billing for dental services or procedures; hospitals are required to use the CMS 1500 (08-05) when billing for professional services.  Health care providers shall provide their name and credentials in an appropriate box of the CMS 1500 (08-05).
(2)        UB-04 - shall be used by all hospitals, hospital-based ambulance/air services, Children’s Hospitals, CAHs, Veterans’ Administration Facilities, home health and facilities meeting the definitions found in Rule 16-2 when billing for hospital services or any facility fees billed by any other provider, such as ASCs, except for urgent care which may use the CMS 1500 (08-05).
(3)        American Dental Association’s Dental Claim Form, Version 2006 shall be used by all providers billing for dental services or procedures.
(4)        With the agreement of the payer, the ANSI ASC X12 (American National Standards Institute Accredited Standards Committee) or NCPDP (National Council For Prescription Drug Programs) electronic billing transaction containing the same information as in  (1), (2) or (3) in this subsection may be used.
(C)        Required Billing Codes
             All billed services shall be itemized on the appropriate billing form as set forth in Rule 16-7(A) and (B), and shall include applicable billing codes and modifiers from the fee schedule.  Currently nNational provider identification (NPI) numbers are not required for workers’ compensation bills; providers who are not permitted to obtain NPI numbers are exempt from this requirement.  When billing on a CMS 1500 (08-05), the NPI should be that of the rendering professional at the line level whenever possible.
(D)        Inaccurate Billing Forms or Codes
Payment for any services not billed on the forms identified and/or not itemized as instructed in Rule 16-7(B) and (C), may be contested until the provider complies.  However, when payment is contested, the payer shall comply with the applicable provisions set forth in Rule 16-11 Payment of Medical Benefits.
(E)        Accompanying Documentation
(1)        Authorized treating physicians sign (or countersign) and submit to the payer, with their initial and final visit billings, a completed “Physician’s Report of Workers’ Compensation Injury” (Form WC164) specifying:  
(a)        The report type as “initial” when the injured worker has their initial visit with the authorized treating physician managing the total workers’ compensation claim of the patient.  Generally, this will be the designated or selected authorized treating physician.  When 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)        The report type as “closing” when the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient determines the injured worker has reached maximum medical improvement (MMI) for all injuries or diseases covered under this workers’ compensation claim, with or without a permanent impairment.  The form requires the completion of items 1-5, 6.B, C, 7, 8 and 10.  If the injured worker has sustained a permanent impairment, then item 9 must be completed also and the following additional information shall be attached to the bill at the time MMI is determined:
 (1)        All necessary permanent impairment rating reports when the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is Level II Accredited; or
(2)        Referral to a Level II Accredited physician requested 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)     At no charge, the physician shall supply the injured worker with one legible copy of all completed “Physician’s Report of Workers’ Compensation Injury” (WC164) forms at the time the form is completed.
(d)     The provider shall submit to the payer the completed WC164 form as specified in Rule 16-7(E), no later than fourteen (14) days from the date of service.
(2)      Providers, other than hospitals, shall provide the payer with all supporting documentation at the time of submission of the bill unless other agreements have been made between the payer and provider.  This shall include copies of the examination, surgical, and/or treatment records.
(3)      Hospital documentation shall be available to the payer upon request.  Payers shall specify what portion of a hospital record is being requested.  (For example, only the emergency room (ER) chart notes, in-patient physician orders and chart notes, x-rays, pathology reports, etc.)
(4)      In accordance with Rule 16-11, the payer may contest payment for billed services until the provider completes and submits the relevant required accompanying documentation as specified by Rule 16-7(E).
(F)	Providers shall submit their bills for services rendered within one hundred twenty (120) days of the date of service or the bill may be denied unless extenuating circumstances exist.  Extenuating circumstances may include but are not limited to delays in compensability being decided or the provider has not been informed where to send the bill.
16-8      REQUIRED MEDICAL RECORD DOCUMENTATION
(A)        A treating provider shall maintain medical records for each injured worker when the provider intends to bill for the provided services.
(B)        All medical records shall contain legible documentation substantiating the services billed.  The documentation shall itemize each contact with the injured worker and shall detail at least the following information per contact or, at a minimum for cases where contact occurs more than once a week, be summarized once per week:
(1)        Patient's name;
(2)        Date of contact, office visit or treatment;
(3)        Name and professional designation of person providing the billed service;
(4)        Assessment or diagnosis of current condition with appropriate objective findings;
(5)        Treatment status or patient’s functional response to current treatment;
(6)        Treatment plan including specific therapy with time limits and measurable goals and detail of referrals;
(7)        If being completed by an authorized treating physician, all pertinent changes to work and/or activity restrictions which reflect lifting, standing, stooping, kneeling, hot or cold environment, repetitive motion or other appropriate physical considerations; and
(8)        All prior authorization(s) for payment received from the payer (i.e., who approved the prior authorization for payment, services authorized, dollar amount, length of time, etc.).
16-9      PRIOR AUTHORIZATION
(A)        Prior authorization for payment shall be requested by the provider when:
(1)        A prescribed service exceeds the recommended limitations set forth in the medical treatment guidelines;
(2)        The medical treatment guidelines otherwise require prior authorization for that specific service;
(3)        A prescribed service is identified within the medical fee schedule as requiring prior authorization for payment; or
(4)        A prescribed service is not identified in the fee schedule as referenced in Rule 16-6(C).
(B)        All prior authorization for a prescribed service or procedure may be granted immediately and without medical review.  However, the payer shall respond to all providers requesting prior authorization within seven (7) business days from receipt of the provider’s completed request as defined in Rule 16-9(E).  The duty to respond to a provider's written request applies without regard for who transmitted the request.
(C)        The payer, upon receipt of the "Employer's First Report of Injury" or a "Worker's Claim for Compensation,” shall give written notice to the injured worker stating that the requirements for obtaining prior authorization for payment are available from the payer.
(D)        The payer, unless they have previously notified said provider, shall give notice to the provider of these procedures for obtaining prior authorization for payment upon receipt of the initial bill from that provider.  
(E)        To complete a prior authorization request, the provider shall concurrently explain the medical necessity of the services requested and provide relevant supporting medical documentation.  Supporting medical documentation is defined as documents used in the provider’s decision-making process to substantiate the need for the requested service or procedure.
(F)        To contest a request for prior authorization, the payer is required to comply with the provisions outlined in Rule 16-10.
(G)        The Division recommends payers confirm in writing, to providers and all parties, when a request for prior authorization is approved.
(H)        If, after the service was provided, the payer agrees the service provided was reasonable and necessary, lack of prior authorization for payment does not warrant denial of payment.
16-10    CONTEST OF A REQUEST FOR PRIOR AUTHORIZATION
(A)        If the payer contests a request for prior authorization for non-medical reasons as defined under Rule 16-11(B)(1), the payer shall notify the provider and parties, in writing, of the basis for the contest within seven (7) business days from receipt of the provider’s completed request as defined in Rule 16-9(E).  A certificate of mailing of the written contest must be sent to the provider and parties. 
            If an ATP requests prior authorization and indicates in writing,  including their reasoning and relevant documentation, that they believe the requested treatment is related to the admitted workers’ compensation claim, the insurer cannot deny based solely on relatedness without a medical review as under Rule 16-10(B).  
(B)       If the payer is contesting a request for prior authorization for medical reasons, the payer shall, within seven (7) business days of the completed request:
(1)        Have all the submitted documentation under Rule 16-9(E) reviewed by a physician or other health care professional, as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review; and
(2)        After reviewing all the submitted documentation, the reviewing provider may call the requesting provider to expedite communication and processing of prior authorization requests.  However, the written contest or approval still needs to be completed within the specified seven (7) days under Rule 16-10(B).
(3)        Furnish the provider and the parties with either a verbal or written approval, or a written contest that sets forth the following information:
(a)        An explanation of the specific medical reasons for the contest, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;
(b)        The specific cite from the Division’s Medical Treatment Guidelines exhibits to Rule 17, when applicable;
(c)        Identification of the information deemed most likely to influence the reconsideration of the contest when applicable; and
(d)        A certificate of mailing to the provider and parties.
(C)        Prior Authorization Disputes
(1)        The requesting party or provider shall have seven (7) business days from the date of the certificate of mailing on the written contest to provide a written response to the payer, including a certificate of mailing.  The response is not considered a "special report" when prepared by the provider of the requested service.
(2)        The payer shall have seven (7) business days from the date of the certificate of mailing of the response to issue a final decision, including a certificate of mailing to the provider and parties.
(3)        In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
(D)        An urgent need for prior authorization of health care services, as recommended in writing by an authorized treating provider, shall be deemed good cause for an expedited hearing.
(E)        Failure of the payer to timely comply in full with the requirements of Rule 16-10(A) or (B), shall be deemed authorization for payment of the requested treatment unless:
(1)	a hearing is requested within the time prescribed for responding as set forth in Rule 16-10(A) or (B), and
(2)	the requesting provider is notified that the request is being contested and the matter is going to hearing.
(F)        Unreasonable delay or denial of prior authorization, as determined by the Director or an administrative law judge, may subject the payer to penalties under the Workers’ Compensation Act.
16-11    PAYMENT OF MEDICAL BENEFITS
(A)        Payer Requirements for Processing Medical Service Bills
(1)	For every medical service bill submitted by a provider, the payer shall reply with a written notice or explanation of benefits.   In those instances where the payer reimburses the exact billed amount, identification of the patient’s name, the payer, the paid bill, the amount paid and the dates of service are required.  If any adjustments are made then the payer’s written notice shall include: 
	(a)        Name of the injured worker or patient;
(b)        Specific identifying information coordinating the notice with any payment instrument associated with the bill;
(c)	Date(s) of service(s), if date(s) was(were) submitted on the bill;
(d)        Payer’s claim number and/or Division’s workers’ compensation claim number, if one has been created; 
(e)        Reference to the bill and each item of the bill;
(f)         Notice that the billing party may resubmit the bill or corrected bill within sixty (60) days;
(g) 	For compensable services for a work-related injury or occupational disease the payer shall notify the billing provider that the injured worker shall not be balance-billed for services related to the  work-related injury or occupational disease;
(h)	Name of insurer with admitted, ordered or contested liability for the workers’ compensation claim, when known;  
(i)	Nname, address, e-mail (if any), phone number and fax of a person who has responsibility and authority to discuss and resolve disputes on the bill;
(j)	Name and address of the employer, when known;
 (k j)	If applicable, a statement that the payment is being held in abeyance because a relevant issue is being brought to hearing.
(2)        The payer shall send the billing party written notice that complies with 16-11(A)(1) within thirty (30) days of receipt of the bill.  Any notice that fails to include the required information set forth in 16-11(A)(1) is defective and does not satisfy the payer’s 30-day notice requirements set forth in this section.   
(3)	Unless the payer provides timely and proper reasons as set forth by the provisions outlined in 16-11(B) - (D), all bills submitted by a provider are due and payable in accordance with the Medical Fee Schedule within thirty (30) days after receipt of the bill by the payer.  
(4)	If the payer discounts a bill and the provider requests clarification in writing, the payer shall furnish to the requester the specifics of the discount within 30 days including a copy of any contract relied on for the discount.  If no response is forthcoming within 30 days, the payer must pay the maximum fee schedule allowance or the billed charges, whichever is less.
(5)	Date of receipt of the bill may be established by the payer’s date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) business days after the date the bill was mailed to the payer’s correct address.   
(6)	Unreasonable delay in processing payment or denial of payment of medical service bills, as determined by the Director or an administrative law judge, may subject the payer to penalties under the Workers’ Compensation Act.
(7)	If the payer fails to make timely payment of uncontested billed services, the billing party may report the incident to the Division’s Carrier Practices Unit who may use it during an audit.
 (B)    	Process for Contesting Payment of Billed Services Based on Non-Medical Reasons
 (1)       Non-medical reasons are administrative issues.  Examples of non-medical reasons for contesting payment include the following:  no claim has been filed with the payer; compensability has not been established; the billed services are not related to the admitted injury; the provider is not authorized to treat; the insurance coverage is at issue; typographic, gender or date errors are in the bill; failure to submit any medical documentation at all; unrecognized CPT® code.
(2)        If an ATP bills for medical services and indicates in writing, including their reasoning and relevant documentation, that they believe the medical services are related to the admitted WC claim, the payer cannot deny based solely on relatedness without a medical review as under Rule 16-11(C).  
(3)        In all cases where a billed service is contested for non-medical reasons, the payer shall send the billing party written notice of the contest within 30 days of receipt of the bill.  The written notice shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s)  was(were) submitted on the bill;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested; and
(d)        Clear and persuasive reasons for contesting the payment of any item specific to that bill including the citing of appropriate statutes, rules and/or documents supporting the payer’s reasons for contesting payment.
Any notice that fails to include the required information set forth in this section is defective and does not satisfy the notice requirement set forth in this section.  Such defective notice shall not satisfy the payer’s 30 day notice requirement set forth in this section.
(4)        Prior to modifying a billed code, the payer must contact the billing provider and determine if the modified code is accurate.
(a)        If the billing provider agrees with the payer, then the payer shall process the service with the agreed upon code and shall document on their explanation of benefits (EOB) the agreement with the provider.  The EOB shall include the name of the person at the provider’s office who made the agreement.
(b)        If the provider is in disagreement, then the payer shall proceed according to Rule 16-11(B) or 16-11(C), as appropriate.
(5)        If the payer agrees a service or procedure was reasonable and necessary, the provider’s lack of prior authorization for payment does not warrant denial of liability for payment.
(C)     Process for Contesting Payment of Billed Services Based on Medical Reasons
When contesting payment of billed services based on medical reasons, the payer shall:
(1)        Have the bill and all supporting medical documentation under Rule 16-7(E) reviewed by a physician or other health care professional as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  After reviewing the supporting medical documentation, the reviewing provider may call the billing provider to expedite communication and timely processing of the contested or paid medical bill.  
(2)        In all cases where a billed service is contested for medical reasons, the payer shall send the provider and the parties written notice of the contest within thirty (30) days of receipt of the bill.  The written notice shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s) was(were) submitted on the bill;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested;
(d)        An explanation of the clear and persuasive  medical reasons for the decision, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;
(e)        The specific cite from the Division’s Medical Treatment Guidelines exhibits to Rule 17, when applicable; and 
(f)        Identification of the information deemed most likely to influence the reconsideration of the contest, when applicable.
Any notice that fails to include the required information set forth in this section is defective and does not satisfy the notice requirement set forth in this section.  Such defective notice shall not satisfy the payer’s 30-day notice requirement set forth in this section. 
(D)	Process for Ongoing Contest of Billed Services 
(1)        The billing party shall have sixty (60) days to respond to the payer’s written notice under 16-11(A) – (C).  The billing party’s timely response must include:
(a)	A copy of the original or corrected bill;
(b)	A copy of the written notice or EOB received;
(c)	A statement of the specific item(s) contested;
(d)	Clear and persuasive supporting documentation or clear and persuasive reasons for the appeal; and 
(e)	Any available additional information requested in the payer’s written notice.
(2)	If the billing party responds timely and in compliance with Rule 16-11(D)(1), the payer shall:
(a) 	When contesting for medical reasons, have the bill and all supporting medical documentation and reasoning under 16-7(E) and, if applicable, 16-11(D)(1) reviewed by a physician or other health care professional as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  After reviewing the provider’s documentation and response, the reviewing provider may call the billing provider to expedite communication and timely processing of the contested or paid medical bill. 
(b)	When contesting for non-medical reasons, have the bill and all supporting medical documentation and reasoning under 16-7(E) and, if applicable, 16-11(D)(1) reviewed by a person who has knowledge of the bill.  After reviewing the provider’s documentation and response, the reviewing person may call the billing provider to expedite communication and timely processing of the contested or paid medical bill. 
(3)	If before or after conducting a review pursuant to 16-11(D)(2), the payer agrees with the billing party’s response, the billed service is due and payable in accordance with the Medical Fee Schedule within thirty (30) days after receipt of the billing party’s response.  Date of receipt may be established by the payer’s date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) business days after the date the response was mailed to the payer’s correct address.  
(4)        After conducting a review pursuant to 16-11(D)(2), if there is still a dispute regarding the billed services, the payer shall send the billing party written notice of contest within thirty (30) days of receipt of the response.  The written notice shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s) was(were) submitted by the provider;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested;
(d)        An explanation of the clear and persuasive medical or non-medical reasons for the decision, including the name and professional credentials of the person performing the medical or non-medical review and a copy of the medical reviewer's opinion when the contest is over a medical reason; and 
(e)        The explanation shall include the citing of appropriate statutes, rules and/or documents supporting the payer’s reasons for contesting payment.
	Any notice that fails to include the required information set forth in this section is defective and does not satisfy the notice requirement set forth in this section.  Such defective notice shall not satisfy the payer’s 30-day notice requirement set forth in this section.
(5)        In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
(E)        When seeking clarification or dispute resolution from the Division’s Medical Policy Unit (MPU), the requesting party must provide:
(1)        A copy of the bill with the contested codes and dates of services in dispute;
(2)        A copy of the payer’s explanation as to why the billed services are being contested; and
(3)        A copy of any applicable medical record documentation.
The MPU will try to provide a written analysis and opinion to the parties regarding the appropriate application of the Medical Fee Schedule within thirty (30) days of receipt of the complete documentation and the written request for assistance; or as soon thereafter as possible.
(F)	Retroactive review of Medical Bills
(1)        All medical bills paid by a payer shall be considered final at twelve months after the date of the original explanation of benefits unless the provider is notified that:
(a)	a hearing is requested within the twelve month period, or and
(b)	a request for utilization review has been filed pursuant to § 8-43-501.  the requesting provider is notified that the payment is being contested and the matter is going to hearing, or
(2)        If the payer conducts a retroactive review to recover overpayments from a provider based on medical reasons, the payer shall have the bill and all supporting documentation reviewed by a physician or other health care professional as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  The payer shall send the billing party written notice that shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)	Reference to each item of the bill where payer seeks to recover overpayments; and
(b)	Clear and persuasive medical reason(s) for seeking recovery of overpayment(s).  The explanation shall include the citing of appropriate statutes, rules, and/or other documents supporting the payer’s reason for seeking to recover overpayment; and 
(c)	Evidence that these payments were in fact made to the provider.
(3)	If the payer conducts a retroactive review to recover overpayments from a provider based on non-medical reasons, the payer shall send the billing party written notice that shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)	Reference to each item of the bill where payer seeks to recover overpayments; and
(b)	Clear and persuasive reason(s) for seeking recovery of overpayment(s).  The explanation shall include the citing of appropriate statutes, rules, and/or other documents supporting the payer’s reason for seeking to recover overpayment; and 
(c)	Evidence that these payments were in fact made to the provider.
 (4)	In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
(G)        An injured worker shall never be required to directly pay for admitted or ordered medical benefits covered under the Workers’ Compensation Act.  In the event the injured worker has directly paid for medical services that are then admitted or ordered as covered under the Workers’ Compensation Act , the payer shall reimburse the injured worker for the amounts actually paid for authorized services within thirty (30) days after receipt of the bill.  If the actual costs exceed the maximum fee allowed by the medical fee schedule, the payer may seek a refund from the medical provider for the difference between the amount charged to the injured worker and the maximum fee.  Each request for a refund shall indicate the service provided and the date of service(s) involved.
(H)        To the extent not otherwise precluded by the laws of this state, contracts between providers, payers and any agents acting on behalf of providers or payers shall comply with Rule 16-11.  
16-12    ONSITE REVIEW OF HOSPITAL OR OTHER MEDICAL CHARGES
(A)        The payer may conduct a review of billed and non-billed hospital or medical facility charges related to a specific workers’ compensation claim.
(B)        The payer shall comply with the following procedures:
Within thirty (30) days of receipt of the billing, notify the hospital or other medical facility of its intent to conduct a review. Notification shall be in writing and shall set forth the following information:
(1)        Name of the injured worker;
(2)        Claim and/or hospital or other medical facility I.D. number associated with the injured worker's bill;
(3)        An outline of the items to be reviewed; and
(4)        If applicable, the name, address and telephone number of any person who has been designated by the payer to conduct the review (reviewer).
(C)        The hospital or other medical facility shall comply with the following procedures:
(1)        Allow the review to begin within thirty (30) days of the payer's notification;
(2)        Upon receipt of the patient's signed release of information form, allow the reviewer access to all items identified on the injured worker's signed release of information form;
(3)        Designate an individual(s) to serve as the primary liaison(s) between the hospital or other medical facility and the reviewer who will acquaint the reviewer with the documentation and charging practices of the hospital or other medical facility;
(4)        Provide a written response to each of the preliminary review findings within ten (10) business days of receipt of those findings; and
(5)        Participate in the exit conference in an effort to resolve discrepancies.
(D)        The reviewer shall comply with the following procedures:
(1)        Obtain from the injured worker a signed information release form; 
(2)        Negotiate the starting date for the review;
(3)        Assign staff members who are familiar with medical terminology, general hospital or other medical facility charging and medical records documentation procedures or have a level of knowledge equivalent at least to that of an LPN;
(4)        Establish the schedule for the review which shall include, at a minimum, the dates for the delivery of preliminary findings to the hospital or other medical facility, a 10 business day response period for the hospital or other medical facility, and the delivery of an itemized listing of discrepancies at an exit conference upon the completion of the review; and
(5)        Provide the payer and hospital or other medical facility with a written summary of the review within twenty (20) business days of the exit conference.

DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 ccr 1101-3
WORKERS’ COMPENSATION RULES OF PROCEDURE
Rule 18          MEDICAL FEE SCHEDULE
 
18-1      STATEMENT OF PURPOSE
Pursuant to § 8-42-101(3)(a)(I) C.R.S. and Section 8-47-107, C.R.S., the Director promulgates this medical fee schedule to review and establish maximum allowable fees for health care services falling within the purview of the Act.  The Director adopts and hereby incorporates by reference as modified herein the 2010 2009 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®  2010 2009, Professional Edition, published by the American Medical Association (AMA) and Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 28.0 27.0 developed and published by 3M Health Information Systems using MS-DRGs effective after October 1, 2010 2009.  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 2010.  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 2010 2009, 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 – version 28.0 27.0 incorporated by reference in Rule 18-1.
(D)        RVP© – the 2010 2009 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, 2010 2009  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)  .
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/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 73/RVU
            Physical Medicine and Rehabilitation, Medical Nutrition Therapy and Acupuncture
Evaluation & Management (E&M)                     $   9.62 16/RVU
18-5      INSTRUCTIONS AND/OR MODIFICATIONS TO THE DOCUMENTS INCORPORATED BY REFERENCE IN RULE 18-1 
(A)        Maximum allowance for all providers under Rule 16-5 is 100% of the RVP© value or as defined in this Rule 18. 
(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 2009 is adopted for codes, descriptions, parenthetical notes and coding guidelines, unless modified in this rule. 
(C)        CPT® Category III codes listed in the RVP© may be used for billing with agreement of the payer as to reimbursement.  Payment shall be in compliance with Rule 16-6(C).
(D)        Surgery/Anesthesia
(1)        Anesthesia Section:
(a)        All anesthesia base values shall be established by the use of the codes as set forth in the RVP©, Anesthesia Section.  Anesthesia services are only reimbursable if the anesthesia is administered by a physician or Certified Registered Nurse Anesthetist (CRNA) who remains in constant attendance during the procedure for the sole purpose of rendering anesthesia.
When anesthesia is administered by a CRNA:
(1)        Not under the medical direction of an anesthesiologist, reimbursement shall be 90% of the maximum anesthesia value,
(2)        Under the medical direction of an anesthesiologist, reimbursement shall be 50% of the maximum anesthesia value.  The other 50% is payable to the anesthesiologist providing the medical direction to the CRNA,
(3)        Medical direction for administering the anesthesia includes performing the following activities:
·           Performs a pre-anesthesia examination and evaluation,
·           Prescribes the anesthesia plan,
·           Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence,
·           Ensures that any procedure in the anesthesia plan that s/he does not perform is performed by a qualified anesthetist,
·           Monitors the course of anesthesia administration at frequent intervals,
·           Remains physically present and available for immediate diagnosis and treatment of emergencies, and
·           Provides indicated post-anesthesia care.
(b)        Anesthesia physical status modifiers and qualifying circumstances 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.”  
(c)        The following modifiers are to be used when billing for anesthesia services:
AA – anesthesia services performed personally by the anesthesiologist
QX – CRNA service; with medical direction by a physician
QZ – CRNA service; without medical direction by a physician
QY – Medical direction of one CRNA by an anesthesiologist
(d)        Surgery X Procedures 
(1)        The surgery X procedures are limited to those listed below and found in the table under the RVP©, Anesthesia section’s Guidelines XIII, “Anesthesia Services Where Time Units Are Not Allowed”:
·         Providing local anesthetic or other medications through a regional IV
·         Daily drug management
·         Endotracheal intubation
·         Venipuncture, including cutdowns
·         Arterial punctures
·         Epidural or subarachnoid spine injections
·         Somatic and Sympathetic Nerve Injections 
·         Paravertebral facet joint injections and rhizotomies
In addition, lumbar plexus spine anesthetic injection, posterior approach with daily administration = 7 RVUs; paravertebral facet, zygapophyseal joint or nerves with guidance are reimbursed at 10 RVUs for a single level of the cervical or thoracic, 5 RVUs for second level or more, and 8 RVUs for the lumbar or sacral single level, 4 RVUs for the second level or more.
(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.  
(3)        When performing more than one surgery X procedure in a single surgical setting, multiple surgery guidelines shall apply (100% of the listed value for the primary procedure and 50% of the listed value for additional procedures).  Use modifier -51 to indicate multiple surgery X procedures performed on the same day during a single operative setting.  The 50% reduction does not apply to procedures that are identified in the RVP© as “Add-on” procedures.
(4)        Bilateral injections:  see 18-5(D)(2)(g). 
(5)        Other procedures from Table XIII not described above may be found in another section of the RVP© (e.g., surgery).  Any procedures found in the table under the RVP©, Anesthesia section’s Guidelines XIII, “Anesthesia Services Where Time Units Are Not Allowed” but not contained in this list (Rule 18-5(D)(1)(d)(1)) are reimbursed in accordance with the assigned units from their respective sections multiplied by their respective CF.
(2)        Surgical Section: 
(a)        The use of assistant surgeons shall be limited according to the American College Of Surgeons'  Physicians as Assistants at Surgery:  2007 Study (January 2007), available from the American College of Surgeons, Chicago, IL, or from their web page at http://www.facs.org/ahp/pubs/2007physasstsurg.pdf (accessed September 1, 2009).  The incorporation is limited to the edition named and does not include later revisions or additions.  Copies of the material incorporated by reference may be inspected at any State publications depository library.  For information about inspecting or obtaining copies of the incorporated material, contact the Medical Fee Schedule Administrator, 633 17th Street, Suite 400, Denver, Colorado, 80202-3626.  
Where the publication restricts use of such assistants to "almost never" or a procedure is not referenced in the publication, prior authorization for payment (see Rule 16-9 and 16-10) is required.
(b)        Incidental procedures are commonly performed as an integral part of a total service and do not warrant a separate benefit.  
(c)        No payment shall be made for more than one assistant surgeon or minimum assistant surgeon without prior authorization for payment (see Rule 16-9 and 16-10) unless a trauma team was activated due to the emergency nature of the injury(ies).
(d)        The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate modifier should be used on the bill.  To modify a billed code refer to Rule 16-11(B)(4).
(e)        Non-physician, minimum assistant surgeons used as surgical assistants shall be reimbursed at 10 % of the listed value.
(f)         Global Period 
(1)        The following services performed during a global period would warrant separate billing if documentation demonstrates significant identifiable services were involved, such as:
¨         E&M services unrelated to the primary surgical procedure,
¨         Services necessary to stabilize the patient for the primary surgical procedure,
¨         Services not usually part of the surgical procedure, including an E&M visit by an authorized treating physician for disability management,
¨         Unusual circumstances, complications, exacerbations, or recurrences, or
¨         Unrelated diseases or injuries.
¨         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.
(2)        Separate identifiable services shall use an appropriate RVP© modifier in conjunction with the billed service.
(g)        Bilateral procedures are reimbursed the same as all multiple procedures:  100% for the first primary procedure and then 50% for all other procedures, including the 2nd "primary" procedure.
(h)        The “Services with Significant Direct Costs” section of the RVP© is not adopted.  Supplies shall be reimbursed as set out in Rule 18-6(H).
(i)	If a surgical arthroscopic procedure is converted to the same surgical open procedure on the same joint, only the open procedure is payable.  If an arthroscopic procedure and open procedure are performed on different joints, the two procedures may be separately payable with anatomic modifiers or modifier 50.
(j)	Use code G0289 to report any combination of surgical knee arthroscopies for removal of loose body, foreign body, and/or debridement/shaving of articular cartilage.  G0289 is 11.2 RVUs and is paid using the surgical conversion factor.
	G0289 shall not be paid when reported in conjunction with other knee arthroscopy codes in the same compartment of the same knee.
	G0289 shall be paid when reported in conjunction with other knee arthroscopy codes in a different compartment of the knee.  G0289 is subject to the 50% multiple surgical reduction guidelines.
(E)        Radiology Section: 
(1)        General
(a)        The cost of dyes and contrast shall be reimbursed in accordance with Rule 18-6(H).  at 80 % of billed charges.
(b)        Copying charges for X-Rays and MRIs shall be $15.00/film regardless of the size of the film.
(c)        The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate RVP© modifier should have been used on the bill.  To modify a billed code, refer to Rule 16-11(B)(4).
(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
(a)        The physician supervising and interpreting the thermographic evaluation shall be board certified by the examining board of one of the following national organizations and follow their recognized protocols:
American Academy of Thermology;
American Chiropractic College of Infrared Imaging.
(b)        Indications for diagnostic thermographic evaluation must be one of the following:
Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy (CRPS/RSD);
Sympathetically Maintained Pain (SMP);
Autonomic neuropathy;
(c)        Protocol for stress testing is outlined in the Medical Treatment Guidelines found in Rule 17.
(d)        Thermography Billing Codes:
DoWC Z200  Upper body w/ Autonomic Stress Testing     $865.37
DoWC Z201  Lower body w/Autonomic Stress Testing      $865.37
 (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: 
	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: 
(1)        Medicine home therapy services in the RVP© are not adopted.  For appropriate codes see Rule 18-6(N), Home Therapy.
(2)        Anesthesia qualifying circumstance 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 2010 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) 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.
(b)        An office visit may be billed on the same day as manipulation codes when the documentation meets the E&M requirement and an appropriate modifier is used.
(6)        Psychiatric/Psychological CNS Tests and Assessment Services:
(a)        A licensed 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.
(b)        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 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) except where specifically addressed in the treatment guidelines.
(7)        Hyperbaric Oxygen Therapy Services
            The maximum unit value shall be 24 units, instead of 14 units as listed in the RVP©.
(8)	Qualified Non-Physician Provider Telephone or On-Line Services
	Reimbursement to qualified non-physician providers for coordination of care with professionals shall be based upon the telephone codes for qualified non-physician providers found in the RVP© Medicine Section.  Coordination of care reimbursement is limited to telephone calls made to professionals outside of the non-physician provider’s employment facility(ies) and/or to the injured worker or their family.
(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).
(2)        For recommendations on the use of the physical medicine and rehabilitation procedures, modalities, and testing, see Rule 17, Medical Treatment Guidelines Exhibits.
(3)        Special Note to All Physical Medicine and Rehabilitation Providers:
Prior authorization 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).
An interdisciplinary rehabilitation program is one that provides focused, coordinated, and goal-oriented services using a team of professionals from varying disciplines to deliver care.  These programs can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning.  As defined in Rule 17 Medical Treatment Guidelines, interdisciplinary rehabilitation programs may include, but are not limited to:  chronic pain, spinal cord, or brain injury programs.
Billing Restrictions:  All billing providers shall detail to the payer the services, frequency of services, duration of the program and their proposed fees for the entire program, inclusive for all professionals.  The billing provider and payer shall attempt to mutually agree upon billing code(s) and fee(s) for each interdisciplinary rehabilitation program.
If there is a single billing provider for the entire interdisciplinary rehabilitation program and a daily per diem rate is mutually agreed upon, use billing code Z500.
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 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), 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) unit for the patient's independent use shall be billed using the education code in the Medicine section of the RVP©.  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 
Bill only one of the dry needling modality codes.  See relevant treatment guidelines for limitations on frequencies. 
DoWC Z501            Single or multiple needles, one or two muscles,		5.4 RVUs  
DoWC Z502                  three or more muscles,		   5.8 RVUs

(7)        Evaluation Services for Therapists:  Physical Therapy (PT), Occupational Therapy (OT) and Athletic Trainers (ATC) (cf. §12-36-106 C.R.S.) 
(a)        All evaluation services must be supported by the appropriate history, physical examination documentation, treatment goals and treatment plan or re-evaluation of the treatment plan.  The provider shall clearly state the reason for the evaluation, the nature and results of the physical examination of the patient, and the reasoning for recommending the continuation or adjustment of the treatment protocol.  Without appropriate supporting documentation, the payer may deny payment.  The re-evaluation codes shall not be billed for routine pre-treatment patient assessment.
If a new problem or abnormality is encountered that requires a new evaluation and treatment plan, the professional may perform and bill for another initial evaluation.  A new problem or abnormality may be caused by a surgical procedure being performed after the initial evaluation has been completed.
(b)        Payers are only required to pay for evaluation services directly performed by a PT, OT, or ATC as defined in Title  §12-36-106 of the C.R.S.  All evaluation notes or reports must be written and signed by the PT or OT.  Physicians shall bill the appropriate E&M code from the E&M section of the RVP©.
(c)        A patient may be seen by more than one health care professional on the same day.  An evaluation service with appropriate documentation may be charged for each professional per patient per day.
(d)        Reimbursement to PTs, OTs, speech language pathologists and audiologists for coordination of care with professionals shall be based upon the telephone codes for qualified non-physician providers found in the RVP© Medicine Section.  Coordination of care reimbursement is limited to telephone calls made to professionals outside of the therapist’s/pathologist’s/ audiologist’s employment facility(ies) and/or to the injured worker or their family.
(e)	All interdisciplinary team conferences shall be billed in compliance with Rule 18-5(I)(5).
(8)        Special Tests 
The following respective tests are considered special tests:  
·         Job Site Evaluation 
•	Functional Capacity Evaluation 
·         Assistive technology assessment 
·         Speech
•	Computer Enhanced Evaluation (DoWC Z503)
•	Work Tolerance Screening (DoWC Z504)
(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 per test or more than 6 tests per claim.  Functional Capacity Evaluations require prior authorization for payment for more than 4 hours per test or 2 tests per claim.
(2)        The provider shall specify the time required to perform the test in 15-minute increments.
(3)        The value for the analysis and the written report is included in the code’s value.
(4)        No E&M services or PT, OT, or acupuncture evaluations shall be charged separately for these tests.
(5)        Data from computerized equipment shall always include the supporting analysis developed by the physical medicine professional before it is payable as a special test.
(b)        Provider Restrictions: all special tests must be fully supervised by a physician, a PT, an OT, a speech language pathologist/therapist or audiologist.  Final reports must be written and signed by the physician, the PT, the OT, the speech language pathologist/therapist or the audiologist.
(9)        Speech Therapy/Evaluation and Treatment
Reimbursement shall be according to the unit values as listed in the RVP© multiplied by their section’s respective CF.
(10)       Supplies
Physical medicine supplies are reimbursed in accordance with Rule 18-6(H).
(11)       Unattended Treatment
When a patient uses a facility or its equipment but is performing unattended procedures, in either an individual or group setting, bill:
DoWC Z505     fixed fee per day                        1.5 RVU
(12)       Non-Medical Facility
Fees, such as gyms, pools, etc., and training or supervision by non-medical providers require prior authorization for payment (see Rule 16-9 and 16-10) and a written negotiated fee.
(13)       Unlisted Service Physical Medicine
All unlisted services or procedures require a report.
(14)       Work Conditioning, Work Hardening, Work Simulation
(a)        Work conditioning is a non-interdisciplinary program that is focused on the individual needs of the patient to return to work.  Usually one discipline oversees the patient in meeting goals to return to work.  Refer to Rule 17, Medical Treatment Guidelines.
Restriction:  Maximum daily time is two (2) hours per day without additional prior authorization 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).  
(c)        Work Simulation is a program where an individual completes specific work-related tasks for a particular job and return to work.  Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision.  The need for work simulation should be based upon the results of a functional capacity evaluation and/or job analysis.  Refer to Rule 17, Medical Treatment Guidelines.
(d)        For Work Conditioning, Work Hardening, or Work Simulation, the following apply.
(1)        The provider shall submit a treatment plan including expected frequency and duration of treatment.  If requested by the provider, the payer will prior authorize payment for the treatment plan services or shall identify any concerns including those based on the reasonableness or necessity of care.  
(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.
(3)      	Provider Restrictions:  All procedures must be performed by or under the onsite supervision of a physician, psychologist, PT, OT, speech language pathologist or audiologist.
(I)         Evaluation and Management Section (E&M)
(1)        Medical record documentation shall encompass the RVP© “E&M Guideline” criteria to justify the billed E&M service.  If 50% of the time spent 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.
Disability counseling should be an integral part of managing workers’ compensation injuries.  The counseling shall be completely documented in the medical records, including, but not limited to, the amount of time spent with the injured worker and the specifics of the discussion as it relates to the individual patient.  Disability counseling shall include, but not be limited to, return to work, temporary and permanent work restrictions, self management of symptoms while working, correct posture/mechanics to perform work functions, job task exercises for muscle strengthening and stretching, and appropriate tool and equipment use to prevent re-injury and/or worsening of the existing injury.
(2)        New or Established Patients   
An E&M visit shall be billed as a “new” patient service for each “new injury” even though the provider has seen the patient within the last three years.  Any subsequent E&M visits are to be billed as an “established patient” and reflect the level of service indicated by the documentation when addressing all of the current injuries. 
(3)        Number of Office Visits
All providers, as defined in Rule 16-5 (A-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.  The E&M Guideline criteria as specified in the RVP© E&M Section shall be used in all office visits to determine the appropriate level.
(4)        Treating Physician Telephone or On-line Services.
Telephone or on-line services may be billed if: 
(a)	the service is performed more than one day prior to a related E&M office visit,  or
(b)	the service is performed more than 7 days following a related E&M office visit, and 
(c)	when the medical records/documentation specifies all the following:
(1)        the amount of time and date;
(2)        the patient, family member, or healthcare provider talked to, and
(3)        the specifics of the discussion and/or decision made during the communication. 
 (5)  	Face-to-face or Telephonic Treating Physician or Qualified Non-physician Medical Team Conferences.
A medical team conference can only be billed if all of the criteria are met under CPT® .   A medical team conference shall consist of medical professionals caring for the injured worker. 
The billing statement shall be prepared in accordance with Rule 16, Utilization Standards.
(6)	Face -to-face or telephonic meeting by a non-treating physician with the employer, claim representatives or any attorney in order to provide a medical opinion on a specific workers’ compensation case which is not accompanied by a specific report or written record. 
Billing Code DoWC Z601:	$65.00 per 15 minutes billed to the requesting party.
(7)	Face-to-face or telephonic meeting by a non-treating physician with the employer, claim representatives or any attorney in order to provide a medical opinion on a specific workers’ compensation case which is accompanied by a report or written record shall be billed as a special report (Rule 18-6(G)(4)).
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:
(1)	Each meeting shall be at a minimum 15 minutes.  
(2)	A report or written record signed by the physician is required and shall include the following:
(a)	Who was present at the meeting and their role at the meeting
(b)	Purpose of the meeting
(c)	A brief statement of recommendations and actions at the conclusion of the meeting.
(d)	Documented time (both start and end times)
(e)	Billing code DoWC Z701 
•	$75.00 per 15 minutes for time attending the meeting and preparing the report (no travel time or mileage is separately payable).  The fee includes the cost of the report for all parties, including the injured worker.
(B)        Cancellation Fees For Payer Made Appointments
(1)        A cancellation fee is payable only when a payer schedules an appointment the injured worker fails to keep, and the payer has not canceled three (3) business days prior to the appointment.  The payer shall pay:
One-half of the usual fee for the scheduled services, or
$150.00, whichever is less.
Cancellation Fee Billing Code:     DoWC Z720 
(2)        Missed Appointments:
When claimants fail to keep scheduled appointments, the provider should contact the payer within two (2) business days.  Upon reporting the missed appointment, the provider may request whether the payer wishes to reschedule the appointment for the claimant.  If the claimant fails to keep the payer’s rescheduled appointment, the provider may bill for a cancellation fee according to this Rule 18-6(B).
(C)        Copying Fees
The payer, payer's representative, injured worker and injured worker's representative shall pay a reasonable fee for the reproduction of the injured worker's medical record.  Reasonable cost for paper copies shall not exceed $14.00 for the first 10 or fewer pages, $0.50 per page for pages 11-40, and $0.33 per page thereafter. Actual postage or shipping costs and applicable sales tax, if any, may also be charged.  The per-page fee for records copied from microfilm shall be $1.50 per page.  
If the requester and provider agree, the copy may be provided on a disc.  The fee will not exceed $14.00 per disc.  
If the requester and provider agree and appropriate security is in place, including, but not limited to, compatible encryption, the copies may be submitted electronically.  Requester and provider should attempt to agree on a reasonable fee.  Absent an agreement to the contrary, the fee shall be $0.10/page.
Copying charges do not apply for the initial submission of records that are part of the required documentation for billing.    
Copying Fee Billing Code:           DoWC Z721 
(D)        Deposition and Testimony Fees
(1)        When requesting deposition or testimony from physicians or any other type of provider, guidance should be obtained from the Interprofessional Code, as prepared by the Colorado Bar Association, the Denver Bar Association, the Colorado Medical Society and the Denver Medical Society.  If the parties cannot agree upon lesser fees for the deposition or testimony services, or cancellation time frames and/or fees, the following deposition and testimony rules and fees shall be used.  
If, in an individual case, a party can show good cause to an Administrative Law Judge (ALJ) for exceeding the fee schedule, that ALJ may allow a greater fee than listed in Rule 18-6(D) in that case.  
 (2)        By prior agreement, the provider 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:
                                                DoWC Z730	                 $325.00 per hour
(3)       Deposition:
Payment for a treating or non-treating provider’s testimony at a deposition shall not exceed $325.00 per hour billed in half-hour increments.  Calculation of the provider’s time shall be "portal to portal."
If requested, the provider is entitled to a full hour deposit in advance in order to schedule the deposition.
If the provider 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.
If the provider is notified of the cancellation of the deposition at least five (5) business days but less than seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours he or she has reasonably spent in preparation and one-half the time scheduled for the deposition. Bill using code DoWC Z732.
If the provider is notified less than five (5) business days in advance of a cancellation, or the deposition is shorter than the time scheduled, the provider shall be paid the number of hours he or she has reasonably spent in preparation and has scheduled for the deposition. Bill using code DoWC Z733.
Deposition:                                
Treating or Non-treating  provider:
                        DoWC Z734		$325.00 per hr.
                                                Billed in half-hour increments
(4)        Testimony:
Calculation of the provider’s  time shall be "portal to portal (includes travel time and mileage in both directions)."
For testifying at a hearing, if requested the provider is entitled to a four (4) hour deposit in advance in order to schedule the testimony.
If the provider 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.
If the provider is notified of the cancellation of the testimony at least  five (5) business days but less than seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours he or she has reasonably spent in preparation and one-half the time scheduled for the testimony. Bill using code DoWC Z736.
If the provider is notified of a cancellation less than five (5) business days prior to the date of the testimony or the testimony is shorter than the time scheduled, the provider shall be paid the number of hours s/he has reasonably spent in preparation and has scheduled for the testimony. Bill using code DoWC Z737.
Testimony:                    
Treating or Non-treating  provider:
                        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 47 52  cents per mile.  The injured worker shall submit a statement to the payer showing the date(s) of travel and number of miles traveled, with receipts for any other reasonable and necessary travel expenses incurred.  
Mileage Expense Billing Code:    DoWC Z723 
(F)        Permanent Impairment Rating
(1)        The payer is only required to pay for one combined whole-person permanent impairment rating per claim, except as otherwise provided in the Workers' Compensation Rules of Procedures.  Exceptions that may require payment for an additional impairment rating include, but are not limited to, reopened cases, as ordered by the Director or an administrative law judge, or a subsequent request to review apportionment.  The authorized treating provider is required to submit in writing all permanent restrictions and future maintenance care related to the injury or occupational disease.
(2)        Provider Restrictions
The permanent impairment rating shall be determined by the authorized Level II accredited physician (see Rule 5-5(D)).
 (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. The authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient should complete the Physician’s Report of Workers’ Compensation Injury (Closing Report), WC164 (See Rule 18-6(G)(2)).  Reimbursement for the appropriate level of E&M service is only applicable if the physician examines the injured worker and meets the criteria as defined in the RVP©.
(4)        MMI Determined with a Calculated Permanent Impairment Rating
(a)        Calculated Impairment:  The total fee includes the office visit, a complete physical examination, complete history, review of all medical records, determining MMI, completing all required measurements, referencing all tables used to determine the rating, using all report forms from the AMA's Guide to the Evaluation of Permanent Impairment, Third Edition (Revised), (AMA Guides), and completing the Division form, titled Physician's Report of Workers’ Compensation Injury (Closing Report) WC164.
(b)        Use the appropriate DoWC code:
(1)        Fee for the Level II Accredited Authorized Treating Physician Providing Primary Care:
 Bill DoWC Z759 $355.00.                                   
(2)        Fee for the Referral, Level II Accredited Authorized Physician:
 Bill DoWC Z760 $575.00.                                 
(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©.
(4)        Fee for a Multiple Impairment Evaluation Requiring More Than One Level II Accredited Physician:
All physicians providing consulting services for the completion of a whole person impairment rating shall bill using the appropriate E&M consultation code and shall forward their portion of the rating to the authorized physician determining the combined whole person rating.
(G)        Report Preparation
(1)        Routine Reports
Completion of routine reports or records are incorporated in all fees for service and include:
Diagnostic testing 
Procedure reports
Progress notes
Office notes 
Operative reports
Supply invoices, if requested by the payer
Providers shall submit routine reports free of charge as directed in Rule 16-7(E) and by statute.  Requests for additional copies of routine reports and for reports not in Rule 16-7(E) or in statute are reimbursable under the copying fee section of Rule 18.
(2)        Completion of the Physician’s Report of Workers’ Compensation Injury (WC164) 
(a)        Initial Report
The authorized treating physician (generally the designated or selected physician)  managing the total workers’ compensation claim of the patient 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 injured worker is at maximum medical improvement for all injuries or diseases covered under this workers’ compensation claim, with or without a permanent impairment.  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 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 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 provider wants to use the WC164 report as a progress report or for any purpose other than those designated in Rule 18-6(G)(2)(a), (b) or (c), and seeks reimbursement for completion of the form, the provider shall get prior approval from the payer.
(e)        Billing Codes and Maximum Allowance for completion and submission of WC164 report 
Maximum allowance for the completion and submission of the WC164 Report is:
DoWC Z750  	$42.00	Initial Report
DoWC Z751	$42.00	Progress Report (Payer Requested or Provider Initiated)
DoWC Z752	$42.00	Closing Report
DoWC Z753	$42.00	Initial and Closing Reports are completed on the same form for the same date of service
(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 below.  Forms requiring more than 15 minutes shall be paid as a special report.
(a) 	Billing Code Z754 
(b)	Maximum fee is $42.00 per form completion
(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.  
Billable Hours:  Because narrative reports may have variable content, the content and total payment shall be agreed upon by the provider and the report's requester before the provider begins the report.
Advance Payment:  If requested, the provider is entitled to a two hour deposit in advance in order to schedule any patient exam associated with a special report.    
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 Z761.
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) meeting and report with
Non-treating Physician		DoWC Code:	Z758
Special Report Maximum Fees: 	$325.00 per hour.
	Billed in 15- minute 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 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 Program (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 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)	Oordering and reviewing drug tests
(2)	Oordering and reviewing PDMP results
(3)	Reviewing the medical records
(4)	Reviewing the injured workers’ current functional status
(5)	Ddetermining what actions, if any, need to be taken
(6)	Appropriate chronic pain diagnostic code (ICD).
	Bill using code DoWC Z765	$75.00 per 15 minutes
	 – maximum of 30 minutes per report
	NOTE:  This code is not to be used for acute or subacute pain management.
(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 a 20% markup and shipping 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%.
(5)        Payment for professional services associated with the fabrication and/or modification of orthotics, custom splints, adaptive equipment, and/or adaptation and programming of communication systems and devices shall be paid in accordance with the Colorado Medicare HCPCS Level II values RVP©.
(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).
(2)        Bills for Services 
(a)        Inpatient hospital facility fees shall be billed on the UB-04 and require summary level billing by revenue code.  The provider must submit itemized bills along with the UB-04.
(b)        The maximum inpatient facility fee is determined by applying the Center for Medicare and Medicaid Services (CMS) “Medicare Severity Diagnosis Related Groups” (MS-DRGs) classification system.  Exhibit 1 to Rule 18 shows the relative weights per MS-DRGs that are used in calculating the maximum allowance.
The hospital shall indicate the MS-DRG code number in the remarks section (form locator 80) of the UB-04 billing form and maintain documentation on file showing how the MS-DRG was determined. The hospital shall determine the MS-DRG using the MS-DRGs Definitions Manual.  The attending physician shall not be required to certify this documentation unless a dispute arises between the hospital and the payer regarding MS-DRG assignment.  The payer may deny payment for services until the appropriate MS-DRG code is supplied.
(c)        Exhibit 1 to Rule 18 establishes the maximum length of stay (LOS) using the “arithmetic mean LOS”.  However, no additional allowance for exceeding this LOS, other than through the cost outlier criteria under Rule 18-6(I)(3)(d) is allowed.
(d)        Any inpatient admission requiring the use of both an acute care hospital and its Medicare certified rehabilitation facility is considered as one admission and MS-DRG.  This does not apply to long term care and licensed rehabilitation facilities.
(3)        Inpatient Facility Reimbursement:  
(a)        The following types of inpatient facilities are reimbursed at 100% of billed inpatient charges:
(1)        Children’s hospital
(2)        Veterans’ Administration hospital
(3)        State psychiatric hospital
(b)        The following types of inpatient facilities are reimbursed at 80% of billed inpatient charges:
(1)        Medicare certified Critical Access Hospital (CAH) (listed in Exhibit 3 of Rule 18) 
(2)        Medicare certified long-term care hospital
(3)        Colorado Department of Public Health and Environment (CDPHE) licensed rehabilitation facility, and,
(4)        CDPHE licensed psychiatric facilities that are privately owned.
(5)	CDPHE licensed skilled nursing facilities (SNF).
(c)        All other inpatient facilities are reimbursed as follows:
Retrieve the relative weights for the assigned MS-DRG from the MS-DRG table in Exhibit 1 to Rule 18 and locate the hospital’s base rate in Exhibit 2 to Rule 18.
The “Maximum Fee Allowance” is determined by calculating:
(1)        (MS-DRG Relative Wt x Specific hospital base rate x 155% 160%) + (reimbursement for all “Supply et al.”) + (trauma center activation allowance)
(2)        “Supply et al.” is defined in Rule 16-2. Reimbursement shall be consistent with Rule 18-6(H).  The billing provider is responsible for identifying and itemizing all “Supply et al.” items.
(3)        For trauma center activation allowance, see Rule 18-6(M)(3)(g).
(d)        Outliers are admissions with extraordinary cost warranting additional reimbursement beyond the maximum allowance under (3) (c) of Rule 18-6(I).  To calculate the additional reimbursement, if any:
(1)        Determine the “Hospital’s Cost”: 
total billed charges (excluding any “Supply et al.” billed charges and trauma center activation billed charges) multiplied by the hospital’s cost-to-charge ratio.
(2)        Each hospital’s cost-to-charge ratio is given in Exhibit 2 of Rule 18.
(3)        The “Difference” = “Hospital’s Cost” – “Maximum Fee Allowance” excluding any “Supply et al.” allowance and trauma center activation allowance (see (c) above)
(4)        If the “Difference” is greater than $25,800.00, additional reimbursement is warranted.  The additional reimbursement is determined by the following equation: 
“Difference” x .80 = additional fee allowance
(e)                 Inpatient combined with ERD or Trauma Center reimbursement
(1)     If an injured worker is admitted to the hospital, the ERD reimbursement is included in the inpatient reimbursement under 18-6 (I)(3),
(2)     Except, Trauma Center activation fees (see 18-6(M)(3)(g)) are paid in addition to inpatient fees (18-6(I)(3)(c-d)).
(f)         If an injured worker is admitted to one hospital and is subsequently transferred to another hospital, the payment to the transferring hospital will be based upon a per diem value of the MS-DRG maximum value.  The per diem value is calculated based upon the transferring hospital’s MS-DRG relative weight multiplied by the hospital’s specific base rate (Exhibit 2 to Rule 18) divided by the MS-DRG geometric mean length of stay (Exhibit 1 to Rule 18).  This per diem amount is multiplied by the actual LOS.  If the patient is admitted and transferred on the same day, the actual LOS equals one (1).  The receiving hospital shall receive the appropriate MS-DRG maximum value.
(g)        To comply with Rule 16-6(B), the payer shall compare each billed charge type:
o                  The MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier allowance),
o                  "Supply et al." billed charges to the "Supply et al." allowance [cost + 20%], and
o                  The trauma center activation billed charge to the trauma center activation allowance.  
            The MS-DRG adjusted billed charges are determined by subtracting the "Supply et al." billed charges and the trauma center activation billed charges from the total billed charges.  The final payment is the sum of the lesser of each of these comparisons.
(J)         Scheduled Outpatient Surgery Facility Fees
(1)        Provider Restrictions
(a)        All non-emergency outpatient surgeries require prior authorization for payment (see Rule 16-9 and 16-10).
(b)        A separate facility fee is only payable if the facility is licensed by the Colorado Department of Public Health and Environment (CDPHE) as:
(1)        a hospital; or 
(2)        an Ambulatory Surgery Center (ASC).
(2)        Bills for Services
(a)        Outpatient facility fees shall be billed on the UB-04 and require summary level billing by revenue code.  The provider must submit itemized bills along with the UB-04.
(b)        All professional charges are subject to the RVP© and Dental Fee Schedules as incorporated by Rule 18.
(c)        ASCs and hospitals shall bill using the surgical RVP© code(s) as indicated by the surgeon’s operative note up to a maximum of four surgery codes per surgical episode.
(3)        Outpatient Surgery Facility Reimbursement: 
(a)        The following types of outpatient facilities are reimbursed at 100% of billed outpatient charges:
(1)        Children’s hospital
(2)        Veterans’ Administration hospital
(3)        State psychiatric hospital
(b)        CAHs, listed in Exhibit 3 of Rule 18, are to be reimbursed at 80% of billed charges.
(c)        All other outpatient surgery facilities are reimbursed based on Exhibit 4 of this Rule 18.  Exhibit 4 lists Medicare’s Outpatient Hospital Ambulatory Prospective Payment Codes (APC) with the Division’s values for each APC code.  Grouper code 210, found in Exhibit 4, was DoWC created to reimburse RVP© spinal fusion codes not listed in Medicare's Revised January 2010 Update to reflect Affordable Care Act 05/18/2010- Addendum B [PDF, 961KB]  (Revised Addendum B) http://www.cms.gov/apps/ama/license.asp?file=/hospitaloutpatientpps/downloads/2010revisedwebjanuary_addb_05.17.10.zip  (last accessed June 8, 2010) Addendum B.
The surgical procedure codes are classified by APC code in Medicare’s April 2009 Revised 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 Revised Addendum B warrants a separate facility fee.
The April 2009 Revised Addendum B can be accessed at Medicare’s Hospital Outpatient PPS website.  
Total maximum facility value for an outpatient surgical episode of care includes the sum of:
(1)        The highest valued APC code per Exhibit 4 plus 50% of any lesser-valued APC code values.
Multiple procedures and bilateral procedures are to be indicated by the use of modifiers –51 and –50, respectively.  The 50% reduction applies to all lower valued procedures, even if they are identified in the RVP© as modifier -51 exempt.  The reduction also applies to the second "primary" procedure of bilateral procedures.
The surgery discogram procedure (APC 388) value is for all levels and includes conscious sedation and the technical component of the radiological procedure.
Facility fee reimbursement is limited to a maximum of four surgical procedures per surgical episode with a maximum of only one procedure reimbursed at 100% of the allowed value.
If an arthroscopic procedure is converted to an open procedure on the same joint, only the open procedure is payable.  If an arthroscopic procedure and open procedure are performed on different joints, the two procedures may be separately payable with anatomic modifiers.  
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; and
(2)        “Supply et al.” is defined in Rule 16-2.  Reimbursement shall be consistent with Rule 18-6(H).  The billing provider is responsible for identifying and itemizing all “Supply et al.” items; and
(3)        Diagnostic testing and preoperative labs may be 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 Revised Aaddendum 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.)
CPT® radiological procedure codes (not the injection codes) 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.
            Billing Codes:
G0378 Observation/Convalescence rate:  $45.00 per hour rounded to the nearest hour. 
(5)        Additional reimbursement is payable for the following services not included in the values found in Exhibit 4 of Rule 18:
·         ambulance services 
·         blood, blood plasma, platelets 
(d)        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:

•	Has a zero dollar value in Exhibit 4, and/or 
•	Cannot be assigned to an APC Grouper based on Medicare’s Revised Addendum B. 
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 Revised Addendum B.  If a value does not exist in Exhibit 4, then the APC dollar value from Medicare’s Revised Addendum B with reductions for “Supply et al.” is multiplied by 160% 158%.   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.
(e)	Discontinued surgeries require the use of modifier -73 (discontinued prior to administration of anesthesia) or modifier -74 (discontinued after administration of anesthesia).  Modifier -73 results in a reimbursement of 50% of the APC value for the primary procedure only.  Modifier -74 allows reimbursement of 100% of the primary procedure value only.
(f)        All surgical procedures performed in one operating room, regardless of the number of surgeons, are considered one outpatient surgical episode of care for purposes of facility fee reimbursement.
(g)         In compliance with Rule 16-6(B), the sum of Rule 18-6(J)(3)(c)(1-5) is compared to the total facility fee billed charges.  The lesser of the two amounts shall be the maximum facility allowance for the surgical episode of care.  A line by line comparison of billed charges to the calculated maximum fee schedule allowance of 18-6(J)(3)(c) is not appropriate.
(K)        Outpatient Diagnostic Testing and Clinic Facility Fees
(1)        Bills for Services
All providers shall indicate whether they are billing for the total, professional only or technical only component of a diagnostic test by listing the appropriate RVP© modifier on the UB-04 or CMS 1500 (08-05).
(2)        Reimbursement
(a)        The following types of outpatient diagnostic testing and clinic facilities are reimbursed at 100% of billed charges:
(1)        Children’s hospitals, 
(2)        Veterans’ Administration hospitals 
(3)        State psychiatric hospitals
(b)        Rural health facilities listed in Exhibit 5 are reimbursed at 80% of billed charges for clinic visits, diagnostic testing, and supplies and drugs that do not meet the “Supply et al.” threshold.
“Supply et al.” is defined in Rule 16-2 and reimbursement shall be consistent with Rule 18-6(H).  The billing provider is responsible for identifying and itemizing all “Supply et al.” items.
(c)        All other facilities:
(1)        No separate allowance for clinic visit fees.  Supplies are reimbursed in accordance with Rule 18-6(H).
(2)        No separate facility fee allowance for diagnostic testing.  Facility fees for diagnostic testing are considered part of the procedure’s technical component value 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) at 80% of billed charges.
(3)        “Supply et al.” is defined in Rule 16-2 and reimbursement shall be consistent with Rule 18-6(H).  The billing provider is responsible for identifying and itemizing all “Supply et al.” items.
(d)        Any prescription for a drug supply to be used longer than a 24 hour period, filled at any clinic, shall fall under the requirements of and be reimbursed as, a pharmacy fee.  See Rule 18-6(O).
(L)        Outpatient Urgent Care Facility Fees
(1)        Provider Restrictions:
(a)        Prior agreement or authorization is recommended for all facilities billing a separate Urgent Care fee.  Facilities must provide documentation of the required urgent care facility criteria if requested by the payer.
(b)        Urgent care facility fees are only payable if the facility qualifies as an Urgent Care facility. Facilities licensed by the CDPHE as a Community Clinic (CC) or a Community Clinic and Emergency Center (CCEC) under 6 CCR 1011-1, Chapter IX, should still provide evidence of these qualifications to be reimbursed as an Urgent Care facility.  The facility shall meet all of the following criteria to be eligible for a separate Urgent Care facility fee:
(1)        Separate facility dedicated to providing initial walk-in urgent care;
(2)        Access without appointment during all operating hours;
(3)        State licensed physician on-site at all times exclusively to evaluate walk-in patients;
(4)        Support staff dedicated to urgent walk-in visits with certifications in Basic Life Support (BLS);
(5)        Advanced Cardiac Life Support (ACLS) certified life support capabilities to stabilize emergencies including, but not limited to, EKG, defibrillator, oxygen and respiratory support equipment (full crash cart), etc.;
(6)        Ambulance access;
(7)        Professional staff on-site at the facility certified in ACLS;
(8)        Extended hours including evening and some weekend hours;
(9)        Basic X-ray availability on-site during all operating hours;
(10)       Clinical Laboratory Improvement Amendments (CLIA) certified laboratory on-site for basic diagnostic labs or ability to obtain basic laboratory results within 1 hour;
(11)       Capabilities include, but are not limited to, suturing, minor procedures, splinting, IV medications and hydration;
(12)       Written procedures exist for the facility’s stabilization and transport processes.
(c)        No separate facility fees are allowed for follow-up care.  Subsequent care for an initial diagnosis does not qualify for a separate facility fee.  To receive another facility fee any subsequent diagnosis shall be a new acute care situation entirely different from the initial diagnosis.
(d)        No facility fee is appropriate when the injured worker is sent to the employer's designated provider for a non-urgent episode of care during regular business hours of 8 am to 5 pm, Monday through Friday.
(2)       Bills for Services 
(a)        Urgent care facility fees may be billed on a CMS 1500 (08-05).
(b)        Urgent care facility fees shall be billed using HCPCS Level II code:  S9088 – “Services provided in an Urgent care facility.” 
(3)        Urgent Care Reimbursement
The total maximum value for an urgent care episode of care includes the sum of:
(a)        An Urgent Care Facility fee maximum allowance of $75.00; and
(b)        “Supply et al.” is defined in Rule 16-2 and reimbursement shall be consistent with Rule 18-6(H).  The billing provider is responsible for identifying and itemizing all “Supply et al.” items.
Supplies and drugs that do not meet the “Supply et al.” threshold and treatment rooms are included in the Urgent Care facility maximum fees; and 
(c)        All diagnostic testing, laboratory services and therapeutic services (including, but not limited to, radiology, pathology, respiratory therapy, physical therapy or occupational therapy) shall be reimbursed by multiplying the appropriate CF by the unit value for the specific CPT® code as listed in the RVP© and Rule 18; and 
(d)        The Observation Room allowance shall not exceed a rate of $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).
(e)        In compliance with Rule 16-6 (B), the sum of all Urgent Care fees charged, less any amounts charged for professional fees or dispensed prescriptions per Rule 18-6(L)(4) found on the same bill, is to be compared to the maximum reimbursement allowed by the calculated value of Rule 18-6(L)(3)(a-d).  The lesser of the two amounts shall be the maximum facility allowance for the episode of urgent care.  A line by line comparison is not appropriate. 
(4)        Any prescription for a drug supply to be used longer than a 24 hour period, filled at any Urgent Care facility, shall fall under the requirements of, and be reimbursed as, a pharmacy fee. See Rule 18-6(O).
(M)       Outpatient Emergency Room Department (ERD) Facility Fees
(1)        Provider Restrictions
To be reimbursed under this section (M), all outpatient ERDs within Colorado must be physically located within a hospital licensed by the CDPHE as a general hospital, or if free-standing ERD, must have equivalent operations as a licensed ERD.  To be paid as an ERD, out-of-state facilities shall meet that state’s licensure requirements.
(2)        Bills For Services
(a)        ERD facility fees shall be billed on the UB-04 and require summary level billing by revenue code.  The provider must submit itemized bills along with the UB-04.
(b)        Documentation should support the “Level of Care” being billed.
(3)        ERD Reimbursement
(a)        The following types of facilities are reimbursed at 100% of billed ERD charges:
(1)        Children’s hospitals
(2)        Veterans’ Administration hospitals
(3)        State psychiatric hospitals
(b)        Medicare certified Critical Access Hospitals (CAH) (listed in Exhibit 3 of Rule 18) are reimbursed at 80% of billed charges.
(c)        The ERD “Level of Care” is identified based upon one of five levels of care.  The level of care is defined by 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.  Upon request the provider shall supply a copy of their level of care guidelines 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			$	    160.00 240.00 
2			$    360.00 390.00
3			$    620.00 590.00
4			$    870.00 840.00
5			$ 1,640.00 1,540.00 
Critical Care			$ 1,640.00 1,540.00
(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.
(e)        For the purposes of Rule 16-6 (B), the sum of all outpatient ERD fees charged, less any amounts charged for professional fees found on the same bill, is to be compared to the maximum reimbursement allowed by the calculated value of Rule 18-6(M)(3)(d).  The lesser of the two amounts shall be the maximum facility allowance for the ERD episode of care.  A line by line comparison is not appropriate.
(f)         If an injured worker is admitted to the hospital through that hospital’s ERD, the ERD reimbursement is included in the inpatient reimbursement under 18-6(I)(3).
(g)        Trauma Center fees are not paid for alerts.  Activation fees are as follows:
Level I                                                             $3,000.00
Level II                                                            $2,500.00
Level III                                                           $1,000.00
Level IV                                                               $00.00
(1)        These fees are in addition to ERD and inpatient fees.
(2)        Activation fees mean a trauma team has been activated, not just alerted. 
(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. 
(1)        Home Infusion Therapy
The per diem rates for home infusion therapy shall include the initial patient evaluation, education, coordination of care, products, equipment, IV administration sets, supplies, supply management, and delivery services.  Nursing fees should be billed as indicated in Rule 18-6(N)(2).
(a)        Parenteral Nutrition:
0 -1 liter                        $140.00/day
1.1 - 2.0 liter                  $200.00/day
2.1 - 3.0 liter                  $260.00/day
(b)        Antibiotic Therapy:
$105.00/day + Average Wholesale Price (AWP) (See Rule 18-6(O)(14))
(c)        Chemotherapy:
$ 85.00/day + AWP (See Rule 18-6(O)(14))
(d)        Enteral nutrition:
Category I                     $ 43.00/day
Category II                     $ 41.00/day
Category III                    $ 52.00/day
(e)        Pain Management:         $ 95.00/day + AWP (See Rule 18-6(O)(14))
(f)         Fluid Replacement:        $ 70.00/day + AWP (See Rule 18-6(O)(14))
(g)        Multiple Therapies:
Rate per day for highest cost therapy only + AWP (See Rule 18-6(O)(14)) for all drugs 
Medication/Drug Restrictions - the payment for drugs may be based upon the AWP (See Rule 18-6(O)(14)) of the drug as determined through the use of industry publications such as the monthly Price Alert, First Databank, Inc.
(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.
The amount of time spent with the injured worker must be specified in the medical records and on the bill.
(3)        Physical Medicine
Physical medicine procedures are payable at the same rate as provided in the physical medicine and rehabilitation services section of Rule 18.
(4)        Mileage 
Travel allowances should be agreed upon with the payer and the mileage rate should not exceed $0.47 52  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
(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.
(P)        Complementary Alternative Medicine (CAM) (Requires prior authorization for payment (see Rule 16-9 and 16-10)
CAM is a term used to describe a broad range of treatment modalities, some of which are generally accepted in the medical community and others that remain outside the accepted practice of conventional western medicine.  Providers of CAM may be both licensed and non-licensed health practitioners with training in one or more forms of therapy.  Refer to Rule 17, Medical Treatment Guidelines for the specific types of CAM modalities. 
(Q)        Acupuncture 
Acupuncture is an accepted procedure for the relief of pain and tissue inflammation.  While commonly used for treatment of pain, it may also be used as an adjunct to physical rehabilitation and/or surgery to hasten return of functional recovery.  Acupuncture may be performed with or without the use of electrical current on the needles at the acupuncture site.
(1)        Provider Restrictions
All providers must be Registered Acupuncturists (LAc) or certified by an existing licensing board as provided in Rule 16, Utilization Standards, and must provide evidence of training, registration and/or certification upon request of the payer.
(2)        Billing Restrictions
(a).       For treatment frequencies exceeding the maximum allowed in Rule 17 Medical Treatment Guidelines, the provider must obtain prior authorization for payment (see Rule 16-9 and 16-10).
(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), the maximum amount of time allowed for acupuncture and procedures is one hour of procedures, per day, per discipline.
(3)        Billing Codes:
(a)        Reimburse acupuncture, including or not including electrical stimulation, as listed in the RVP©.
(b)        Non-Physician evaluation services
(1)        New or established patient services are reimbursable only if the medical record specifies the appropriate history, physical examination, treatment plan or evaluation of the treatment plan.  Payers are only required to pay for evaluation services directly performed by an LAc.  All evaluation notes or reports must be written and signed by the LAc.  Without appropriate supporting documentation, the payer may deny payment.  (See Rule 16-11)
(2)        LAc new patient visit:
            DoWC Z800     Maximum value $94.40 91.68 
(3)        LAc established patient visit:
            DoWC Z801     Maximum value $63.72 61.88 
(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);
(d)        See the appropriate physical medicine and rehabilitation section of the RVP© for other billing codes and limitations (see also Rule 18-5(H)). 
(e)        Acupuncture supplies are reimbursed in accordance with Rule 18-6(H).
(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  (CDT-2009-2010).  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 dental codes.
Regarding prosthetic appliances, the provider may bill and be reimbursed for 50% of the allowed fee at the time the master casts are prepared for removable prosthodontics or the final impressions are taken for fixed prosthodontics.  The remaining 50% may be billed on insertion of the final prosthesis.

Exhibit 1 Struck and Replaced
Exhibit #1	
Effective for Dates of Service on and After 1/1/2011	
MS-DRG	MDC	TYPE	MS-DRG Title	Weights	Geometric mean LOS	Arithmetic mean LOS	
001	PRE	SURG	HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC	26.1241	31.7	41.8	
002	PRE	SURG	HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC	13.5332	17.7	22.8	
003	PRE	SURG	ECMO OR TRACH W MV 96+ HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.	18.0135	30.0	36.6	
004	PRE	SURG	TRACH W MV 96+ HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.	11.1832	22.2	27.1	
005	PRE	SURG	LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT	10.2640	15.0	20.0	
006	PRE	SURG	LIVER TRANSPLANT W/O MCC	4.8067	8.3	9.2	
007	PRE	SURG	LUNG TRANSPLANT	9.3918	15.6	18.7	
008	PRE	SURG	SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT	4.9951	10.2	11.8	
010	PRE	SURG	PANCREAS TRANSPLANT	3.7220	8.6	9.7	
011	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W MCC	4.7558	12.3	15.6	
012	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W CC	3.1179	8.5	10.1	
013	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W/O CC/MCC	1.9480	5.7	6.7	
014	PRE	SURG	ALLOGENEIC BONE MARROW TRANSPLANT	11.3961	20.7	27.7	
015	PRE	SURG	AUTOLOGOUS BONE MARROW TRANSPLANT	5.8721	16.7	19.2	
020	01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC	8.2168	14.0	17.2	
021	01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC	6.2673	12.2	13.9	
022	01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC	4.1377	6.6	8.4	
023	01	SURG	CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT	5.0829	8.3	11.8	
024	01	SURG	CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC	3.4948	5.7	8.1	
025	01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC	4.7528	8.8	11.5	
026	01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC	2.9804	5.8	7.3	
027	01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC	2.1382	3.0	3.9	
028	01	SURG	SPINAL PROCEDURES W MCC	5.3583	10.1	13.1	
029	01	SURG	SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS	2.8798	4.7	6.6	
030	01	SURG	SPINAL PROCEDURES W/O CC/MCC	1.6452	2.5	3.3	
031	01	SURG	VENTRICULAR SHUNT PROCEDURES W MCC	4.1020	8.5	12.2	
032	01	SURG	VENTRICULAR SHUNT PROCEDURES W CC	1.9339	3.7	5.4	
033	01	SURG	VENTRICULAR SHUNT PROCEDURES W/O CC/MCC	1.3695	2.1	2.7	
034	01	SURG	CAROTID ARTERY STENT PROCEDURE W MCC	3.5290	4.7	7.0	
035	01	SURG	CAROTID ARTERY STENT PROCEDURE W CC	2.1572	2.2	3.2	
036	01	SURG	CAROTID ARTERY STENT PROCEDURE W/O CC/MCC	1.6539	1.3	1.5	
037	01	SURG	EXTRACRANIAL PROCEDURES W MCC	3.1652	5.8	8.4	
038	01	SURG	EXTRACRANIAL PROCEDURES W CC	1.5610	2.4	3.5	
039	01	SURG	EXTRACRANIAL PROCEDURES W/O CC/MCC	1.0278	1.4	1.7	
040	01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC	3.9264	9.0	12.2	
041	01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM	2.1447	5.0	6.7	
042	01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC	1.6950	2.3	3.2	
052	01	MED	SPINAL DISORDERS & INJURIES W CC/MCC	1.5964	4.5	6.6	
053	01	MED	SPINAL DISORDERS & INJURIES W/O CC/MCC	0.8417	2.9	3.6	
054	01	MED	NERVOUS SYSTEM NEOPLASMS W MCC	1.4801	4.6	6.3	
055	01	MED	NERVOUS SYSTEM NEOPLASMS W/O MCC	1.0651	3.5	4.6	
056	01	MED	DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC	1.6720	5.5	7.2	
057	01	MED	DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC	0.9316	3.7	4.9	
058	01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W MCC	1.5781	5.5	7.3	
059	01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W CC	0.9818	4.1	4.9	
060	01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W/O CC/MCC	0.7525	3.2	3.8	
061	01	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W MCC	2.9397	6.4	8.4	
062	01	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W CC	1.9450	4.8	5.6	
063	01	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W/O CC/MCC	1.5296	3.4	3.9	
064	01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC	1.8601	5.1	6.9	
065	01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC	1.1637	4.0	4.8	
066	01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC	0.8174	2.7	3.3	
067	01	MED	NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W MCC	1.4176	4.2	5.5	
068	01	MED	NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC	0.8746	2.7	3.3	
069	01	MED	TRANSIENT ISCHEMIA	0.7292	2.3	2.8	
070	01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC	1.8345	5.6	7.4	
071	01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W CC	1.1008	4.1	5.1	
072	01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC	0.7468	2.5	3.1	
073	01	MED	CRANIAL & PERIPHERAL NERVE DISORDERS W MCC	1.2959	4.2	5.6	
074	01	MED	CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC	0.8592	3.2	4.1	
075	01	MED	VIRAL MENINGITIS W CC/MCC	1.6538	5.5	7.0	
076	01	MED	VIRAL MENINGITIS W/O CC/MCC	0.9054	3.3	3.9	
077	01	MED	HYPERTENSIVE ENCEPHALOPATHY W MCC	1.7332	5.1	6.4	
078	01	MED	HYPERTENSIVE ENCEPHALOPATHY W CC	1.0145	3.5	4.4	
079	01	MED	HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC	0.7500	2.6	3.1	
080	01	MED	NONTRAUMATIC STUPOR & COMA W MCC	1.1831	3.6	4.9	
081	01	MED	NONTRAUMATIC STUPOR & COMA W/O MCC	0.7350	2.7	3.4	
082	01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC	2.0028	3.5	6.1	
083	01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W CC	1.3194	3.4	4.7	
084	01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC	0.8899	2.2	2.8	
085	01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC	2.1345	5.2	7.2	
086	01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W CC	1.1979	3.7	4.6	
087	01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC	0.7872	2.3	2.9	
088	01	MED	CONCUSSION W MCC	1.5102	4.2	5.5	
089	01	MED	CONCUSSION W CC	0.9644	2.9	3.7	
090	01	MED	CONCUSSION W/O CC/MCC	0.6943	1.9	2.3	
091	01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W MCC	1.6299	4.4	6.2	
092	01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W CC	0.9372	3.3	4.2	
093	01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC	0.6800	2.3	2.9	
094	01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W MCC	3.6910	8.9	11.8	
095	01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC	2.3934	6.6	8.4	
096	01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W/O CC/MCC	1.9171	4.6	5.7	
097	01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC	3.2271	9.0	11.6	
098	01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W CC	1.9053	6.4	7.9	
099	01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W/O CC/MCC	1.2170	4.1	5.2	
100	01	MED	SEIZURES W MCC	1.5091	4.5	6.0	
101	01	MED	SEIZURES W/O MCC	0.7588	2.8	3.4	
102	01	MED	HEADACHES W MCC	0.9997	3.1	4.3	
103	01	MED	HEADACHES W/O MCC	0.6691	2.4	3.0	
113	02	SURG	ORBITAL PROCEDURES W CC/MCC	1.8278	3.9	5.6	
114	02	SURG	ORBITAL PROCEDURES W/O CC/MCC	0.9224	2.0	2.6	
115	02	SURG	EXTRAOCULAR PROCEDURES EXCEPT ORBIT	1.2130	3.4	4.6	
116	02	SURG	INTRAOCULAR PROCEDURES W CC/MCC	1.2920	3.0	4.5	
117	02	SURG	INTRAOCULAR PROCEDURES W/O CC/MCC	0.7393	1.6	2.0	
121	02	MED	ACUTE MAJOR EYE INFECTIONS W CC/MCC	0.9040	4.1	5.1	
122	02	MED	ACUTE MAJOR EYE INFECTIONS W/O CC/MCC	0.6451	3.3	4.0	
123	02	MED	NEUROLOGICAL EYE DISORDERS	0.7135	2.2	2.7	
124	02	MED	OTHER DISORDERS OF THE EYE W MCC	1.1861	3.8	5.3	
125	02	MED	OTHER DISORDERS OF THE EYE W/O MCC	0.6819	2.6	3.4	
129	03	SURG	MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE	2.2555	3.7	5.2	
130	03	SURG	MAJOR HEAD & NECK PROCEDURES W/O CC/MCC	1.2316	2.3	2.9	
131	03	SURG	CRANIAL/FACIAL PROCEDURES W CC/MCC	2.0829	4.1	5.6	
132	03	SURG	CRANIAL/FACIAL PROCEDURES W/O CC/MCC	1.2451	2.1	2.7	
133	03	SURG	OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC	1.6960	3.6	5.4	
134	03	SURG	OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC	0.8518	1.7	2.1	
135	03	SURG	SINUS & MASTOID PROCEDURES W CC/MCC	1.9029	4.3	6.3	
136	03	SURG	SINUS & MASTOID PROCEDURES W/O CC/MCC	0.9772	1.7	2.2	
137	03	SURG	MOUTH PROCEDURES W CC/MCC	1.2952	3.6	5.0	
138	03	SURG	MOUTH PROCEDURES W/O CC/MCC	0.7822	1.9	2.5	
139	03	SURG	SALIVARY GLAND PROCEDURES	0.8827	1.4	1.8	
146	03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC	2.1722	6.5	9.0	
147	03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC	1.2284	4.1	5.7	
148	03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W/O CC/MCC	0.8118	2.4	3.3	
149	03	MED	DYSEQUILIBRIUM	0.6363	2.2	2.6	
150	03	MED	EPISTAXIS W MCC	1.2811	3.7	5.0	
151	03	MED	EPISTAXIS W/O MCC	0.6366	2.3	2.9	
152	03	MED	OTITIS MEDIA & URI W MCC	0.9623	3.3	4.3	
153	03	MED	OTITIS MEDIA & URI W/O MCC	0.6256	2.5	3.1	
154	03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W MCC	1.3957	4.3	5.8	
155	03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC	0.9032	3.3	4.2	
156	03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC	0.6184	2.4	2.9	
157	03	MED	DENTAL & ORAL DISEASES W MCC	1.5699	4.8	6.7	
158	03	MED	DENTAL & ORAL DISEASES W CC	0.8951	3.3	4.3	
159	03	MED	DENTAL & ORAL DISEASES W/O CC/MCC	0.5858	2.1	2.7	
163	04	SURG	MAJOR CHEST PROCEDURES W MCC	5.0701	11.5	14.0	
164	04	SURG	MAJOR CHEST PROCEDURES W CC	2.6177	6.2	7.4	
165	04	SURG	MAJOR CHEST PROCEDURES W/O CC/MCC	1.7756	3.7	4.4	
166	04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W MCC	3.7415	9.5	12.0	
167	04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W CC	2.0537	5.8	7.4	
168	04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC	1.3012	3.3	4.3	
175	04	MED	PULMONARY EMBOLISM W MCC	1.6088	5.7	6.8	
176	04	MED	PULMONARY EMBOLISM W/O MCC	1.0666	4.2	4.9	
177	04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC	2.0651	6.8	8.6	
178	04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W CC	1.4859	5.6	6.8	
179	04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC	0.9836	4.1	5.0	
180	04	MED	RESPIRATORY NEOPLASMS W MCC	1.7310	5.7	7.5	
181	04	MED	RESPIRATORY NEOPLASMS W CC	1.2155	4.2	5.4	
182	04	MED	RESPIRATORY NEOPLASMS W/O CC/MCC	0.8086	2.8	3.7	
183	04	MED	MAJOR CHEST TRAUMA W MCC	1.4874	5.2	6.5	
184	04	MED	MAJOR CHEST TRAUMA W CC	0.9670	3.6	4.3	
185	04	MED	MAJOR CHEST TRAUMA W/O CC/MCC	0.6761	2.6	3.0	
186	04	MED	PLEURAL EFFUSION W MCC	1.5600	5.3	6.7	
187	04	MED	PLEURAL EFFUSION W CC	1.0991	3.9	4.9	
188	04	MED	PLEURAL EFFUSION W/O CC/MCC	0.7628	2.8	3.5	
189	04	MED	PULMONARY EDEMA & RESPIRATORY FAILURE	1.2776	4.3	5.5	
190	04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC	1.1894	4.5	5.5	
191	04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC	0.9712	3.8	4.6	
192	04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC	0.7200	3.1	3.7	
193	04	MED	SIMPLE PNEUMONIA & PLEURISY W MCC	1.4753	5.3	6.5	
194	04	MED	SIMPLE PNEUMONIA & PLEURISY W CC	1.0124	4.2	5.0	
195	04	MED	SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC	0.7073	3.1	3.7	
196	04	MED	INTERSTITIAL LUNG DISEASE W MCC	1.6053	5.6	7.0	
197	04	MED	INTERSTITIAL LUNG DISEASE W CC	1.1149	4.2	5.1	
198	04	MED	INTERSTITIAL LUNG DISEASE W/O CC/MCC	0.8149	3.1	3.8	
199	04	MED	PNEUMOTHORAX W MCC	1.7760	6.2	8.0	
200	04	MED	PNEUMOTHORAX W CC	1.0198	3.7	4.8	
201	04	MED	PNEUMOTHORAX W/O CC/MCC	0.7167	2.8	3.5	
202	04	MED	BRONCHITIS & ASTHMA W CC/MCC	0.8395	3.4	4.1	
203	04	MED	BRONCHITIS & ASTHMA W/O CC/MCC	0.6051	2.6	3.2	
204	04	MED	RESPIRATORY SIGNS & SYMPTOMS	0.6705	2.1	2.7	
205	04	MED	OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC	1.3018	4.0	5.3	
206	04	MED	OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC	0.7546	2.6	3.3	
207	04	MED	RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS	5.1936	12.6	14.8	
208	04	MED	RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <96 HOURS	2.2522	5.1	7.0	
215	05	SURG	OTHER HEART ASSIST SYSTEM IMPLANT	12.7451	7.0	12.6	
216	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC	10.0309	14.7	17.1	
217	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W CC	6.8081	9.8	11.0	
218	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W/O CC/MCC	5.3407	7.2	8.0	
219	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC	8.0975	10.8	13.1	
220	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC	5.3923	7.2	8.0	
221	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC	4.4941	5.6	6.0	
222	05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W MCC	8.5634	9.4	11.9	
223	05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W/O MCC	6.4649	4.5	6.2	
224	05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC	7.6030	7.7	9.7	
225	05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC	6.0613	4.2	5.3	
226	05	SURG	CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC	6.4967	5.0	7.8	
227	05	SURG	CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC	5.2285	2.0	3.1	
228	05	SURG	OTHER CARDIOTHORACIC PROCEDURES W MCC	7.6151	11.8	14.2	
229	05	SURG	OTHER CARDIOTHORACIC PROCEDURES W CC	4.7934	7.3	8.3	
230	05	SURG	OTHER CARDIOTHORACIC PROCEDURES W/O CC/MCC	3.5608	4.6	5.5	
231	05	SURG	CORONARY BYPASS W PTCA W MCC	7.8893	10.9	12.9	
232	05	SURG	CORONARY BYPASS W PTCA W/O MCC	5.8492	8.5	9.4	
233	05	SURG	CORONARY BYPASS W CARDIAC CATH W MCC	7.2273	12.1	13.7	
234	05	SURG	CORONARY BYPASS W CARDIAC CATH W/O MCC	4.8441	8.2	8.9	
235	05	SURG	CORONARY BYPASS W/O CARDIAC CATH W MCC	5.8556	9.3	10.8	
236	05	SURG	CORONARY BYPASS W/O CARDIAC CATH W/O MCC	3.7839	6.0	6.5	
237	05	SURG	MAJOR CARDIOVASC PROCEDURES W MCC OR THORACIC AORTIC ANEURYSM REPAIR	5.1927	7.1	10.2	
238	05	SURG	MAJOR CARDIOVASC PROCEDURES W/O MCC	3.1008	2.9	4.2	
239	05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC	4.5646	11.3	14.3	
240	05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC	2.6639	7.8	9.6	
241	05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W/O CC/MCC	1.4626	5.0	6.0	
242	05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W MCC	3.7327	6.3	8.1	
243	05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W CC	2.6570	3.8	4.9	
244	05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC	2.0486	2.2	2.8	
245	05	SURG	AICD GENERATOR PROCEDURES	4.2684	2.5	3.8	
246	05	SURG	PERC CARDIOVASC PROC W DRUG-ELUTING STENT W MCC OR 4+ VESSELS/STENTS	3.1923	3.5	5.0	
247	05	SURG	PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC	1.9812	1.8	2.3	
248	05	SURG	PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W MCC OR 4+ VES/STENTS	2.9295	4.4	6.0	
249	05	SURG	PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC	1.7814	2.2	2.8	
250	05	SURG	PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC	2.8844	5.0	7.0	
251	05	SURG	PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC	1.8040	2.1	2.9	
252	05	SURG	OTHER VASCULAR PROCEDURES W MCC	2.9853	5.2	7.9	
253	05	SURG	OTHER VASCULAR PROCEDURES W CC	2.4104	4.4	6.0	
254	05	SURG	OTHER VASCULAR PROCEDURES W/O CC/MCC	1.6244	2.0	2.7	
255	05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W MCC	2.4930	7.0	9.2	
256	05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC	1.5992	5.6	7.0	
257	05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W/O CC/MCC	0.9629	3.4	4.3	
258	05	SURG	CARDIAC PACEMAKER DEVICE REPLACEMENT W MCC	2.8707	5.2	7.0	
259	05	SURG	CARDIAC PACEMAKER DEVICE REPLACEMENT W/O MCC	1.8381	2.4	3.2	
260	05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC	3.5636	7.7	10.8	
261	05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC	1.6515	3.2	4.5	
262	05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W/O CC/MCC	1.1284	2.0	2.6	
263	05	SURG	VEIN LIGATION & STRIPPING	1.7560	3.5	5.6	
264	05	SURG	OTHER CIRCULATORY SYSTEM O.R. PROCEDURES	2.5446	5.5	8.3	
265	05	SURG	AICD LEAD PROCEDURES	2.3205	2.2	3.3	
280	05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC	1.8435	5.2	6.6	
281	05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC	1.1852	3.6	4.4	
282	05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC	0.8042	2.2	2.8	
283	05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC	1.7107	3.2	5.1	
284	05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC	0.8884	2.1	3.0	
285	05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W/O CC/MCC	0.5717	1.4	1.8	
286	05	MED	CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC	1.9978	4.8	6.5	
287	05	MED	CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC	1.0876	2.5	3.2	
288	05	MED	ACUTE & SUBACUTE ENDOCARDITIS W MCC	2.9607	8.6	10.9	
289	05	MED	ACUTE & SUBACUTE ENDOCARDITIS W CC	1.8355	6.4	7.8	
290	05	MED	ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC	1.2880	4.4	5.6	
291	05	MED	HEART FAILURE & SHOCK W MCC	1.4882	4.8	6.2	
292	05	MED	HEART FAILURE & SHOCK W CC	1.0245	4.0	4.9	
293	05	MED	HEART FAILURE & SHOCK W/O CC/MCC	0.6810	2.8	3.3	
294	05	MED	DEEP VEIN THROMBOPHLEBITIS W CC/MCC	1.0394	4.4	5.4	
295	05	MED	DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC	0.6356	3.4	4.0	
296	05	MED	CARDIAC ARREST, UNEXPLAINED W MCC	1.1698	1.8	2.8	
297	05	MED	CARDIAC ARREST, UNEXPLAINED W CC	0.6844	1.4	1.8	
298	05	MED	CARDIAC ARREST, UNEXPLAINED W/O CC/MCC	0.4523	1.1	1.2	
299	05	MED	PERIPHERAL VASCULAR DISORDERS W MCC	1.4050	4.7	6.1	
300	05	MED	PERIPHERAL VASCULAR DISORDERS W CC	0.9737	3.9	4.9	
301	05	MED	PERIPHERAL VASCULAR DISORDERS W/O CC/MCC	0.6579	2.8	3.5	
302	05	MED	ATHEROSCLEROSIS W MCC	0.9712	3.0	4.0	
303	05	MED	ATHEROSCLEROSIS W/O MCC	0.5804	2.0	2.4	
304	05	MED	HYPERTENSION W MCC	1.0182	3.5	4.5	
305	05	MED	HYPERTENSION W/O MCC	0.6117	2.2	2.7	
306	05	MED	CARDIAC CONGENITAL & VALVULAR DISORDERS W MCC	1.4681	4.4	5.9	
307	05	MED	CARDIAC CONGENITAL & VALVULAR DISORDERS W/O MCC	0.7927	2.7	3.4	
308	05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC	1.2270	4.0	5.2	
309	05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC	0.8331	3.0	3.7	
310	05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC	0.5670	2.1	2.5	
311	05	MED	ANGINA PECTORIS	0.5038	1.8	2.2	
312	05	MED	SYNCOPE & COLLAPSE	0.7136	2.4	2.9	
313	05	MED	CHEST PAIN	0.5481	1.7	2.1	
314	05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC	1.8232	5.0	6.9	
315	05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W CC	0.9645	3.3	4.2	
316	05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC	0.6124	2.1	2.6	
326	06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC	5.8087	12.6	16.3	
327	06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W CC	2.7293	6.9	8.8	
328	06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC	1.4363	2.9	3.8	
329	06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC	5.2995	12.5	15.4	
330	06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W CC	2.5865	7.8	9.1	
331	06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC	1.6299	4.8	5.3	
332	06	SURG	RECTAL RESECTION W MCC	4.8539	11.8	14.2	
333	06	SURG	RECTAL RESECTION W CC	2.5015	7.1	8.1	
334	06	SURG	RECTAL RESECTION W/O CC/MCC	1.5980	4.2	4.9	
335	06	SURG	PERITONEAL ADHESIOLYSIS W MCC	4.2742	11.4	13.7	
336	06	SURG	PERITONEAL ADHESIOLYSIS W CC	2.3459	7.2	8.8	
337	06	SURG	PERITONEAL ADHESIOLYSIS W/O CC/MCC	1.4851	4.0	5.1	
338	06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W MCC	3.2121	8.3	10.0	
339	06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC	1.8691	5.6	6.5	
340	06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC	1.2447	3.2	3.7	
341	06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC	2.2602	4.9	6.6	
342	06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC	1.3301	3.0	3.8	
343	06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC	0.9636	1.7	2.0	
344	06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W MCC	3.1533	8.9	11.2	
345	06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W CC	1.6999	6.0	7.0	
346	06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC	1.1887	4.2	4.6	
347	06	SURG	ANAL & STOMAL PROCEDURES W MCC	2.4021	6.3	8.8	
348	06	SURG	ANAL & STOMAL PROCEDURES W CC	1.3720	4.1	5.4	
349	06	SURG	ANAL & STOMAL PROCEDURES W/O CC/MCC	0.7996	2.3	2.9	
350	06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W MCC	2.4467	5.6	7.8	
351	06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W CC	1.3581	3.5	4.5	
352	06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC	0.8651	1.9	2.4	
353	06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W MCC	2.7608	6.3	8.4	
354	06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC	1.5574	4.0	5.0	
355	06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC	1.0383	2.3	2.8	
356	06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC	4.0301	9.2	12.7	
357	06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC	2.1501	5.7	7.4	
358	06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC	1.3042	3.0	4.0	
368	06	MED	MAJOR ESOPHAGEAL DISORDERS W MCC	1.7585	5.1	6.7	
369	06	MED	MAJOR ESOPHAGEAL DISORDERS W CC	1.0755	3.7	4.5	
370	06	MED	MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC	0.7497	2.6	3.1	
371	06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC	2.0998	6.8	8.9	
372	06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC	1.2891	5.3	6.5	
373	06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC	0.8543	3.9	4.6	
374	06	MED	DIGESTIVE MALIGNANCY W MCC	2.0619	6.3	8.5	
375	06	MED	DIGESTIVE MALIGNANCY W CC	1.2773	4.4	5.8	
376	06	MED	DIGESTIVE MALIGNANCY W/O CC/MCC	0.8405	2.8	3.6	
377	06	MED	G.I. HEMORRHAGE W MCC	1.7496	5.0	6.4	
378	06	MED	G.I. HEMORRHAGE W CC	1.0235	3.5	4.2	
379	06	MED	G.I. HEMORRHAGE W/O CC/MCC	0.7107	2.6	3.0	
380	06	MED	COMPLICATED PEPTIC ULCER W MCC	1.9498	5.8	7.5	
381	06	MED	COMPLICATED PEPTIC ULCER W CC	1.1172	3.9	4.8	
382	06	MED	COMPLICATED PEPTIC ULCER W/O CC/MCC	0.8117	2.9	3.5	
383	06	MED	UNCOMPLICATED PEPTIC ULCER W MCC	1.1936	4.2	5.3	
384	06	MED	UNCOMPLICATED PEPTIC ULCER W/O MCC	0.8308	3.0	3.6	
385	06	MED	INFLAMMATORY BOWEL DISEASE W MCC	1.9145	6.3	8.4	
386	06	MED	INFLAMMATORY BOWEL DISEASE W CC	1.0439	4.2	5.3	
387	06	MED	INFLAMMATORY BOWEL DISEASE W/O CC/MCC	0.7775	3.2	3.9	
388	06	MED	G.I. OBSTRUCTION W MCC	1.6490	5.5	7.2	
389	06	MED	G.I. OBSTRUCTION W CC	0.9323	3.9	4.8	
390	06	MED	G.I. OBSTRUCTION W/O CC/MCC	0.6361	2.8	3.3	
391	06	MED	ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC	1.1553	3.9	5.2	
392	06	MED	ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC	0.7152	2.8	3.4	
393	06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC	1.6569	4.9	6.9	
394	06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W CC	0.9917	3.7	4.7	
395	06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC	0.6717	2.5	3.1	
405	07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W MCC	5.6074	12.0	15.9	
406	07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W CC	2.7826	6.5	8.4	
407	07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W/O CC/MCC	1.8691	4.2	5.2	
408	07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W MCC	3.9590	11.0	13.5	
409	07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC	2.4837	7.4	8.9	
410	07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC	1.6208	4.9	5.8	
411	07	SURG	CHOLECYSTECTOMY W C.D.E. W MCC	3.6953	9.9	11.8	
412	07	SURG	CHOLECYSTECTOMY W C.D.E. W CC	2.5380	7.0	8.3	
413	07	SURG	CHOLECYSTECTOMY W C.D.E. W/O CC/MCC	1.7385	4.5	5.4	
414	07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC	3.6719	9.3	11.4	
415	07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC	2.1000	6.2	7.3	
416	07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC	1.3123	3.7	4.4	
417	07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC	2.5055	6.2	7.8	
418	07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC	1.7047	4.4	5.4	
419	07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC	1.1754	2.4	3.0	
420	07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W MCC	3.6914	9.2	13.1	
421	07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC	1.8890	5.1	7.0	
422	07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W/O CC/MCC	1.2777	3.1	4.1	
423	07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W MCC	4.4476	10.9	14.4	
424	07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W CC	2.4219	7.1	9.1	
425	07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC	1.6265	4.5	5.7	
432	07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC	1.6939	4.9	6.5	
433	07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W CC	0.9487	3.6	4.6	
434	07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC	0.6116	2.5	3.2	
435	07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC	1.8035	5.6	7.4	
436	07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC	1.2175	4.2	5.5	
437	07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W/O CC/MCC	0.8973	2.8	3.7	
438	07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC	1.8265	5.4	7.5	
439	07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC	1.0081	4.0	5.0	
440	07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC	0.6878	2.9	3.5	
441	07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W MCC	1.8335	5.2	7.1	
442	07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC	0.9843	3.7	4.8	
443	07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC/MCC	0.6578	2.7	3.3	
444	07	MED	DISORDERS OF THE BILIARY TRACT W MCC	1.5571	4.8	6.2	
445	07	MED	DISORDERS OF THE BILIARY TRACT W CC	1.0681	3.6	4.5	
446	07	MED	DISORDERS OF THE BILIARY TRACT W/O CC/MCC	0.7404	2.5	3.1	
453	08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC	10.3048	10.7	13.5	
454	08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC	7.3001	5.5	6.8	
455	08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC	5.4796	3.1	3.8	
456	08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR 9+ FUS W MCC	9.2948	10.8	13.5	
457	08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR 9+ FUS W CC	6.2478	5.9	7.0	
458	08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR 9+ FUS W/O CC/MCC	4.9778	3.5	4.1	
459	08	SURG	SPINAL FUSION EXCEPT CERVICAL W MCC	6.5382	7.4	9.1	
460	08	SURG	SPINAL FUSION EXCEPT CERVICAL W/O MCC	3.9004	3.3	3.9	
461	08	SURG	BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC	4.9653	6.7	8.3	
462	08	SURG	BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC	3.3634	3.7	4.1	
463	08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC	4.9853	11.1	15.1	
464	08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC	2.8664	6.9	8.9	
465	08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC	1.7885	4.1	5.3	
466	08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W MCC	4.9381	7.3	9.0	
467	08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W CC	3.2568	4.3	5.0	
468	08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC	2.5912	3.3	3.6	
469	08	SURG	MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC	3.4827	6.7	8.0	
470	08	SURG	MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC	2.1173	3.4	3.7	
471	08	SURG	CERVICAL SPINAL FUSION W MCC	4.7410	6.6	9.3	
472	08	SURG	CERVICAL SPINAL FUSION W CC	2.7945	2.6	3.8	
473	08	SURG	CERVICAL SPINAL FUSION W/O CC/MCC	2.0987	1.5	1.9	
474	08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC	3.5131	9.2	12.0	
475	08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC	1.9640	6.1	7.7	
476	08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W/O CC/MCC	0.9985	3.2	4.1	
477	08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC	3.3163	8.9	11.1	
478	08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC	2.2598	5.3	6.9	
479	08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC	1.6417	2.4	3.4	
480	08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC	3.0913	7.7	9.0	
481	08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC	1.8944	5.1	5.6	
482	08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC	1.5431	4.1	4.5	
483	08	SURG	MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC	2.4235	3.1	3.7	
484	08	SURG	MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W/O CC/MCC	1.9713	2.0	2.2	
485	08	SURG	KNEE PROCEDURES W PDX OF INFECTION W MCC	3.1808	9.0	10.9	
486	08	SURG	KNEE PROCEDURES W PDX OF INFECTION W CC	2.0450	6.1	7.2	
487	08	SURG	KNEE PROCEDURES W PDX OF INFECTION W/O CC/MCC	1.4752	4.4	5.1	
488	08	SURG	KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC	1.7294	3.8	4.7	
489	08	SURG	KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC	1.2220	2.5	2.9	
490	08	SURG	BACK & NECK PROC EXC SPINAL FUSION W CC/MCC OR DISC DEVICE/NEUROSTIM	1.7996	3.0	4.3	
491	08	SURG	BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC	0.9982	1.7	2.1	
492	08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W MCC	3.0748	6.8	8.6	
493	08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W CC	1.8573	4.2	5.0	
494	08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W/O CC/MCC	1.3220	2.7	3.1	
495	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W MCC	2.8691	7.6	10.2	
496	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC	1.6275	4.1	5.4	
497	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W/O CC/MCC	1.0813	2.0	2.6	
498	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC	1.9968	5.4	7.3	
499	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W/O CC/MCC	0.9936	2.2	3.0	
500	08	SURG	SOFT TISSUE PROCEDURES W MCC	3.0486	7.7	10.5	
501	08	SURG	SOFT TISSUE PROCEDURES W CC	1.5858	4.6	6.0	
502	08	SURG	SOFT TISSUE PROCEDURES W/O CC/MCC	1.0354	2.3	2.8	
503	08	SURG	FOOT PROCEDURES W MCC	2.2681	6.5	8.4	
504	08	SURG	FOOT PROCEDURES W CC	1.5696	5.0	6.2	
505	08	SURG	FOOT PROCEDURES W/O CC/MCC	1.0792	2.5	3.1	
506	08	SURG	MAJOR THUMB OR JOINT PROCEDURES	1.1834	2.7	3.8	
507	08	SURG	MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC	1.8823	3.4	4.5	
508	08	SURG	MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC	1.4101	1.7	2.1	
509	08	SURG	ARTHROSCOPY	1.3044	2.3	3.5	
510	08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W MCC	2.1698	5.0	6.3	
511	08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W CC	1.4748	3.2	3.9	
512	08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W/O CC/MCC	1.0533	1.8	2.1	
513	08	SURG	HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC	1.3000	3.5	4.8	
514	08	SURG	HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC	0.8215	2.1	2.6	
515	08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC	3.1992	7.7	9.9	
516	08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC	1.9292	4.7	5.9	
517	08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC	1.4856	2.6	3.4	
533	08	MED	FRACTURES OF FEMUR W MCC	1.5545	4.9	6.5	
534	08	MED	FRACTURES OF FEMUR W/O MCC	0.7576	3.1	3.9	
535	08	MED	FRACTURES OF HIP & PELVIS W MCC	1.3495	4.5	5.8	
536	08	MED	FRACTURES OF HIP & PELVIS W/O MCC	0.7175	3.2	3.7	
537	08	MED	SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W CC/MCC	0.8242	3.5	4.1	
538	08	MED	SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W/O CC/MCC	0.6060	2.6	3.0	
539	08	MED	OSTEOMYELITIS W MCC	2.0525	7.1	9.5	
540	08	MED	OSTEOMYELITIS W CC	1.3139	5.4	6.8	
541	08	MED	OSTEOMYELITIS W/O CC/MCC	0.8733	3.7	4.8	
542	08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC	1.9499	6.3	8.3	
543	08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC	1.1564	4.5	5.6	
544	08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC	0.7753	3.4	4.0	
545	08	MED	CONNECTIVE TISSUE DISORDERS W MCC	2.5453	6.3	9.0	
546	08	MED	CONNECTIVE TISSUE DISORDERS W CC	1.1596	4.2	5.3	
547	08	MED	CONNECTIVE TISSUE DISORDERS W/O CC/MCC	0.7297	2.9	3.5	
548	08	MED	SEPTIC ARTHRITIS W MCC	1.9836	6.6	8.7	
549	08	MED	SEPTIC ARTHRITIS W CC	1.2003	4.8	6.1	
550	08	MED	SEPTIC ARTHRITIS W/O CC/MCC	0.8223	3.3	4.0	
551	08	MED	MEDICAL BACK PROBLEMS W MCC	1.6337	5.2	6.8	
552	08	MED	MEDICAL BACK PROBLEMS W/O MCC	0.8160	3.3	4.0	
553	08	MED	BONE DISEASES & ARTHROPATHIES W MCC	1.1369	4.3	5.6	
554	08	MED	BONE DISEASES & ARTHROPATHIES W/O MCC	0.6774	3.0	3.6	
555	08	MED	SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W MCC	1.0941	3.6	4.8	
556	08	MED	SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC	0.6536	2.5	3.2	
557	08	MED	TENDONITIS, MYOSITIS & BURSITIS W MCC	1.5997	5.4	6.9	
558	08	MED	TENDONITIS, MYOSITIS & BURSITIS W/O MCC	0.8796	3.6	4.3	
559	08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC	1.7624	5.2	7.1	
560	08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC	0.9992	3.6	4.6	
561	08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC	0.6201	2.0	2.6	
562	08	MED	FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W MCC	1.3925	4.5	5.9	
563	08	MED	FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC	0.7120	3.0	3.6	
564	08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC	1.4686	5.0	6.6	
565	08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC	0.9051	3.7	4.6	
566	08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC	0.6592	2.7	3.4	
573	09	SURG	SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W MCC	3.2654	9.2	12.6	
574	09	SURG	SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W CC	1.8708	6.7	8.5	
575	09	SURG	SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W/O CC/MCC	1.0915	4.2	5.2	
576	09	SURG	SKIN GRAFT &/OR DEBRID EXC FOR SKIN ULCER OR CELLULITIS W MCC	3.9309	9.1	13.0	
577	09	SURG	SKIN GRAFT &/OR DEBRID EXC FOR SKIN ULCER OR CELLULITIS W CC	1.7025	4.1	6.2	
578	09	SURG	SKIN GRAFT &/OR DEBRID EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC	1.0505	2.4	3.3	
579	09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC	2.9643	7.7	10.5	
580	09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W CC	1.4993	3.8	5.4	
581	09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC	0.9301	1.8	2.4	
582	09	SURG	MASTECTOMY FOR MALIGNANCY W CC/MCC	1.0633	2.0	2.7	
583	09	SURG	MASTECTOMY FOR MALIGNANCY W/O CC/MCC	0.8543	1.5	1.7	
584	09	SURG	BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC	1.5258	3.5	5.0	
585	09	SURG	BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC	1.0568	1.7	2.1	
592	09	MED	SKIN ULCERS W MCC	1.7757	6.2	8.3	
593	09	MED	SKIN ULCERS W CC	1.0631	4.8	5.9	
594	09	MED	SKIN ULCERS W/O CC/MCC	0.7550	3.6	4.7	
595	09	MED	MAJOR SKIN DISORDERS W MCC	1.8752	5.9	7.9	
596	09	MED	MAJOR SKIN DISORDERS W/O MCC	0.8700	3.7	4.6	
597	09	MED	MALIGNANT BREAST DISORDERS W MCC	1.5651	5.5	7.5	
598	09	MED	MALIGNANT BREAST DISORDERS W CC	1.0728	4.1	5.5	
599	09	MED	MALIGNANT BREAST DISORDERS W/O CC/MCC	0.6318	2.5	3.3	
600	09	MED	NON-MALIGNANT BREAST DISORDERS W CC/MCC	0.9639	4.1	4.9	
601	09	MED	NON-MALIGNANT BREAST DISORDERS W/O CC/MCC	0.6731	3.0	3.6	
602	09	MED	CELLULITIS W MCC	1.4705	5.3	6.7	
603	09	MED	CELLULITIS W/O MCC	0.8346	3.8	4.5	
604	09	MED	TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W MCC	1.2286	3.9	5.2	
605	09	MED	TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC	0.7145	2.7	3.3	
606	09	MED	MINOR SKIN DISORDERS W MCC	1.3114	4.3	6.0	
607	09	MED	MINOR SKIN DISORDERS W/O MCC	0.6803	2.8	3.6	
614	10	SURG	ADRENAL & PITUITARY PROCEDURES W CC/MCC	2.4584	4.7	6.5	
615	10	SURG	ADRENAL & PITUITARY PROCEDURES W/O CC/MCC	1.3993	2.5	3.0	
616	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W MCC	4.4871	12.5	15.6	
617	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W CC	2.0083	6.5	7.9	
618	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W/O CC/MCC	1.2176	4.1	5.1	
619	10	SURG	O.R. PROCEDURES FOR OBESITY W MCC	3.6116	4.6	7.7	
620	10	SURG	O.R. PROCEDURES FOR OBESITY W CC	1.8814	2.6	3.4	
621	10	SURG	O.R. PROCEDURES FOR OBESITY W/O CC/MCC	1.4877	1.6	1.9	
622	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC	3.3683	9.4	12.4	
623	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC	1.8501	6.1	7.6	
624	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W/O CC/MCC	1.0337	3.9	4.8	
625	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W MCC	2.2439	4.6	6.9	
626	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W CC	1.1771	2.1	3.1	
627	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC	0.7884	1.2	1.4	
628	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC	3.3820	7.2	10.6	
629	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC	2.2645	6.5	8.0	
630	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC/MCC	1.4425	3.4	4.5	
637	10	MED	DIABETES W MCC	1.4431	4.5	6.0	
638	10	MED	DIABETES W CC	0.8267	3.2	4.0	
639	10	MED	DIABETES W/O CC/MCC	0.5508	2.3	2.8	
640	10	MED	NUTRITIONAL & MISC METABOLIC DISORDERS W MCC	1.1361	3.6	5.1	
641	10	MED	NUTRITIONAL & MISC METABOLIC DISORDERS W/O MCC	0.6887	2.9	3.6	
642	10	MED	INBORN ERRORS OF METABOLISM	1.0385	3.4	4.7	
643	10	MED	ENDOCRINE DISORDERS W MCC	1.8172	6.0	7.6	
644	10	MED	ENDOCRINE DISORDERS W CC	1.0586	4.2	5.2	
645	10	MED	ENDOCRINE DISORDERS W/O CC/MCC	0.7169	2.9	3.6	
652	11	SURG	KIDNEY TRANSPLANT	3.0630	6.3	7.5	
653	11	SURG	MAJOR BLADDER PROCEDURES W MCC	6.0950	13.6	16.6	
654	11	SURG	MAJOR BLADDER PROCEDURES W CC	3.0117	8.2	9.3	
655	11	SURG	MAJOR BLADDER PROCEDURES W/O CC/MCC	1.9644	4.8	5.7	
656	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC	3.5861	7.7	10.1	
657	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC	2.0062	4.9	5.9	
658	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC	1.4305	3.0	3.4	
659	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC	3.5110	8.0	10.8	
660	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC	1.9077	4.5	6.0	
661	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC	1.2709	2.4	2.9	
662	11	SURG	MINOR BLADDER PROCEDURES W MCC	3.0413	7.6	10.8	
663	11	SURG	MINOR BLADDER PROCEDURES W CC	1.4721	3.6	5.2	
664	11	SURG	MINOR BLADDER PROCEDURES W/O CC/MCC	1.1170	1.5	1.9	
665	11	SURG	PROSTATECTOMY W MCC	2.8519	8.7	11.3	
666	11	SURG	PROSTATECTOMY W CC	1.6440	4.5	6.4	
667	11	SURG	PROSTATECTOMY W/O CC/MCC	0.7945	1.8	2.4	
668	11	SURG	TRANSURETHRAL PROCEDURES W MCC	2.5102	6.6	8.9	
669	11	SURG	TRANSURETHRAL PROCEDURES W CC	1.2610	3.2	4.4	
670	11	SURG	TRANSURETHRAL PROCEDURES W/O CC/MCC	0.7790	1.8	2.3	
671	11	SURG	URETHRAL PROCEDURES W CC/MCC	1.4360	4.1	5.6	
672	11	SURG	URETHRAL PROCEDURES W/O CC/MCC	0.7921	1.8	2.2	
673	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC	2.9238	5.9	9.6	
674	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W CC	2.1004	4.6	6.7	
675	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC	1.3469	1.6	2.1	
682	11	MED	RENAL FAILURE W MCC	1.6383	5.1	6.8	
683	11	MED	RENAL FAILURE W CC	1.0208	4.0	4.9	
684	11	MED	RENAL FAILURE W/O CC/MCC	0.6561	2.8	3.3	
685	11	MED	ADMIT FOR RENAL DIALYSIS	0.8892	2.5	3.4	
686	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W MCC	1.8264	5.8	7.8	
687	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W CC	1.0822	3.8	5.0	
688	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W/O CC/MCC	0.6447	2.2	2.8	
689	11	MED	KIDNEY & URINARY TRACT INFECTIONS W MCC	1.2155	4.6	5.8	
690	11	MED	KIDNEY & URINARY TRACT INFECTIONS W/O MCC	0.7838	3.4	4.1	
691	11	MED	URINARY STONES W ESW LITHOTRIPSY W CC/MCC	1.6152	3.3	4.3	
692	11	MED	URINARY STONES W ESW LITHOTRIPSY W/O CC/MCC	1.1211	1.8	2.2	
693	11	MED	URINARY STONES W/O ESW LITHOTRIPSY W MCC	1.3487	3.9	5.2	
694	11	MED	URINARY STONES W/O ESW LITHOTRIPSY W/O MCC	0.7098	2.0	2.6	
695	11	MED	KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W MCC	1.2029	4.3	5.6	
696	11	MED	KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC	0.6555	2.6	3.2	
697	11	MED	URETHRAL STRICTURE	0.7776	2.4	3.1	
698	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC	1.6033	5.2	6.8	
699	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC	0.9988	3.7	4.7	
700	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC	0.6703	2.6	3.2	
707	12	SURG	MAJOR MALE PELVIC PROCEDURES W CC/MCC	1.7846	3.2	4.2	
708	12	SURG	MAJOR MALE PELVIC PROCEDURES W/O CC/MCC	1.2691	1.6	1.9	
709	12	SURG	PENIS PROCEDURES W CC/MCC	1.8781	3.3	5.7	
710	12	SURG	PENIS PROCEDURES W/O CC/MCC	1.2779	1.4	1.7	
711	12	SURG	TESTES PROCEDURES W CC/MCC	1.7619	5.1	7.3	
712	12	SURG	TESTES PROCEDURES W/O CC/MCC	0.8121	2.1	2.7	
713	12	SURG	TRANSURETHRAL PROSTATECTOMY W CC/MCC	1.1836	2.9	4.1	
714	12	SURG	TRANSURETHRAL PROSTATECTOMY W/O CC/MCC	0.6583	1.6	1.8	
715	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W CC/MCC	1.7470	4.1	6.1	
716	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W/O CC/MCC	1.0022	1.2	1.4	
717	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC	1.6076	4.6	6.4	
718	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W/O CC/MCC	0.8033	2.0	2.6	
722	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W MCC	1.6785	5.4	7.7	
723	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W CC	1.0170	3.9	5.1	
724	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.6171	2.0	2.7	
725	12	MED	BENIGN PROSTATIC HYPERTROPHY W MCC	1.2620	4.6	6.1	
726	12	MED	BENIGN PROSTATIC HYPERTROPHY W/O MCC	0.6977	2.8	3.5	
727	12	MED	INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC	1.3582	4.9	6.3	
728	12	MED	INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC	0.7599	3.3	4.1	
729	12	MED	OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W CC/MCC	0.9802	3.6	4.7	
730	12	MED	OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W/O CC/MCC	0.6377	2.3	2.8	
734	13	SURG	PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W CC/MCC	2.4243	5.1	6.9	
735	13	SURG	PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W/O CC/MCC	1.1801	2.2	2.7	
736	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W MCC	4.3876	11.5	14.0	
737	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W CC	2.0407	5.7	6.7	
738	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC	1.2377	3.2	3.6	
739	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC	3.4188	7.5	9.9	
740	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC	1.5323	3.8	4.7	
741	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC/MCC	1.1068	2.2	2.6	
742	13	SURG	UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC	1.3971	3.2	4.1	
743	13	SURG	UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC	0.9150	1.8	2.1	
744	13	SURG	D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC	1.5367	4.0	5.6	
745	13	SURG	D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W/O CC/MCC	0.8077	1.9	2.4	
746	13	SURG	VAGINA, CERVIX & VULVA PROCEDURES W CC/MCC	1.3373	3.0	4.2	
747	13	SURG	VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC	0.8929	1.5	1.8	
748	13	SURG	FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES	0.9231	1.4	1.7	
749	13	SURG	OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W CC/MCC	2.5219	6.2	8.5	
750	13	SURG	OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC	0.9389	2.2	2.8	
754	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W MCC	2.0061	6.4	8.8	
755	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC	1.1371	4.0	5.3	
756	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.6370	2.3	3.1	
757	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W MCC	1.6490	6.0	7.8	
758	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W CC	1.0895	4.7	5.7	
759	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.7344	3.3	4.0	
760	13	MED	MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W CC/MCC	0.8298	2.9	3.8	
761	13	MED	MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W/O CC/MCC	0.5246	1.8	2.2	
765	14	SURG	CESAREAN SECTION W CC/MCC	1.1316	3.9	4.9	
766	14	SURG	CESAREAN SECTION W/O CC/MCC	0.8063	2.9	3.1	
767	14	SURG	VAGINAL DELIVERY W STERILIZATION &/OR D&C	0.9173	2.4	2.7	
768	14	SURG	VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C	1.8108	0.0	0.0	
769	14	SURG	POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE	2.0588	3.6	5.7	
770	14	SURG	ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY	0.7140	1.6	2.1	
774	14	MED	VAGINAL DELIVERY W COMPLICATING DIAGNOSES	0.6894	2.6	3.2	
775	14	MED	VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES	0.5276	2.1	2.3	
776	14	MED	POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE	0.6419	2.6	3.3	
777	14	MED	ECTOPIC PREGNANCY	0.7401	1.7	2.1	
778	14	MED	THREATENED ABORTION	0.4880	2.0	3.2	
779	14	MED	ABORTION W/O D&C	0.5637	1.6	2.1	
780	14	MED	FALSE LABOR	0.2277	1.2	1.6	
781	14	MED	OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS	0.6807	2.7	3.8	
782	14	MED	OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS	0.4731	1.9	2.6	
789	15	MED	NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY	1.4874	0.0	0.0	
790	15	MED	EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE	4.9049	0.0	0.0	
791	15	MED	PREMATURITY W MAJOR PROBLEMS	3.3499	0.0	0.0	
792	15	MED	PREMATURITY W/O MAJOR PROBLEMS	2.0213	0.0	0.0	
793	15	MED	FULL TERM NEONATE W MAJOR PROBLEMS	3.4411	0.0	0.0	
794	15	MED	NEONATE W OTHER SIGNIFICANT PROBLEMS	1.2179	0.0	0.0	
795	15	MED	NORMAL NEWBORN	0.1649	0.0	0.0	
799	16	SURG	SPLENECTOMY W MCC	4.9483	10.4	13.4	
800	16	SURG	SPLENECTOMY W CC	2.6030	5.9	7.5	
801	16	SURG	SPLENECTOMY W/O CC/MCC	1.5588	3.1	3.9	
802	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W MCC	3.6327	8.6	12.2	
803	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W CC	1.8899	4.9	6.5	
804	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W/O CC/MCC	1.0419	2.3	3.0	
808	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC	2.1429	6.3	8.2	
809	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC	1.1935	4.0	5.1	
810	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC	0.9204	3.0	3.7	
811	16	MED	RED BLOOD CELL DISORDERS W MCC	1.2574	3.9	5.3	
812	16	MED	RED BLOOD CELL DISORDERS W/O MCC	0.7996	2.8	3.7	
813	16	MED	COAGULATION DISORDERS	1.4355	3.6	5.0	
814	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W MCC	1.6466	5.0	6.9	
815	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC	0.9989	3.6	4.6	
816	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC	0.6826	2.6	3.2	
820	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC	5.7484	13.2	17.5	
821	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC	2.3960	5.3	7.4	
822	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W/O CC/MCC	1.2251	2.3	3.1	
823	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W MCC	4.5904	12.2	16.0	
824	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC	2.3004	6.6	8.7	
825	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC/MCC	1.2439	2.7	3.9	
826	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W MCC	4.8575	11.2	14.8	
827	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC	2.1547	5.3	6.9	
828	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC/MCC	1.3894	3.0	3.8	
829	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R. PROC W CC/MCC	2.7281	6.2	9.3	
830	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R. PROC W/O CC/MCC	1.0911	2.3	3.1	
834	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC	4.9043	10.1	16.2	
835	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC	2.4310	5.7	9.3	
836	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W/O CC/MCC	1.1364	3.0	4.4	
837	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH DOSE CHEMO AGENT W MCC	6.6543	17.9	23.6	
838	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX W CC OR HIGH DOSE CHEMO AGENT	3.1384	8.1	12.3	
839	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC	1.2874	4.6	5.7	
840	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W MCC	2.9245	7.8	10.6	
841	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W CC	1.6376	5.1	6.8	
842	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC	1.0382	3.2	4.2	
843	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W MCC	1.8400	6.0	8.0	
844	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC	1.1895	4.3	5.6	
845	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC/MCC	0.8099	2.9	3.8	
846	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC	2.1885	5.4	8.0	
847	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC	0.9901	2.8	3.4	
848	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W/O CC/MCC	0.8070	2.4	3.0	
849	17	MED	RADIOTHERAPY	1.2501	4.4	6.0	
853	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC	5.5154	12.1	15.7	
854	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC	2.7976	8.2	10.0	
855	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W/O CC/MCC	1.3920	3.9	5.4	
856	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC	5.1335	11.2	15.0	
857	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC	2.1011	6.2	7.9	
858	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC	1.3079	4.1	5.1	
862	18	MED	POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC	1.9553	5.8	7.8	
863	18	MED	POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC	0.9765	4.0	4.9	
864	18	MED	FEVER	0.8255	3.0	3.8	
865	18	MED	VIRAL ILLNESS W MCC	1.5524	4.5	6.4	
866	18	MED	VIRAL ILLNESS W/O MCC	0.7420	2.8	3.5	
867	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC	2.4723	6.8	9.2	
868	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W CC	1.1597	4.3	5.4	
869	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W/O CC/MCC	0.7183	3.0	3.6	
870	18	MED	SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS	5.8105	12.8	15.2	
871	18	MED	SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC	1.9056	5.4	7.2	
872	18	MED	SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W/O MCC	1.1522	4.5	5.4	
876	19	SURG	O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS	2.8176	8.1	12.7	
880	19	MED	ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION	0.6148	2.3	3.0	
881	19	MED	DEPRESSIVE NEUROSES	0.6140	3.1	4.2	
882	19	MED	NEUROSES EXCEPT DEPRESSIVE	0.6250	3.1	4.3	
883	19	MED	DISORDERS OF PERSONALITY & IMPULSE CONTROL	1.0741	4.9	7.7	
884	19	MED	ORGANIC DISTURBANCES & MENTAL RETARDATION	0.9345	4.0	5.4	
885	19	MED	PSYCHOSES	0.8920	5.4	7.4	
886	19	MED	BEHAVIORAL & DEVELOPMENTAL DISORDERS	0.8253	3.9	6.2	
887	19	MED	OTHER MENTAL DISORDER DIAGNOSES	0.7744	2.9	4.0	
894	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA	0.4007	2.1	2.9	
895	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY	1.0145	8.5	10.9	
896	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC	1.4528	4.7	6.5	
897	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC	0.6413	3.2	4.0	
901	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W MCC	3.9427	9.1	14.1	
902	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W CC	1.7989	5.4	7.5	
903	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC	1.0616	3.3	4.4	
904	21	SURG	SKIN GRAFTS FOR INJURIES W CC/MCC	3.0388	7.3	11.1	
905	21	SURG	SKIN GRAFTS FOR INJURIES W/O CC/MCC	1.1720	3.4	4.5	
906	21	SURG	HAND PROCEDURES FOR INJURIES	1.0393	2.1	3.1	
907	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W MCC	3.8155	7.8	11.1	
908	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W CC	1.9277	4.7	6.3	
909	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC	1.1622	2.6	3.4	
913	21	MED	TRAUMATIC INJURY W MCC	1.3305	4.0	5.6	
914	21	MED	TRAUMATIC INJURY W/O MCC	0.6943	2.5	3.2	
915	21	MED	ALLERGIC REACTIONS W MCC	1.4162	3.6	5.1	
916	21	MED	ALLERGIC REACTIONS W/O MCC	0.4820	1.7	2.1	
917	21	MED	POISONING & TOXIC EFFECTS OF DRUGS W MCC	1.4814	3.7	5.1	
918	21	MED	POISONING & TOXIC EFFECTS OF DRUGS W/O MCC	0.6234	2.1	2.7	
919	21	MED	COMPLICATIONS OF TREATMENT W MCC	1.5999	4.4	6.2	
920	21	MED	COMPLICATIONS OF TREATMENT W CC	0.9760	3.2	4.3	
921	21	MED	COMPLICATIONS OF TREATMENT W/O CC/MCC	0.6179	2.2	2.8	
922	21	MED	OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC	1.3409	3.8	5.4	
923	21	MED	OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC	0.6742	2.3	3.2	
927	22	SURG	EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV 96+ HRS W SKIN GRAFT	12.6506	21.8	28.2	
928	22	SURG	FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC/MCC	4.7191	10.8	14.9	
929	22	SURG	FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W/O CC/MCC	2.0261	5.3	7.7	
933	22	MED	EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV 96+ HRS W/O SKIN GRAFT	2.2750	2.3	5.2	
934	22	MED	FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ	1.3530	4.1	5.8	
935	22	MED	NON-EXTENSIVE BURNS	1.2817	3.5	5.2	
939	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W MCC	2.8683	6.8	10.0	
940	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC	1.6847	3.6	5.4	
941	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC	1.1488	2.0	2.6	
945	23	MED	REHABILITATION W CC/MCC	1.2883	8.3	10.2	
946	23	MED	REHABILITATION W/O CC/MCC	1.1140	6.6	7.5	
947	23	MED	SIGNS & SYMPTOMS W MCC	1.0970	3.7	4.9	
948	23	MED	SIGNS & SYMPTOMS W/O MCC	0.6840	2.7	3.4	
949	23	MED	AFTERCARE W CC/MCC	0.9823	2.6	4.3	
950	23	MED	AFTERCARE W/O CC/MCC	0.4983	2.1	2.8	
951	23	MED	OTHER FACTORS INFLUENCING HEALTH STATUS	0.6963	2.2	4.5	
955	24	SURG	CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA	5.4991	9.0	12.6	
956	24	SURG	LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA	3.3461	7.0	8.4	
957	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC	6.3035	10.2	14.3	
958	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC	3.8041	7.6	9.5	
959	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC	2.2479	4.5	5.6	
963	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC	2.8145	6.0	8.7	
964	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W CC	1.4818	4.5	5.6	
965	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC	0.9316	3.1	3.8	
969	25	SURG	HIV W EXTENSIVE O.R. PROCEDURE W MCC	5.5054	12.1	17.1	
970	25	SURG	HIV W EXTENSIVE O.R. PROCEDURE W/O MCC	2.7380	6.3	8.7	
974	25	MED	HIV W MAJOR RELATED CONDITION W MCC	2.5819	6.9	9.6	
975	25	MED	HIV W MAJOR RELATED CONDITION W CC	1.3551	5.1	6.6	
976	25	MED	HIV W MAJOR RELATED CONDITION W/O CC/MCC	0.9004	3.5	4.4	
977	25	MED	HIV W OR W/O OTHER RELATED CONDITION	1.0398	3.6	4.9	
981		SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	5.0726	11.0	14.1	
982		SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC	2.9434	6.8	8.7	
983		SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.7800	3.1	4.2	
984		SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	3.3086	10.5	13.3	
985		SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC	2.1518	6.9	9.0	
986		SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.1129	2.8	4.1	
987		SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	3.4500	9.3	12.2	
988		SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC	1.8721	5.6	7.4	
989		SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.0568	2.5	3.5	
998		**	PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS	0.0000	0.0	0.0	
999		**	UNGROUPABLE	0.0000	0.0	0.0	
MS-DRGs 998 and 999 contain cases that could not be assigned to valid DRGs.	
Note: If there is no value in either the geometric mean length of stay or the arithmetic mean length of stay columns, the volume of cases is insufficient to determine a meaningful computation of these statistics. 	

Exhibit #2 struck and replaced
Exhibit #2	
Hospital Base Rates and CCRs, Effective 1/1/2011	
Provider Number	Provider Name 	Base Rate	Total CCR	
60001	BANNER HEALTH DBA NORTH COLORADO MEDICAL CENTER	$6,471.50	0.311	
60003	LONGMONT UNITED HOSPITAL	$5,846.67	0.343	
60004	PLATTE VALLEY MEDICAL CENTER	$6,318.04	0.388	
60006	MONTROSE MEMORIAL HOSPITAL	$5,845.23	0.449	
60008	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	$5,954.11	0.407	
60009	EXEMPLA LUTHERAN MEDICAL CENTER	$5,952.37	0.243	
60010	POUDRE VALLEY HEALTH CARE  INC	$5,860.68	0.37	
60011	DENVER HEALTH  & HOSPITAL AUTHORITY	$9,587.56	0.387	
60012	CENTURA HEALTH--ST MARY CORWIN MEDICAL CENTER	$5,961.97	0.291	
60013	MERCY REGIONAL MEDICAL CENTER	$7,010.46	0.407	
60014	PRESBYTERIAN/ST LUKE'S	$6,923.60	0.264	
60015	CENTURA HEALTH--ST ANTHONY HOSPITAL CENTRAL	$6,068.25	0.217	
60016	CENTURA HEALTH--ST THOMAS MORE HOSPITAL	$5,960.01	0.365	
60018	SOUTHWEST MEMORIAL HOSPITAL	 	 	
60020	PARKVIEW MEDICAL CENTER	$5,984.25	0.221	
60022	MEMORIAL HOSPITAL CENTRAL--COLORADO SPRINGS	$6,022.59	0.464	
60022	MEMORIAL HOSPITAL NORTH	$6,022.59	0.464	
60023	ST MARY'S HOSPITAL & MEDICAL CENTER	$6,326.13	0.377	
60024	UNIVERSITY OF COLORADO HOSPITAL AT FITZSIMONS	$8,731.65	0.248	
60027	BOULDER COMMUNITY HOSPITAL	$5,630.88	0.337	
60028	EXEMPLA SAINT JOSEPH HOSPITAL	$6,509.06	0.258	
60030	BANNER HEALTH DBA MCKEE MEDICAL CENTER	$5,604.12	0.448	
60031	CENTURA HEALTH--PENROSE-ST FRANCIS HEALTH SERVICES	$5,669.71	0.254	
60032	ROSE MEDICAL CENTER	$6,542.92	0.225	
60034	SWEDISH MEDICAL CENTER A	$6,032.35	0.227	
60036	ARKANSAS VALLEY REGIONAL MEDICAL CENTER	$5,954.11	0.454	
60043	KEEFE MEMORIAL HOSPITAL	$14,582.36	1.226	
60044	COLORADO  PLAINS MEDICAL CENTER	$5,982.80	0.327	
60049	YAMPA VALLEY MEDICAL CENTER	$8,763.45	0.599	
60054	COMMUNITY HOSPITAL	$5,523.50	0.536	
60064	CENTURA HEALTH-PORTER ADVENTIST HOSPITAL	$5,696.37	0.261	
60065	NORTH SUBURBAN MEDICAL CENTER	$6,461.21	0.236	
60071	DELTA COUNTY MEMORIAL HOSPITAL	$5,627.88	0.501	
60075	VALLEY VIEW HOSPITAL	$7,499.19	0.501	
60076	BANNER HEALTH DBA STERLING REGIONAL MEDCENTER	$7,114.62	0.502	
60096	VAIL VALLEY MEDICAL CENTER	$10,980.80	0.513	
60100	MEDICAL CENTER OF AURORA	$6,069.77	0.238	
60103	CENTURA HEALTH-AVISTA ADVENTIST HOSPITAL	$6,344.32	0.359	
60104	CENTURA HEALTH--ST ANTHONY HOSPITAL NORTH	$6,312.44	0.259	
60107	NATIONAL JEWISH MEDICAL & RESEARCH CENTER	$6,318.04	0.425	
60112	SKYRIDGE MEDICAL CENTER	$5,699.31	0.227	
60113	CENTURA HEALTH-LITTLETON ADVENTIST HOSPITAL	$5,693.57	0.231	
60114	CENTURA HEALTH-PARKER ADVENTIST HOSPITAL	$5,687.70	0.263	
60115	COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO	$5,359.97	0.979	
60116	EXEMPLA GOOD SAMARITAN MEDICAL CENTER	$5,625.88	0.288	
60117	ANIMAS SURGICAL HOSPITAL	$5,359.97	0.512	
60118	SAINT ANTHONY SUMMIT MEDICAL CENTER	$5,826.07	0.316	

Exhibit 3
Effective January 1, 2011 2010
Critical Access Hospitals
Name	Location in Colorado 	
Aspen Valley Hospital	Aspen 	
Conejos County Hospital	La Jara 	
East Morgan County Hospital 	Brush 	
Estes Park Medical Center	Estes Park	
Family Health West Hospital 	Fruita 	
Grand River Medical Center	Rifle	
Gunnison Valley Hospital	Gunnison	
Haxtun Hospital District	Haxtun	
Heart of the Rockies Regional Medical Center	Salida	
Kit Carson County Memeorial Hospital	Burlington	
Kremmling Memorial Hospital 	Kremmling	
Lincoln Community Hospital	Hugo	
Melissa Memorial Hospital	Holyoke	
The Memorial Hospital	Craig	
Mt. San Rafael Hospital	Trinidad	
Pagosa Mountain Hospital	Pagosa Springs	
Pikes Peak Regional Hospital	Woodland Park	
Pioneers Medical Center
Prowers Medical Center	Meeker
Lamar	
Rangeley District Hospital	Rangely	
Rio Grande Hospital	Del Norte	
Sedgwick County Memorial Hospital	Julesburg	
Southeast Colorado Hospital	Springfield	
Southwest Memorial Hospital	Cortez	
Spanish Peaks Regional Helath Center	Walsenburg	
St. Vincent General Hospital	Leadville	
Weisbrod Memorial County Hospital	Eads	
Wray Community District Hospital	Wray	
Yuma District Hospital	Yuma	

Exhibit 4 Struck and Replaced
	Exhibit #4		
	Effective: January 1, 2011		
	Outpatient Surgery Facility Groupers and Fees 		
APC	Group Title	Adjusted Addendum B 5/17/2010 at 160% & Adjusted for Implants	
1	Level I Photochemotherapy	$0.00	
2	Fine Needle Biopsy/Aspiration	$0.00	
3	Bone Marrow Biopsy/Aspiration	$333.49	
4	Level I Needle Biopsy/ Aspiration Except Bone Marrow	$494.65	
5	Level II Needle Biopsy/Aspiration Except Bone Marrow	$805.58	
6	Level I Incision & Drainage	$0.00	
7	Level II Incision & Drainage	$1,348.39	
8	Level III Incision and Drainage	$2,082.19	
12	Level I Debridement & Destruction	$0.00	
13	Level II Debridement & Destruction	$0.00	
15	Level III Debridement & Destruction	$165.79	
16	Level IV Debridement & Destruction	$301.04	
17	Level VI Debridement & Destruction	$2,283.94	
19	Level I Excision/ Biopsy	$469.34	
20	Level II Excision/ Biopsy	$882.14	
21	Level III Excision/ Biopsy	$1,878.89	
22	Level IV Excision/ Biopsy	$2,507.13	
28	Level I Breast Surgery	$2,656.51	
29	Level II Breast Surgery	$3,654.71	
30	Level III Breast Surgery	$4,448.80	
31	Smoking Cessation Services	$0.00	
34	Mental Health Services Composite	$0.00	
35	Vascular Puncture and Minor Diagnostic Procedures	$0.00	
37	Level IV Needle Biopsy/Aspiration Except Bone Marrow	$1,592.39	
39	Level I Implantation of Neurostimulator Generator	$3,184.19	
40	Percutaneous Implantation of Neurostimulator Electrodes	$2,984.60	
41	Level I Arthroscopy	$3,213.14	
42	Level II Arthroscopy	$4,966.70	
45	Bone/Joint Manipulation Under Anesthesia	$1,643.40	
47	Arthroplasty without Prosthesis	$3,727.37	
48	Level I Arthroplasty or Implantation with Prosthesis	$3,974.40	
49	Level I Musculoskeletal Procedures Except Hand and Foot	$2,359.46	
50	Level II Musculoskeletal Procedures Except Hand and Foot	$3,211.55	
51	Level III Musculoskeletal Procedures Except Hand and Foot	$4,353.61	
52	Level IV Musculoskeletal Procedures Except Hand and Foot	$7,146.47	
53	Level I Hand Musculoskeletal Procedures	$1,831.82	
54	Level II Hand Musculoskeletal Procedures	$2,932.58	
55	Level I Foot Musculoskeletal Procedures	$2,329.13	
56	Level II Foot Musculoskeletal Procedures	$4,186.09	
57	Bunion Procedures	$3,107.81	
58	Level I Strapping and Cast Application	$0.00	
60	Manipulation Therapy	$0.00	
61	Laminectomy, Laparoscopy, or Incision for Implantation of Neurostimulator Electr	$3,376.39	
62	Level I Treatment Fracture/Dislocation	$2,684.63	
63	Level II Treatment Fracture/Dislocation	$4,099.25	
64	Level III Treatment Fracture/Dislocation	$4,433.57	
65	Level I Stereotactic Radiosurgery, MRgFUS, and MEG	$1,536.42	
66	Level II Stereotactic Radiosurgery, MRgFUS, and MEG	$3,971.18	
67	Level III Stereotactic Radiosurgery, MRgFUS, and MEG	$5,700.86	
69	Thoracoscopy	$3,628.74	
70	Thoracentesis/Lavage Procedures	$580.50	
71	Level I Endoscopy Upper Airway	$0.00	
72	Level II Endoscopy Upper Airway	$0.00	
73	Level III Endoscopy Upper Airway	$474.66	
74	Level IV Endoscopy Upper Airway	$2,312.72	
75	Level V Endoscopy Upper Airway	$2,934.56	
76	Level I Endoscopy Lower Airway	$1,115.18	
77	Level I Pulmonary Treatment	$0.00	
78	Level III Pulmonary Treatment	$0.00	
79	Ventilation Initiation and Management	$0.00	
80	Diagnostic Cardiac Catheterization	$3,874.67	
82	Coronary or Non-Coronary Atherectomy	$6,485.41	
83	Coronary or Non-Coronary Angioplasty and Percutaneous Valvuloplasty	$4,209.03	
84	Level I Electrophysiologic Procedures	$1,161.36	
85	Level II Electrophysiologic Procedures	$4,014.64	
86	Level III Electrophysiologic Procedures	$6,715.54	
88	Thrombectomy	$4,048.28	
89	Insertion/Replacement of Permanent Pacemaker and Electrodes	$3,589.38	
90	Insertion/Replacement of Pacemaker Pulse Generator	$2,679.94	
91	Level II Vascular Ligation	$3,376.90	
92	Level I Vascular Ligation	$2,792.20	
93	Vascular Reconstruction/Fistula Repair without Device	$2,938.27	
94	Level I Resuscitation and Cardioversion	$264.16	
95	Cardiac Rehabilitation	$0.00	
96	Level II Noninvasive Physiologic Studies	$0.00	
97	Level I Noninvasive Physiologic Studies	$0.00	
99	Electrocardiograms	$0.00	
100	Cardiac Stress Tests	$0.00	
101	Tilt Table Evaluation	$0.00	
102	Level II Pulmonary Treatment	$0.00	
103	Miscellaneous Vascular Procedures	$1,833.69	
104	Transcatheter Placement of Intracoronary Stents	$4,690.02	
105	Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices	$2,314.99	
106	Insertion/Replacement of Pacemaker Leads and/or Electrodes	$2,947.89	
107	Insertion of Cardioverter-Defibrillator	$3,800.51	
108	Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads	$5,107.96	
110	Transfusion	$363.71	
111	Blood Product Exchange	$1,284.83	
112	Apheresis and Stem Cell Procedures	$3,584.82	
113	Excision Lymphatic System	$2,635.43	
114	Thyroid/Lymphadenectomy Procedures	$5,218.64	
115	Cannula/Access Device Procedures	$2,908.52	
121	Level I Tube or Catheter Changes or Repositioning	$639.92	
126	Level I Urinary and Anal Procedures	$0.00	
127	Level IV Stereotactic Radiosurgery, MRgFUS, and MEG	$11,722.08	
128	Echocardiogram with Contrast	$1,039.31	
129	Level I Closed Treatment Fracture Finger/Toe/Trunk	$178.34	
130	Level I Laparoscopy	$3,963.14	
131	Level II Laparoscopy	$4,960.51	
132	Level III Laparoscopy	$7,583.29	
133	Level I Skin Repair	$0.00	
134	Level II Skin Repair	$337.41	
135	Level III Skin Repair	$476.24	
136	Level IV Skin Repair	$1,723.91	
137	Level V Skin Repair	$2,567.48	
138	Level II Closed Treatment Fracture Finger/Toe/Trunk	$515.82	
139	Level III Closed Treatment Fracture Finger/Toe/Trunk	$1,973.22	
140	Esophageal Dilation without Endoscopy	$633.53	
141	Level I Upper GI Procedures	$929.55	
142	Small Intestine Endoscopy	$1,046.04	
143	Lower GI Endoscopy	$978.80	
146	Level I Sigmoidoscopy and Anoscopy	$621.03	
147	Level II Sigmoidoscopy and Anoscopy	$972.39	
148	Level I Anal/Rectal Procedures	$577.20	
149	Level III Anal/Rectal Procedures	$2,567.49	
150	Level IV Anal/Rectal Procedures	$3,405.67	
151	Endoscopic Retrograde Cholangio-Pancreatography (ERCP)	$2,213.64	
152	Level I Percutaneous Abdominal and Biliary Procedures	$2,289.94	
153	Peritoneal and Abdominal Procedures	$2,887.24	
154	Hernia/Hydrocele Procedures	$3,100.40	
155	Level II Anal/Rectal Procedures	$1,518.01	
156	Level III Urinary and Anal Procedures	$325.06	
157	Colorectal Cancer Screening: Barium Enema	$0.00	
158	Colorectal Cancer Screening: Colonoscopy	$870.23	
159	Colorectal Cancer Screening: Flexible Sigmoidoscopy	$400.51	
160	Level I Cystourethroscopy and other Genitourinary Procedures	$767.54	
161	Level II Cystourethroscopy and other Genitourinary Procedures	$1,777.91	
162	Level III Cystourethroscopy and other Genitourinary Procedures	$2,662.15	
163	Level IV Cystourethroscopy and other Genitourinary Procedures	$3,782.25	
164	Level II Urinary and Anal Procedures	$0.00	
165	Level IV Urinary and Anal Procedures	$2,074.41	
166	Level I Urethral Procedures	$2,173.32	
168	Level II Urethral Procedures	$2,091.15	
169	Lithotripsy	$4,441.09	
170	Dialysis	$731.35	
172	Level I Partial Hospitalization (3 services)	$0.00	
173	Level II Partial Hospitalization (4 or more services)	$0.00	
174	Level IV Laparoscopy	$9,674.48	
181	Level II Male Genital Procedures	$3,630.70	
183	Level I Male Genital Procedures	$2,503.75	
184	Prostate Biopsy	$1,336.62	
188	Level II Female Reproductive Proc	$0.00	
189	Level III Female Reproductive Proc	$0.00	
190	Level I Hysteroscopy	$2,426.25	
191	Level I Female Reproductive Proc	$0.00	
192	Level IV Female Reproductive Proc	$731.04	
193	Level V Female Reproductive Proc	$2,152.04	
195	Level VI Female Reproductive Procedures	$3,586.13	
202	Level VII Female Reproductive Procedures	$3,115.77	
203	Level IV Nerve Injections	$1,421.99	
204	Level I Nerve Injections	$274.96	
206	Level II Nerve Injections	$400.41	
207	Level III Nerve Injections	$774.02	
208	Laminotomies and Laminectomies	$5,193.51	
209	Level II Extended EEG, Sleep, and Cardiovascular Studies	$1,229.87	
210	Spinal Fusion	$5,193.51	
213	Level I Extended EEG, Sleep, and Cardiovascular Studies	$0.00	
215	Level I Nerve and Muscle Tests	$0.00	
216	Level III Nerve and Muscle Tests	$0.00	
218	Level II Nerve and Muscle Tests	$0.00	
220	Level I Nerve Procedures	$2,012.38	
221	Level II Nerve Procedures	$3,403.32	
224	Implantation of Catheter/Reservoir/Shunt	$3,691.52	
225	Implantation of Neurostimulator Electrodes, Cranial Nerve	$4,545.47	
227	Implantation of Drug Infusion Device	$3,658.38	
229	Transcatherter Placement of Intravascular Shunts	$5,933.17	
230	Level I Eye Tests & Treatments	$0.00	
231	Level III Eye Tests & Treatments	$210.59	
232	Level I Anterior Segment Eye Procedures	$484.93	
233	Level II Anterior Segment Eye Procedures	$1,748.11	
234	Level III Anterior Segment Eye Procedures	$2,503.72	
235	Level I Posterior Segment Eye Procedures	$629.36	
237	Level II Posterior Segment Eye Procedures	$2,158.87	
238	Level I Repair and Plastic Eye Procedures	$347.15	
239	Level II Repair and Plastic Eye Procedures	$810.23	
240	Level III Repair and Plastic Eye Procedures	$1,940.81	
241	Level IV Repair and Plastic Eye Procedures	$2,799.55	
242	Level V Repair and Plastic Eye Procedures	$3,647.59	
243	Strabismus/Muscle Procedures	$2,518.39	
244	Corneal and Amniotic Membrane Transplant	$3,515.97	
245	Level I Cataract Procedures without IOL Insert	$1,660.53	
246	Cataract Procedures with IOL Insert	$2,259.40	
247	Laser Eye Procedures	$570.07	
249	Level II Cataract Procedures without IOL Insert	$3,191.36	
250	Level I ENT Procedures	$0.00	
251	Level II ENT Procedures	$368.48	
252	Level III ENT Procedures	$818.20	
253	Level IV ENT Procedures	$1,834.71	
254	Level V ENT Procedures	$2,675.77	
256	Level VI ENT Procedures	$4,513.99	
259	Level VII ENT Procedures	$7,041.63	
260	Level I Plain Film Except Teeth	$0.00	
261	Level II Plain Film Except Teeth Including Bone Density Measurement	$0.00	
262	Plain Film of Teeth	$0.00	
263	Level I Miscellaneous Radiology Procedures	$0.00	
265	Level I Diagnostic and Screening Ultrasound	$0.00	
266	Level II Diagnostic and Screening Ultrasound	$0.00	
267	Level III Diagnostic and Screening Ultrasound	$0.00	
269	Level II Echocardiogram Without Contrast 	$719.78	
270	Level III Echocardiogram Without Contrast 	$951.14	
272	Fluoroscopy	$0.00	
274	Myelography	$777.41	
275	Arthrography	$423.26	
276	Level I Digestive Radiology	$0.00	
277	Level II Digestive Radiology	$0.00	
278	Diagnostic Urography	$0.00	
279	Level II Angiography and Venography	$2,708.23	
280	Level III Angiography and Venography	$4,464.90	
282	Miscellaneous Computed Axial Tomography	$0.00	
283	Computed Tomography with Contrast	$474.08	
284	Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast	$676.58	
288	Bone Density:Axial Skeleton	$0.00	
293	Level V Anterior Segment Eye Procedures	$4,078.39	
299	Hyperthermia and Radiation Treatment Procedures	$607.44	
300	Level I Radiation Therapy	$0.00	
301	Level II Radiation Therapy	$0.00	
303	Treatment Device Construction	$0.00	
304	Level I Therapeutic Radiation Treatment Preparation	$0.00	
305	Level II Therapeutic Radiation Treatment Preparation	$424.94	
307	Myocardial Positron Emission Tomography (PET) imaging	$2,286.98	
308	Non-Myocardial Positron Emission Tomography (PET) imaging	$1,655.70	
310	Level III Therapeutic Radiation Treatment Preparation	$1,475.81	
312	Radioelement Applications	$482.48	
313	Brachytherapy	$1,241.04	
315	Level II Implantation of Neurostimulator Generator 	$3,426.84	
317	Level II Miscellaneous Radiology Procedures	$577.30	
320	Electroconvulsive Therapy	$0.00	
322	Brief Individual Psychotherapy	$0.00	
323	Extended Individual Psychotherapy	$0.00	
324	Family Psychotherapy	$0.00	
325	Group Psychotherapy	$0.00	
330	Dental Procedures	$0.00	
332	Computed Tomography without Contrast	$0.00	
333	Computed Tomography without Contrast followed by Contrast	$532.32	
336	Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast	$557.83	
337	Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast	$854.58	
340	Minor Ancillary Procedures	$0.00	
341	Skin Tests	$0.00	
342	Level I Pathology	$0.00	
343	Level III Pathology	$0.00	
344	Level IV Pathology	$0.00	
345	Level I Transfusion Laboratory Procedures	$0.00	
346	Level II Transfusion Laboratory Procedures	$0.00	
347	Level III Transfusion Laboratory Procedures	$0.00	
350	Administration of flu and PPV vaccine	$0.00	
360	Level I Alimentary Tests	$0.00	
361	Level II Alimentary Tests	$434.66	
363	Level I Otorhinolaryngologic Function Tests	$0.00	
364	Level I Audiometry	$0.00	
365	Level II Audiometry	$0.00	
366	Level III Audiometry	$0.00	
367	Level I Pulmonary Test	$0.00	
368	Level II Pulmonary Tests	$0.00	
369	Level III Pulmonary Tests	$0.00	
370	Allergy Tests	$0.00	
373	Level I Neuropsychological Testing	$0.00	
375	Ancillary Outpatient Services When Patient Expires	$0.00	
377	Level II Cardiac Imaging	$1,237.12	
378	Level II Pulmonary Imaging	$516.54	
379	Injection adenosine 6 MG	$0.00	
381	Single Allergy Tests	$0.00	
382	Level II Neuropsychological Testing	$0.00	
383	Cardiac Computed Tomographic Imaging	$0.00	
384	GI Procedures with Stents	$2,172.67	
385	Level I Prosthetic Urological Procedures	$4,288.07	
386	Level II Prosthetic Urological Procedures	$5,179.25	
387	Level II Hysteroscopy	$3,847.37	
388	Discography	$2,772.17	
389	Level I Non-imaging Nuclear Medicine	$0.00	
390	Level I Endocrine Imaging	$0.00	
391	Level II Endocrine Imaging	$0.00	
392	Level II Non-imaging Nuclear Medicine	$0.00	
393	Hematologic Processing & Studies	$0.00	
394	Hepatobiliary Imaging	$0.00	
395	GI Tract Imaging	$0.00	
396	Bone Imaging	$0.00	
397	Vascular Imaging	$0.00	
398	Level I Cardiac Imaging	$0.00	
400	Hematopoietic Imaging	$0.00	
401	Level I Pulmonary Imaging	$0.00	
402	Level II Nervous System Imaging	$0.00	
403	Level I Nervous System Imaging	$0.00	
404	Renal and Genitourinary Studies	$518.78	
406	Level I Tumor/Infection Imaging	$462.98	
407	Level I Radionuclide Therapy	$0.00	
408	Level III Tumor/Infection Imaging	$1,537.12	
409	Red Blood Cell Tests	$0.00	
412	IMRT Treatment Delivery	$672.30	
413	Level II Radionuclide Therapy	$559.52	
414	Level II Tumor/Infection Imaging	$813.02	
415	Level II Endoscopy Lower Airway	$2,555.41	
418	Insertion of Left Ventricular Pacing Elect.	$4,089.31	
422	Level II Upper GI Procedures	$2,082.66	
423	Level II Percutaneous Abdominal and Biliary Procedures	$4,696.55	
425	Level II Arthroplasty or Implantation with Prosthesis	$5,406.05	
426	Level II Strapping and Cast Application	$0.00	
427	Level II Tube or Catheter Changes or Repositioning	$1,275.31	
428	Level III Sigmoidoscopy and Anoscopy	$2,450.75	
429	Level V Cystourethroscopy and other Genitourinary Procedures	$4,967.22	
432	Health and Behavior Services	$0.00	
433	Level II Pathology	$0.00	
434	Cardiac Defect Repair	$5,295.15	
436	Level I Drug Administration	$0.00	
437	Level II Drug Administration	$0.00	
438	Level III Drug Administration	$0.00	
439	Level IV Drug Administration	$0.00	
440	Level V Drug Administration	$0.00	
442	Dosimetric Drug Administration	$2,772.21	
604	Level 1 Hospital Clinic Visits	$0.00	
605	Level 2 Hospital Clinic Visits	$0.00	
606	Level 3 Hospital Clinic Visits	$0.00	
607	Level 4 Hospital Clinic Visits	$0.00	
608	Level 5 Hospital Clinic Visits	$0.00	
609	Level 1 Type A Emergency Visits	$0.00	
613	Level 2 Type A Emergency Visits	$0.00	
614	Level 3 Type A Emergency Visits	$0.00	
615	Level 4 Type A Emergency Visits	$0.00	
616	Level 5 Type A Emergency Visits	$0.00	
617	Critical Care	$0.00	
618	Trauma Response with Critical Care	$0.00	
621	Level I Vascular Access Procedures	$1,032.58	
622	Level II Vascular Access Procedures	$1,846.63	
623	Level III Vascular Access Procedures	$2,390.12	
624	Phlebotomy and Minor Vascular Access Device Procedures	$0.00	
626	Level 1 Type B Emergency Visits	$0.00	
627	Level 2 Type B Emergency Visits	$0.00	
628	Level 3 Type B Emergency Visits	$0.00	
629	Level 4 Type B Emergency Visits	$0.00	
630	Level 5 Type B Emergency Visits	$0.00	
648	Level IV Breast Surgery	$3,246.39	
651	Complex Interstitial Radiation Source Application	$1,390.93	
652	Insertion of Intraperitoneal and Pleural Catheters	$2,947.25	
653	Vascular Reconstruction/Fistula Repair with Device	$3,755.10	
654	Insertion/Replacement of a permanent dual chamber pacemaker	$2,914.79	
655	Insertion/Replacement/Conversion of a permanent dual chamber pacemaker	$3,823.11	
656	Transcatheter Placement of Intracoronary Drug-Eluting Stents	$4,840.89	
659	Hyperbaric Oxygen	$0.00	
660	Level II Otorhinolaryngologic Function Tests	$0.00	
661	Level V Pathology	$0.00	
662	CT Angiography	$543.37	
664	Level I Proton Beam Radiation Therapy	$1,504.00	
665	Bone Density:AppendicularSkeleton	$0.00	
667	Level II Proton Beam Radiation Therapy	$1,967.46	
668	Level I Angiography and Venography	$1,019.82	
672	Level III Posterior Segment Eye Procedures	$4,216.83	
673	Level IV Anterior Segment Eye Procedures	$3,085.01	
674	Prostate Cryoablation	$5,326.50	
676	Thrombolysis and Other Device Revisions 	$0.00	
678	External Counterpulsation	$0.00	
679	Level II Resuscitation and Cardioversion	$591.21	
680	Insertion of Patient Activated Event Recorders	$2,264.41	
683	Level II Photochemotherapy	$0.00	
685	Level III Needle Biopsy/Aspiration Except Bone Marrow	$1,038.11	
687	Revision/Removal of Neurostimulator Electrodes	$2,081.86	
688	Revision/Removal of Neurostimulator Pulse Generator Receiver	$2,928.30	
689	Level II Electronic Analysis of Devices	$0.00	
690	Level I Electronic Analysis of Devices	$0.00	
691	Level IV Electronic Analysis of Devices	$0.00	
692	Level III Electronic Analysis of Devices	$0.00	
694	Mohs Surgery	$530.80	
697	Level I Echocardiogram Without Contrast 	$421.73	
698	Level II Eye Tests & Treatments	$0.00	
699	Level IV Eye Tests & Treatments	$1,670.78	
8000	Cardiac Electrophysiologic Evaluation and Ablation Composite	$0.00	
8001	LDR Prostate Brachytherapy Composite	$0.00	
8002	Level I Extended Assessment & Management Composite	$0.00	
8003	Level II Extended Assessment & Management Composite	$0.00	
8004	Ultrasound Composite	$0.00	
8005	CT and CTA without Contrast Composite	$0.00	
8006	CT and CTA with Contrast Composite	$0.00	
8007	MRI and MRA without Contrast Composite	$0.00	
8008	MRI and MRA with Contrast Composite	$0.00	

Exhibit 5	
Effective January 1, 2011 2010	
Rural Health Facilities	
	
Akron Clinic	
82 Main	
Akron, CO  80720	
Telephone:  (970) 345-6336, Fax:  (970) 345-6576	
	
Arkansas Valley Family Practice, LLC	
2317 San Juan Avenue	
La Junta, CO  81050	
Telephone:  (719) 383-2325, Fax:  (719) 383-2327	
	
Brush Family Clinic	
2400 W Edison	
Brush, Co 80723 - Morgan County	
Telephone: (970) 842-2833, Fax: (970) 842-6241	
	
Buena Vista Family Practice Clinic	
836 U.S. Hwy 24 So	
Buena Vista, Co 81211 - Chaffee County	
Telephone: (719) 395-9048, Fax: (719) 395-9064	
	
Button Family Practice	
715 South 9th Street 	
Cannon City, Co 81212 – Fremont County	
Telephone:  (719) 269-8820, Fax:  (719) 204-0230	
	
Centennial Family Health Clenter	
319 Main Street	
Ordway, Co 81063 – Crowley County	
Telephone:  (719) 267-3503, Fax:  (719) 267-4153	
	
Colorado Plains Clinic – Wiggins	
226 Main Street	
Wiggins, Co 80654 – Morgan County	
Telephone:  (970) 483-7283	
	
Conejos Medical Clinic	
19021 State Hwy 285	
La Jara, Co 81140 - Conejos County	
Telephone: (719) 274-5121, Fax: (719) 274-6003	
	
Convenient Care Clinic	
403 Kendell Drive	
Lamar, CO  81052	
Telephone:  (719) 336-6767, Fax:  (719( 336-7217	
	
Creed Family Practice Of Rio Grande Hospital	
802 Rio Grande Avenue	
Creed, Co 81130 – Mineral County	
Telephone:  (719) 658-0929, Fax: (719) 657-2851	
	
Custer County Medical Clinic	
704 Edwards	
Westcliffe, Co 81252 - Custer County	
Telephone: (719) 783-2380, Fax: (719) 783-2377	
	
Dolores Medical Center	
507 Central Avenue	
Dolores, Co 81323 - Montezuma County	
Telephone: (970) 882-7221, Fax: (970) 882-4243	
	
Eads Medical Clinic	
1211 Luther Street	
Eads, Co 81036 - Kiowa County	
Telephone: (719) 438-2251, Fax: (719) 438-2254	
	
Eastern Plains Medical Clinic Of Calhan	
555 Colorado Avenue	
Calhan, Co 80808 - El Paso County	
Telephone: (719) 347-0100, Fax: (719) 347-0551	
	
Family Care Clinic	
615 Fairhurst	
Sterling, Co 80751 - Logan County	
Telephone: (970) 521-3223	
	
Family Practice Of Holyoke	
1001 East Johnson Street	
Holyoke, Co 80734 - Phillips County	
Telephone: (970) 854-2500, Fax: (970) 854-3440	
	
Florence Medical Center	
501 W 5th St	
Florence, Co 81226 - Fremont County	
Telephone: (719) 784-4816, Fax: (719) 784-6014	
	
Fort Morgan Pediatric Clinic, PC	
1000 Lincoln Street, Ste. 202	
Fort Morgan, CO  80701	
Telephone:  (970) 542-9187, Fax:  (970) 867-9187	
	
Grand River Primary Care	
501 Airport Road	
Rifle, Co 81650 - Garfield County	
Telephone: (970) 625-1100, Fax: (970) 625-0725	
	
Grand River Primary Care - Battlement Mesa	
73 Sipperelle Drive, Suite K	
Parachute, Co 81635 - Garfield County	
Telephone: (970) 285-7046, Fax: (970) 285-6064	
	
Havens Family Clinic	
109 Latigo Ln Ste C	
Canon City, Co 81212 - Fremont County	
Telephone: (719) 276-3211, Fax: (719) 276-3011	
	
Health Services Clinic	
1800 East 3rd Avenue	
Durango, CO  81301	
Telephone:  (970) 764-1790, Fax:  (970) 375-7927	
	
Holly Medical Clinic	
410 West Colorado	
Holly, CO  81047	
Telephone:  (719) 537-6642, Fax:  (719) 537-0637	
	
Kit Carson Clinic	
102 East 2nd Avenue	
Kit Carson, Co 80825 - Cheyenne County	
Telephone: (719) 962-3501, Fax: (719) 962-3403	
	
La Jara Medical Clinic	
509 Main Street	
La Jara, CO  81140	
Telephone:  (719) 274-6000,. Fax:  (719) 274-4111	
	
Lake City Area Medical Center	
700 N Henson Street	
Lake City, Co 81235 - Hinsdale County	
Telephone: (970) 944-2331, Fax: (970) 944-2320	
	
Lamar Medical Clinic	
403 Kendall Drive	
Lamar, CO  81052	
Telephone:  (719) 336-6767; Fax:  (719) 336-7217	
	
Meadows Family Medical Center	
115 15th Ave., P.O. Box 3243	
Idaho Springs, CO  80452 – Clear Creek County	
Telephone:  (303) 567-2668	
	
Meeker Family Health Center	
345 Cleveland Street	
Meeker, Co 81641 - Rio Blanco County	
Telephone: (970) 878-4014, Fax: (970) 878-3285	
	
Mountain Medical Center Of Buena Vista, P.C	
36 Oak St	
Buena Vista, Co 81211 - Chaffee County	
Telephone: (719) 395-8632, Fax: (719) 395-4971	
	
Mt San Rafael Hospital Health Clinic	
400 Benedicta Ste A	
Trinidad, Co 81082 – Las Animas County	
Telephone:  (719) 846-2206, Fax:  (719) 846-7823	
	
North Park Medical Clinic	
521 5th St	
Walden, Co 80480 - Jackson County	
Telephone: (970) 723-4255, Fax: (970) 723-4268	
	
Olathe Medical Clinic	
308 Main St	
Olathe, Co 81425 - Montrose County	
Telephone: (970) 323-6141, Fax: (970) 323-6117	
	
Pagosa Mountain Clinic	
95 South Pagosa Blvd.	
Pagosa Springs, CO  81147	
Telephone:  (970) 731-3700, Fax:  (970) 731-3707	
	
Parke Health Clinic	
182 16th St	
Burlington, Co 80807 - Kit Carson County	
Telephone: (719) 346-9481, Fax: (719) 346-9485	
	
Pediatric Associates, The	
947 South 5th Street	
Montrose, Co 81401 – Montrose County	
Telephone:  (970) 249-2421, Fax:  (970) 249-8897	
	
Pediatric Association Of Canon City	
1335 Phay Avenue	
Canon City, Co 81212 - Fremont County	
Telephone: (719) 269-1727, Fax: (719) 269-1730	
	
Prairie View Rural Health Clinic	
560 N 6 W Street	
Cheyenne Wells, Co 80810 - Cheyenne County	
Telephone: (719) 767-5669, Fax: (719) 767-8042	
	
Rio Grande Hospital Clinic	
0310C County Road 14	
Del Norte Co 81132 – Rio Grande County	
Telephone:  (719) 657-2418, Fax:  (719) 658-3001	
	
River Valley Pediatrics	
1335 Phay Avenue	
Canon City, Co 81212 – Fremont County	
Telephone:  (719) 276-2222	
	
Rocky Ford Family Health Center	
1014 Elm Avenue	
Rocky Ford, Co 81067 - Otero County	
Telephone: (719) 254-7421, Fax: (719) 254-6966	
	
Sabatini Pediatrics, PC	
612 Yale Place	
Canon City, CO  81212 – Fremont County	
Telephone:  (719) 275-3442, Fax:  (719) 275-2306	
	
Santa Fe Trail Medical Center	
111 Waverly Ave	
Trinidad, Co 81082 - Las Animas County	
Telephone: (719) 846-0123, Fax: (719) 846-0121	
	
Southeast Colorado Physician's Clinic	
210 E Tenth Ave	
Springfield, Co 81073 - Baca County	
Telephone: (719) 523-6628, Fax: (719) 523-4513	
	
Southwest Memorial Primary Care	
33 North Elm Street	
Cortez, CO 81321 – Montezuma County	
Telephone:  (970) 565-8556, Fax:  (970) 564-1134	
	
Stratton Medical Clinic	
500 Nebraska Avenue	
Stratton, Co 80836 - Kit Carson County	
Telephone: (719) 348-4650, Fax: (719) 348-4653	
Surface Creek Family Practice	
255 SWw 8th Ave	
Cedaredge, Co 81413 - Delta County	
Telephone: (970) 856-3146, Fax: (970) 856-4385	
	
Telluride Medical Center	
500 W Pacific	
Telluride, Co 81435 - San Miguel County	
Telephone: (970) 728-3840, Fax: (970) 728-3404	
	
Trinidad Family Medical Center	
1502 E Main St	
Trinidad, Co 81082 - Las Animas County	
Telephone: (719) 846-3305, Fax: (719) 846-4922	
	
United Medical Center Of Berthoud	
549 Mountain Avenue	
Berthoud, Co 80513 - Larimer County	
Telephone: (970) 532-4644, Fax: (970) 532-0608	
	
Valley Medical Clinic	
116 E Ninth Street	
Julesburg, Co 80737 - Sedgwick County	
Telephone: (970) 474-3376, Fax: (970) 474-2461	

Walsh Medical Clinic	
137 Kansas Street	
Walsh, CO 81090	
Telephone:  (719) 324-5253, Fax:  (719) 324-5621	
	
Washington County Clinic	
482 Adams Avenue	
Akron, Co 80720 - Washington County	
Telephone:  (970) 345-2262, Fax:  (970) 345-2265	
	
Wiley Medical Clinic	
302 Main Street	
Wiley, Co 81092 - Prowers County	
Telephone:  (719) 829-4627, Fax:  (719) 829-4269	
	
Yuma Rural Health Clinic	
1000 W 8th Avenue  	
Yuma, Co 80759 - Yuma County	
Telephone: (970) 848-4792, Fax: (970) 848-5405  	

Exhibit 6 Struck and replaced

Exhibit 6
Effective January 1, 2011
Dental Fee Schedule

CDT-2009/2010	2011 Fees	
D0120	$58.00	
D0140	$97.00	
D0145	$90.00	
D0150	$102.00	
D0160	$205.00	
D0170	$68.00	
D0180	$111.00	
D0210	$161.70	
D0220	$32.55	
D0230	$29.40	
D0240	$50.40	
D0250	$61.95	
D0260	$56.70	
D0270	$33.60	
D0272	$54.60	
D0273	$66.15	
D0274	$76.65	
D0277	$115.50	
D0290	$189.00	
D0310	$480.90	
D0320	$819.00	
D0321	BR	
D0322	$661.50	
D0330	$143.00	
D0340	$161.00	
D0350	$77.00	
D0360	$922.00	
D0362	$737.00	
D0363	$768.00	
D0415	$48.00	
D0416	$70.00	
D0417	$65.00	
D0418	$66.00	
D0421	$48.00	
D0425	$41.00	
D0431	$66.00	
D0460	$66.00	
D0470	$145.00	
D0472	$92.40	
D0473	$192.00	
D0474	$217.35	
D0475	$142.80	
D0476	$142.80	
D0477	$172.20	
D0478	$141.00	
D0479	$215.00	
D0480	$133.00	
D0481	$741.30	
D0482	$166.00	
D0483	$166.00	
D0484	$266.70	
D0485	$343.00	
D0486	#N/A	
D0502	BR	
D0999	BR	
D1110	$103.95	
D1120	$72.45	
D1203	$42.00	
D1204	$39.00	
D1206	$63.00	
D1310	$61.00	
D1320	$67.00	
D1330	$84.00	
D1351	$68.00	
D1510	$435.00	
D1515	$609.00	
D1520	$479.00	
D1525	$740.00	
D1550	$94.00	
D1555	$90.00	
D2140	$226.80	
D2150	$292.95	
D2160	$354.90	
D2161	$432.60	
D2330	$206.85	
D2331	$264.60	
D2332	$323.40	
D2335	$383.25	
D2390	$424.20	
D2391	$242.55	
D2392	$318.15	
D2393	$394.80	
D2394	$484.05	
D2410	$395.00	
D2420	$659.00	
D2430	$1,142.00	
D2510	$1,045.00	
D2520	$1,186.00	
D2530	$1,367.00	
D2542	$1,340.00	
D2543	$1,402.00	
D2544	$1,458.00	
D2610	$1,230.00	
D2620	$1,298.00	
D2630	$1,383.00	
D2642	$1,344.00	
D2643	$1,449.00	
D2644	$1,537.00	
D2650	$808.00	
D2651	$963.00	
D2652	$1,012.00	
D2662	$878.00	
D2663	$1,033.00	
D2664	$1,107.00	
D2710	$542.85	
D2712	$542.85	
D2720	$1,337.70	
D2721	$1,253.70	
D2722	$1,281.00	
D2740	$1,372.35	
D2750	$1,354.50	
D2751	$1,261.05	
D2752	$1,291.50	
D2780	$1,298.85	
D2781	$1,222.20	
D2782	$1,262.10	
D2783	$1,335.60	
D2790	$1,306.20	
D2791	$1,237.95	
D2792	$1,261.05	
D2794	$1,337.70	
D2799	$542.85	
D2910	$123.90	
D2915	$123.90	
D2920	$124.95	
D2930	$341.25	
D2931	$386.40	
D2932	$411.60	
D2933	$471.45	
D2934	$471.45	
D2940	$130.20	
D2950	$325.50	
D2951	$73.50	
D2952	$514.50	
D2953	$257.25	
D2954	$411.60	
D2955	$317.10	
D2957	$205.80	
D2960	$995.40	
D2961	$1,128.75	
D2962	$1,226.40	
D2970	$308.70	
D2971	$197.40	
D2975	$600.60	
D2980	BR	
D2999	BR	
D3110	$113.00	
D3120	$91.00	
D3220	$232.00	
D3221	$255.00	
D3222	$236.00	
D3230	$265.65	
D3240	$327.60	
D3310	$1,042.65	
D3320	$1,277.85	
D3330	$1,584.45	
D3331	$408.45	
D3332	$777.00	
D3333	$358.05	
D3346	$1,390.20	
D3347	$1,635.90	
D3348	$2,024.40	
D3351	$836.85	
D3352	$374.85	
D3353	$1,153.95	
D3410	$1,659.00	
D3421	$1,846.95	
D3425	$2,091.60	
D3426	$706.65	
D3430	$519.75	
D3450	$1,081.50	
D3460	$4,039.35	
D3470	$2,063.25	
D3910	$288.75	
D3920	$822.15	
D3950	$374.85	
D3999	BR	
D4210	$1,003.80	
D4211	$434.00	
D4230	$1,496.25	
D4231	$947.10	
D4240	$1,236.00	
D4241	$770.70	
D4245	$911.00	
D4249	$1,356.00	
D4260	$2,060.00	
D4261	$1,106.00	
D4263	$737.00	
D4264	$629.00	
D4265	BR	
D4266	$759.00	
D4267	$976.00	
D4268	BR	
D4270	$1,464.00	
D4271	$1,518.00	
D4273	$1,789.00	
D4274	$1,015.00	
D4275	$1,345.00	
D4276	$2,006.00	
D4320	$540.75	
D4321	$547.05	
D4341	$311.85	
D4342	$187.95	
D4355	$213.15	
D4381	BR	
D4910	$192.15	
D4920	$139.65	
D4999	BR	
D5110	$2,013.90	
D5120	$2,013.90	
D5130	$2,195.55	
D5140	$2,195.55	
D5211	$1,699.95	
D5212	$1,975.05	
D5213	$2,394.00	
D5214	$2,224.95	
D5225	$1,699.95	
D5226	$1,975.05	
D5281	$1,297.80	
D5410	$110.25	
D5411	$110.25	
D5421	$110.25	
D5422	$110.25	
D5510	$237.30	
D5520	$183.75	
D5610	$239.40	
D5620	$273.00	
D5630	$312.90	
D5640	$202.65	
D5650	$276.15	
D5660	$330.75	
D5670	$869.40	
D5671	$869.40	
D5710	$817.95	
D5711	$781.20	
D5720	$771.75	
D5721	$771.75	
D5730	$460.95	
D5731	$460.95	
D5740	$423.15	
D5741	$423.15	
D5750	$615.30	
D5751	$615.30	
D5760	$606.90	
D5761	$606.90	
D5810	$974.40	
D5811	$1,047.90	
D5820	$753.90	
D5821	$799.05	
D5850	$193.20	
D5851	$193.20	
D5860	BR	
D5861	BR	
D5862	BR	
D5867	BR	
D5875	BR	
D5899	BR	
D5911	$511.35	
D5912	$511.35	
D5913	$10,757.25	
D5914	$10,757.25	
D5915	$14,558.25	
D5916	$3,882.90	
D5919	BR	
D5922	BR	
D5923	BR	
D5924	BR	
D5925	BR	
D5926	BR	
D5927	BR	
D5928	BR	
D5929	BR	
D5931	$5,791.80	
D5932	$10,832.85	
D5933	BR	
D5934	$9,873.15	
D5935	$8,591.10	
D5936	$9,649.50	
D5937	$1,212.75	
D5951	$1,577.10	
D5952	$5,119.80	
D5953	$9,723.00	
D5954	$9,010.05	
D5955	$8,333.85	
D5958	BR	
D5959	BR	
D5960	BR	
D5982	$862.05	
D5983	$2,087.40	
D5984	$2,087.40	
D5985	$2,087.40	
D5986	$183.75	
D5987	$3,133.20	
D5988	$536.00	
D5991	$206.00	
D5999	BR	
D6010	$3,364.20	
D6012	$3,179.40	
D6040	$12,455.10	
D6050	$8,637.30	
D6053	$2,511.60	
D6054	$2,511.60	
D6055	$1,011.15	
D6056	$698.25	
D6057	$864.15	
D6058	$1,937.25	
D6059	$2,055.90	
D6060	$1,943.55	
D6061	$1,982.40	
D6062	$1,975.05	
D6063	$1,695.75	
D6064	$1,796.55	
D6065	$1,905.75	
D6066	$1,997.10	
D6067	$1,937.25	
D6068	$1,920.45	
D6069	$2,055.90	
D6070	$1,943.55	
D6071	$1,842.75	
D6072	$2,024.40	
D6073	$1,832.25	
D6074	$1,810.20	
D6075	$1,905.75	
D6076	$1,997.10	
D6077	$1,937.25	
D6078	BR	
D6079	BR	
D6080	$158.55	
D6090	BR	
D6091	$762.30	
D6092	$149.10	
D6093	$233.10	
D6094	$1,630.65	
D6095	BR	
D6100	BR	
D6190	$340.20	
D6194	$1,562.40	
D6199	BR	
D6205	$877.80	
D6210	$1,341.90	
D6211	$1,256.85	
D6212	$1,308.30	
D6214	$1,350.30	
D6240	$1,325.10	
D6241	$1,223.25	
D6242	$1,290.45	
D6245	$1,367.10	
D6250	$1,308.30	
D6251	$1,206.45	
D6252	$1,245.30	
D6253	$563.85	
D6545	$527.10	
D6548	$547.05	
D6600	$1,024.80	
D6601	$1,094.10	
D6602	$1,118.25	
D6603	$1,230.60	
D6604	$1,096.20	
D6605	$1,161.30	
D6606	$1,078.35	
D6607	$1,197.00	
D6608	$1,072.05	
D6609	$1,170.75	
D6610	$1,206.45	
D6611	$1,319.85	
D6612	$1,200.15	
D6613	$1,254.75	
D6614	$1,173.90	
D6615	$1,221.15	
D6624	$1,118.25	
D6634	$1,173.90	
D6710	$1,129.80	
D6720	$1,398.60	
D6721	$1,326.15	
D6722	$1,350.30	
D6740	$1,386.00	
D6750	$1,431.15	
D6751	$1,335.60	
D6752	$1,368.15	
D6780	$1,350.30	
D6781	$1,272.60	
D6782	$1,350.30	
D6783	$1,310.40	
D6790	$1,381.80	
D6791	$1,310.40	
D6792	$1,357.65	
D6793	$534.45	
D6794	$1,357.65	
D6920	$363.30	
D6930	$212.10	
D6940	$480.90	
D6950	$928.20	
D6970	$585.90	
D6972	$476.70	
D6973	$383.25	
D6975	$1,029.00	
D6976	$273.00	
D6977	$242.55	
D6980	BR	
D6985	$807.45	
D6999	BR	
D7111	$198.45	
D7140	$263.55	
D7210	$350.70	
D7220	$439.95	
D7230	$585.90	
D7240	$687.75	
D7241	$864.15	
D7250	$370.65	
D7260	$2,748.90	
D7261	$910.00	
D7270	$683.00	
D7272	$910.00	
D7280	$637.00	
D7282	$319.00	
D7283	$273.00	
D7285	$1,274.00	
D7286	$546.00	
D7287	$218.00	
D7288	$218.00	
D7290	$546.00	
D7291	$403.20	
D7292	$874.00	
D7293	$546.00	
D7294	$455.00	
D7310	$473.00	
D7311	$414.00	
D7320	$769.00	
D7321	$651.00	
D7340	$3,254.00	
D7350	$9,466.00	
D7410	$1,420.00	
D7411	$2,248.00	
D7412	$2,485.00	
D7413	$1,657.00	
D7414	$2,485.00	
D7415	$2,781.00	
D7440	$2,248.00	
D7441	$3,313.00	
D7450	$1,420.00	
D7451	$1,941.00	
D7460	$1,420.00	
D7461	$1,941.00	
D7465	$769.00	
D7471	$1,758.00	
D7472	$2,090.00	
D7473	#N/A	
D7485	#N/A	
D7490	$14,199.00	
D7510	$509.00	
D7511	$769.00	
D7520	$2,423.00	
D7521	$2,662.00	
D7530	$873.00	
D7540	$968.00	
D7550	$603.00	
D7560	$4,792.00	
D7610	$7,750.00	
D7620	$5,812.00	
D7630	$10,077.00	
D7640	$6,394.00	
D7650	$4,844.00	
D7660	$2,856.00	
D7670	$2,229.00	
D7671	$4,201.00	
D7680	$14,533.00	
D7710	$9,109.00	
D7720	$6,394.00	
D7730	$13,177.00	
D7740	$6,520.00	
D7750	$8,292.00	
D7760	$3,327.00	
D7770	$4,508.00	
D7771	$3,479.00	
D7780	$19,377.00	
D7810	$8,524.00	
D7820	$1,396.00	
D7830	$800.00	
D7840	$11,620.00	
D7850	$10,034.00	
D7852	$11,489.00	
D7854	$11,856.00	
D7856	$8,413.00	
D7858	$23,980.00	
D7860	$10,221.00	
D7865	$16,471.00	
D7870	$544.00	
D7871	$1,089.00	
D7872	$5,810.00	
D7873	$6,995.00	
D7874	$10,034.00	
D7875	$10,992.00	
D7876	$11,851.00	
D7877	$10,460.00	
D7880	$1,306.00	
D7899	BR	
D7910	$776.00	
D7911	$1,938.00	
D7912	$3,488.00	
D7920	$5,715.00	
D7940	BR	
D7941	$14,554.00	
D7943	$13,371.00	
D7944	$11,915.00	
D7945	$15,856.00	
D7946	$19,642.00	
D7947	$16,518.00	
D7948	$21,441.00	
D7949	$27,925.00	
D7950	BR	
D7951	BR	
D7953	$402.00	
D7955	BR	
D7960	$651.00	
D7963	$1,065.00	
D7970	$947.00	
D7971	$355.00	
D7972	$1,325.00	
D7980	$1,491.00	
D7981	BR	
D7982	$3,526.00	
D7983	$3,384.00	
D7990	$2,911.00	
D7991	$7,100.00	
D7995	BR	
D7996	BR	
D7997	$544.00	
D7998	$2,367.00	
D7999	BR	
D8010	BR	
D8020	BR	
D8030	BR	
D8040	BR	
D8050	BR	
D8060	BR	
D8070	BR	
D8080	BR	
D8090	BR	
D8210	BR	
D8220	BR	
D8660	$604.80	
D8670	$453.60	
D8680	$997.50	
D8690	$471.45	
D8691	$443.10	
D8692	$493.50	
D8693	$456.75	
D8999	BR	
D9110	$185.85	
D9120	$210.00	
D9210	$59.85	
D9211	$65.10	
D9212	$120.75	
D9215	$51.45	
D9220	$593.25	
D9221	$265.65	
D9230	$98.70	
D9241	$460.95	
D9242	$224.70	
D9248	$142.80	
D9310	$421.05	
D9410	$481.95	
D9420	$780.15	
D9430	$131.25	
D9440	$263.55	
D9450	$131.25	
D9610	BR	
D9612	BR	
D9630	BR	
D9910	$89.00	
D9911	$125.00	
D9920	BR	
D9930	BR	
D9940	$812.70	
D9941	$265.65	
D9942	$306.00	
D9950	$484.00	
D9951	$217.00	
D9952	$1,019.00	
D9970	$115.00	
D9971	$148.00	
D9972	$510.00	
D9973	$84.00	
D9974	$446.00	
D9999	BR