7 Colo. Code Regs. § 1101-3-18-4
Maximum allowances are determined by multiplying the following CFs by the established facility or non-facility total relative value units (RVUs) found in the corresponding RBRVS sections:
RBRVS SECTION | CF |
Anesthesia | $44.00 |
Surgery/Radiology/Pathology/Medicine (SRPM) | $68.00 |
Physical Medicine and Rehabilitation | $49.00 |
(Includes Medical Nutrition Therapy and Acupuncture) | |
Evaluation & Management (E&M) | $56.00 |
* a county outside a Metropolitan Statistical Area (MSA) or
* a Health Professional Shortage Area, located either outside of an MSA or in a rural census tract, as determined by the Office of Rural Health Policy, Health Resources and Services Administration, United States Department of Health and Human Services.
Status | Meaning |
A | Separately Payable |
B & P | Bundled Code |
C | Priced per Rule 16-10-1 |
E | HCPCS J0120 to J9999 and CPT® 90296-90750 are payable. HCPCS Q4074-Q4255 require prior authorization for payment. |
All other codes are not payable unless otherwise specified in this Rule. | |
I | HCPCS A0021-A0998 and S0012-S0199 (see section 18-4(B)(6)(c)) are payable. |
Dental codes are paid per Exhibit #3; | |
All other codes are not payable unless otherwise specified in this Rule. There may be another code for reporting and payment of these services. | |
J | Anesthesia Code |
M & Q | Measurement or Functional Information Codes - No Value |
N | HCPCS A4210-A9300 are payable when these supplies are issued for home use. |
Dental codes are paid per Exhibit #3. | |
HCPCS V2025-V5290 are payable per section 18-6(A). There may be another code for reporting and payment of services associated with V-codes. | |
Codes found in the Medicine Section of CPT® with an assigned RBRVS value (section 18-2(A)) are payable. | |
All other codes are not payable unless otherwise specified in this Rule. | |
R | Dental codes are paid per Exhibit #3. |
All other codes require prior authorization for payment unless otherwise specified in this Rule. | |
T | Paid When It Is the Only Payable Service Performed |
X | Codes with an assigned RBRVS or DMEPOS value (section 18-2(A)) are payable. All other codes are not payable unless otherwise specified in this Rule. |
Indicator | Meaning |
0 | Physician Service Codes - professional component/ technical component (PC/TC) distinction does not apply. |
1 | Diagnostic Radiology Tests - may be billed with or without modifiers 26 or TC. |
2 | Professional Component Only Codes - standalone professional service code (no modifier is appropriate because the code description dictates the service is professional only). |
3 | Technical Component Only Codes - standalone technical service code (no modifier is appropriate because the code description dictates the service is technical only). |
4 | Global Test Only Codes - modifiers 26 and TC cannot be used because the values equal to the sum of the total RVUs (work, practice expense, and malpractice). |
5 | Incident To Codes - do not apply. |
6 | Laboratory Physician Interpretation Codes - separate payments may be made (these codes represent the professional component of a clinical laboratory service and cannot be billed with modifier TC). |
7 | Physical Therapy Service - not recognized. |
8 | Physician Interpretation Codes - separate payments may be made only if a physician interprets an abnormal smear for a hospital inpatient. |
9 | Concept of PC/TC distinction does not apply. |
Indicator | Meaning |
000 | Endoscopies or some minor surgical procedures, typically a zero day post-operative period. E&M visits on the same day as procedures generally are included in the procedure, unless a separately identifiable service is reported with an appropriate modifier. |
010 | Other minor procedures, 10-day post-operative period. E&M visits on the same day as procedures and during the 10-day post-operative period generally are included in the procedure, unless a separately identifiable service is reported with an appropriate modifier. |
090 | Major surgeries, 90-day post-operative period. E&M visits the day before and on same day as procedures, as well as during the 90-day post-operative period generally are included in the procedure, unless a separately identifiable service is reported with an appropriate modifier. |
MMM | Global service days concept does not apply (see Medicare's Global Maternity Care reporting rule). |
XXX | Global concept does not apply. |
YYY | Identifies primarily "BR" procedures where "global days" need to be determined by the Payer. |
ZZZ | Code is related to another service and always included in the global period of the other service. Identifies "add-on" codes. |
Indicator | Meaning |
% | The physician shall append modifier 56 when performing only the pre-operative portion of any surgical procedure. This modifier can be combined with either modifier 54 or 55, but not both. This column lists the allowed percentage of the total surgical relative value unit. |
Indicator | Meaning |
% | The surgeon shall append modifier 54 when performing only the intra-operative portion of a surgical procedure. This modifier can be combined with either modifier 55 or 56, but not both. This column lists the allowed percentage of the total surgical relative value unit. |
Indicator | Meaning |
% | The surgeon shall append modifier 55 when performing only the post-operative portion of a surgical procedure. This modifier can be combined with either modifier 54 or 56, but not both. This column lists the allowed percentage of the total surgical relative value unit. |
Indicator | Meaning |
0 | No payment adjustment for multiple procedures applies. These codes are generally identified as "add-on" codes in CPT®. |
1, 2, or 3 | Standard payment reduction applies (100% for the highest-valued procedure and 50% for all lesser-valued procedures performed during the same operative setting). |
4, 5, 6, or 7 | Not subject to the multiple procedure adjustments. |
9 | Multiple procedure concept does not apply. |
Indicator | Meaning |
0 | Not eligible for the bilateral payment adjustment. Either the procedure cannot be performed bilaterally due to the anatomical constraints or another code more adequately describes the procedure. |
1 | Eligible for bilateral payment adjustment and shall be reported on one line with modifier 50 and "1" in the units box. Providers performing the same bilateral procedure during the same operative setting on multiple sites shall report the second and subsequent procedures with modifiers 50 and 59. Report on one line with one unit for each bilateral procedure performed. The maximum allowance is increased to 150%. If provider performs multiple bilateral procedures during the same setting, Payer shall apply the bilateral payment adjustment rule first, and then apply other applicable payment adjustments (e.g., multiple surgery). |
2 | Not eligible for the bilateral payment adjustment. These procedure codes are already bilateral. |
3 | Not eligible for the bilateral payment adjustment. Report these codes on two lines with RT and LT modifiers. There is one payment per line. |
9 | Not eligible for the bilateral payment adjustment because the concept does not apply. |
Indicator | Meaning |
0 | Documentation of medical necessity and prior authorization is required to allow an assistant at surgery. |
1 | No assistant at surgery is allowed. |
2 | Assistant at surgery is allowed. |
9 | Concept does not apply. |
No separate assistant surgeon or minimum assistant fees shall be paid if a co-surgeon is paid for the same operative procedure during the same surgical episode. See section 18-4(D)(1) for additional payment policies.
Indicator | Meaning |
1 or 2 | Indicators may require two primary surgeons performing two distinct portions of a procedure. Modifier 62 is used with the procedure and maximum allowance is increased to 125% of the fee schedule value. The payment is apportioned to each surgeon in relation to the individual responsibilities and work, or it is apportioned equally between the co-surgeons. |
0 or 9 | Not eligible for co-surgery fee allowance adjustment. These procedures are either straightforward or only one surgeon is required, or the concept does not apply. |
Indicator | Meaning |
0 | Team surgery adjustments are not allowed. |
1 | Prior authorization is required for team surgery adjustments. |
2 | Team surgery adjustments may occur as a "BR." Each team surgeon must bill modifier 66. Payer must adjust the values in consultation with the billing surgeon(s). |
9 | Concept does not apply. |
To justify the level of E&M service billed based on time, the provider shall not count the time spent on other reportable codes.
An E&M visit shall be billed as a "new" patient service for each new injury or new Colorado workers' compensation claim even if the provider has seen the injured worker within the last three years.
Any subsequent E&M visits for the same injury billed by the same provider or another provider of the same specialty or subspecialty in the same group practice shall be billed as an "established patient" visit.
Transfer of care from one physician to another with the same tax ID and specialty or subspecialty shall be billed as an "established patient" regardless of location.
All providers are limited to one office visit per injured worker, per day, per workers' compensation claim, unless prior authorization is obtained.
Telephone or on-line services may be billed even if performed within the one day and seven day timelines listed in CPT®.
A consultation occurs when a treating Physician seeks an opinion from another
Physician regarding an injured worker's diagnosis and/or treatment beyond the treating Physician's expertise. CPT® 99242-99245 are payable codes.
To bill for a consultation, the Physician must document the following:
A transfer of care occurs when one Physician turns over the responsibility for the comprehensive care of an injured worker to another Physician.
An independent medical exam (IME) occurs when a Physician is requested to evaluate an injured worker by any party or party's representative and is billed in accordance with section 18-7(G).
Providers shall document the medical necessity of prolonged services utilizing patient-specific information. Providers shall comply with all applicable CPT® requirements and the following additional requirements.
CPT® 99417 | Non-facility RVU is .92, facility RVU is .89 |
CPT® 99418 | Non-facility and facility RVUs are 1.16 |
When a CRNA or AA administers anesthesia:
P-1 | Healthy patient | 0 RVUs |
P-2 | Patient with mild systemic disease | 0 RVUs |
P-3 | Patient with severe systemic disease | 1 RVU |
P-4 | Patient with severe systemic disease that is a constant threat to life | 2 RVUs |
P-5 | A moribund patient who is not expected to survive without the operation | 3 RVUs |
P-6 | A declared brain-dead patient whose organs are being removed for donor purposes | 0 RVUs |
Anesthesia complicated by extreme age (under one or over 70 yrs) | 1 RVU |
Anesthesia complicated by utilization of total body hypothermia | 5 RVUs |
Anesthesia complicated by utilization of controlled hypotension | 5 RVUs |
Anesthesia complicated by emergency conditions (specify) | 2 RVUs |
Provider shall document the medical necessity for any assistant surgeon in the operative report.
See section 18-4(A)(3) for additional payment policies applicable to assistant surgeons.
CPT® 29822 is not separately payable when another shoulder arthroscopy procedure is billed and paid on the same shoulder at the same encounter. CPT® 29823 is bundled with CPT® 29806 and 29807.
The maximum allowance includes and applies to all body parts, imaging guidance, harvesting, preparation, the injection itself, kits, and supplies.
CPT® 0232T | Non-facility RVU is 11.16, facility RVU is 4.04 |
If all requirements of the Medical Treatment Guidelines for pre- and post- injection functional assessments have been met and documented, the billing codes and maximum allowances are as follows:
DOWC Z0811, $64.26, per episode for the initial functional assessment of pre-injection care, related to spinal or SI joint injections (may be performed by injectionist or non-injectionist no more than seven days prior to the injection).
DOWC Z0812, $35.29, for a subsequent visit of therapeutic post-injection care (preferably done by a non-injectionist and at least seven days after the injection), billed along with the appropriate E&M code, related to follow-up care of spinal or SI joint injections. The injured worker should provide post injection data.
DOWC Z0814, $35.29, for post-diagnostic injection care (repeat functional assessment within the time period for the effective agent given).
The allowance is 80% of the Maximum Fee Schedule.
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.
If an X-ray consultation is requested, the consultant's report shall include the name of the requesting provider, the reason for the request, and documentation that the report was sent to the requesting provider.
The maximum allowance for an X-ray consultation shall be no greater than the maximum allowance for the professional component of the original X-ray.
The time a physician spends reviewing and/or interpreting an existing radiological image is considered a part of the physician's E&M service code.
DoWC Z0200 Upper Body w/ Autonomic Stress Testing | $980.00 |
DoWC Z0201 Lower Body w/Autonomic Stress Testing | $980.00 |
Only laboratories with a CLIA certificate of waiver may perform tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver, or other providers billing for services performed by these laboratories, shall bill using the QW modifier.
Laboratories with a CLIA certificate of compliance or accreditation may perform non- waived tests. Laboratories with a CLIA certificate of compliance or accreditation, or other providers billing for services performed by these laboratories, do not append the QW modifier.
All clinical pathology laboratory tests, except as allowed by this Rule, are reimbursed at 170% of the rate listed in the CMS Clinical Diagnostic Laboratory Fee Schedule, as incorporated by section 18-2.
Technical or professional component maximum split is not separately payable, and therefore should be negotiated between billing parties when applicable.
When a physician clinical pathologist is required for consultation and interpretation, and a separate written report is created, the maximum allowance is determined by using RBRVS values and the Pathology CF. The Pathology CF also determines the maximum allowance when the Pathology CPT® code description includes "interpretation" and "report" or when billing CPT® codes for the following services:
When ordering automated laboratory tests, the ordering physician 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 physician requested additional medical interpretation, judgment, and a separate written report. Upon such a request, the pathologist may bill using the appropriate CPT® code, not DoWC Z0755.
The maximum allowance for CPT® 80050 is $39.95 (equal to the total allowance for CPT® 80053, 85004, and 85027).
Clinical drug screening and testing may be appropriate for therapeutic drug monitoring, to assess compliance, or to identify illicit or non-prescribed drug use.
All drug class immunoassays or enzymatic methods are considered presumptive. Payers shall only pay for one presumptive test per date of service, regardless of the number of drug classes tested.
* These tests may be billed using G0480-G0483.
* Providers may only bill one definitive HCPCS Level II code per day.
A Physician must order definitive quantitative tests. The reasons for ordering a definitive quantification drug test may include:
* Unexpected positive presumptive or qualitative test results inadequately explained by the injured worker.
* Unexpected negative presumptive or qualitative test results and suspected medication diversion.
* Differentiate drug compliance:
* Buprenorphine vs. norbuprenorphine
* Oxycodone vs. oxymorphone and noroxycodone
* Need for quantitative levels to compare with established benchmarks for clinical decision-making, such as tetrahydrocannabinol quantitation to document discontinuation of a drug.
* Chronic opioid management:
* Drug testing shall be done prior to the implementation of the initial long-term drug prescription and randomly repeated at least annually.
* While the injured worker receives chronic opioid management, additional drug screens with documented justification may be conducted (see section 18-9(A) for examples).
CPT® lists definitive drug classes and examples of individual drugs within each class. Each class of drug can only be billed once per day.
Licensed medical and mental health professionals who provide biofeedback must practice within the scope of their training. Non-licensed biofeedback providers must hold Clinical Certification from the Biofeedback Certification International Alliance (BCIA), practice within the scope of their training, and receive prior approval of their biofeedback treatment plan from the injured worker's authorized treating Physician, or Psychologist. Professionals integrating biofeedback with any form of psychotherapy must be a Psychologist, a Clinical Social Worker, a Marriage and Family Therapist, or a Professional Counselor.
All biofeedback providers shall document biofeedback instruments used during each visit (including, but not limited to, surface electromyography (SEMG), heart rate variability (HRV), electroencephalogram (EEG), or temperature training), placement of instruments, and patient response if sufficient time has passed.
The modified RVUs for biofeedback are:
CPT® 90901 | Non-facility RVU is 1.78, facility RVU is 1.76 |
CPT® 90875 | Non-facility RVU is 2.13, facility RVU is 1.82 |
Psychophysiological therapy incorporating biofeedback is not subject to a reduction when performed by non-physician providers.
CPT® 98940 | Non-facility RVU is 1.03, facility RVU is 0.81 |
CPT® 98941 | Non-facility RVU is 1.48, facility RVU is 1.26 |
When testing, evaluation, administration, and scoring services are provided across multiple dates of service, all codes should be billed on the last date of service when the evaluation process is completed. A base code shall be billed only for the first unit of service of the evaluation process, and add-on codes shall be used to capture services provided during subsequent dates of service. The limit for these services is 16 hours unless the provider obtains prior authorization.
Documentation shall include the total time and the approximate time spent on each of the following activities, when performed:
* face-to-face time with the patient;
* reviewing and interpreting standardized test results and clinical data;
* integrating patient data;
* clinical decision-making and treatment planning;
* report preparation.
If there is a delay in scheduling the feedback session, the provider may incorporate feedback into the first psychotherapy session.
The modified RVUs for psychological and neuropsychological services are:
CPT® 96116 | Non-facility RVU is 3.50, facility RVU is 3.07 |
CPT® 96127 | Non-facility and facility RVUs are 0.19 |
CPT® 96130 | Non-facility RVU is 3.74, facility RVU is 3.50 |
CPT® 96131 | Non-facility RVU is 3.00, facility RVU is 2.81 |
CPT® 96132 | Non-facility RVU is 4.23, facility RVU is 3.29 |
CPT® 96133 | Non-facility RVU is 3.20, facility RVU is 2.51 |
CPT® 96146 | Non-facility and facility RVUs are 0.10 |
CPT® 90791 | Non-facility RVU is 10.2, facility RVU is 8.80 |
CPT® 90792 | Non-facility RVU is 11.45, facility RVU is 10.3 |
Psychotherapy for work-related conditions continuing for more than three months after the initiation of therapy requires prior authorization unless the MTGs recommend a longer duration.
Non-medical disciplines cannot bill most E&M codes.
Reimbursement for coordination of care between medical professionals is limited to professionals outside of the Provider's practice.
Telephone services, including those listed in Appendix T and Telephone Services section of CPT®, shall be billed with a modifier 93.
The modified RVUs for the telephone and on-line services are:
CPT® 99421 | Non-facility and facility RVUs are 0.38 |
CPT® 99422 | Non-facility and facility RVUs are 0.75 |
CPT® 99423 | Non-facility and facility RVUs are 1.19 |
CPT® 99441 | Non-facility and facility RVUs are 1.03 |
CPT® 99442 | Non-facility and facility RVUs are 1.95 |
CPT® 99443 | Non-facility and facility RVUs are 2.86 |
CPT® 98966 | Non-facility and facility RVUs are 0.27 |
CPT® 98967 | Non-facility and facility RVUs are 0.53 |
CPT® 98968 | Non-facility and facility RVUs are 0.75 |
For reimbursement of face-to-face or telephonic meetings by a treating Physician or Psychologist with employer, claim representative, or attorney, see section 18-7(A)(1).
IOM identifies compromise to the nervous system during certain surgical procedures. Evoked responses are constantly monitored for changes that could imply damage to the nervous system.
* the American Society of Neurophysiologic Monitoring; or
* the American Society of Electrodiagnostic Technologists
A Colorado-licensed Physician trained in neurophysiology shall monitor the patient's nervous system throughout the surgical procedure. The monitoring Physician's time is billed based upon the actual time the Physician devotes to the individual patient, even if the Physician is monitoring more than one patient. The monitoring Physician's time does not have to be continuous for each patient and may be cumulative. The Physician shall not monitor more than three surgical patients at one time. The Physician shall provide constant neuromonitoring at critical points during the surgical procedure as indicated by the surgeon or any unanticipated testing responses. There must be a neurophysiology-trained Colorado licensed Physician backup available to continue monitoring the other two patients if one of the patients being monitored has complications and/or requires the monitoring Physician's undivided attention. There is no additional payment for the back-up neuro-monitoring Physician, unless utilized.
Physicians shall include an interpretive written report for all primary billed procedures.
Intra-operative neurophysiology codes do not have separate professional and technical components. However, certain tests performed in conjunction with these services have separate professional and technical components, which may be separately payable if documented and otherwise allowed in this Rule.
The neuromonitoring Physician is the only party allowed to report these codes.
The maximum allowance for CPT® 95941 is equal to the maximum allowance for CPT® 95940.
CPT® 92590 | Non-facility value is $165.90, facility value is $93.80 |
CPT® 92591 | Non-facility value is $248.78, facility value is $140.56 |
CPT® 92592 | Non-facility value is $60.31, facility value is $34.07 |
CPT® 92593 | Non-facility value is $90.46, facility value is $51.11 |
CPT® 92594 | Non-facility value is $60.31, facility value is $34.07 |
CPT® 92595 | Non-facility value is $90.46, facility value is $51.11 |
The maximum allowance for CPT® 90371 is $800.
Maximum allowance for supplies and medications provided by a Physician's office for self-administered home care infusion therapy are covered in section 18-6(B).
Providers billing for moderate sedation services shall comply with all applicable CPT® billing instructions. The maximum allowance is determined using the Medicine CF.
Assistant shall be billed with a CQ modifier. Services provided in whole or in part by an Occupational Therapist Assistant shall be billed with a CO modifier. "In part" is defined as exceeding the CPT® mid-point. The CQ and CO modifiers shall be billed in addition to the GP or GO modifiers.
As defined in the MTGs, interdisciplinary rehabilitation programs may include, but are not limited to: chronic pain, spinal cord, or brain injury programs.
All billing providers shall detail the services, frequency of services, duration of the program, and proposed fees for the entire program. The billing Provider and Payer shall attempt to 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 code Z0500.
Individual professionals billing separately for their participation in an interdisciplinary rehabilitation program shall use the applicable CPT® codes.
Medicine and Rehabilitation section of CPT® under the subheading "Therapeutic Procedures." For purposes of this rule, the term "procedure" includes acupuncture.
The billing maximums listed below are per discipline per day, unless medical necessity is documented and prior authorization is obtained. The total amount of time spent performing the procedures shall determine the appropriate number of time based units for a particular visit.
Therapist shall be 72% of the fee schedule.
CPT® 97139 | Non-facility and facility RVUs are 0.87 |
CPT® 97039 | Non-facility and facility RVUs are 0.42 |
Acupuncturists (L.Ac). Both Physician and L.Acs must provide evidence of training, and licensure upon request of the Payer.
L.Ac new patient visit: | DOWC Z0800, $103.84 |
L.Ac established patient visit: | DOWC Z0801, $70.33 |
If a new problem or abnormality is encountered that requires a new evaluation and treatment plan, the provider 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.
A re-examination, re-evaluation, or re-assessment is different from a progress note. Providers shall not bill these codes for a progress note. Providers may bill a re-evaluation code only if:
The WC 196 form shall not be used for an evaluation, re-evaluation, or reassessment. The form must be completed and specify which validated functional tool was used for assessing the injured worker. The form shall be sent to the referring physician before or at the injured worker's follow-up appointment with the physician.
DoWC Z0817 | $15.61. |
Gyms, pools, etc., and training or supervision by non-medical providers require prior authorization and a written negotiated fee for every three month period.
These programs and recommendations for coverage are defined in the MTGs. All procedures must be performed by or under the onsite supervision of a Physician, Psychologist, PT, OT, CCC-SLP, or Audiologist.
CPT® 97545 | Non-facility and facility RVUs are 3.39 |
CPT® 97546 | Non-facility and facility RVUs are 1.7 |
Wound care is separately payable only when devitalized tissue is debrided using a recognized method (chemical, water, vacuums).
All treatment provided through telemedicine shall comply with the applicable requirements found in the Colorado Medical Practice Act and Colorado Mental Health Practice Act, as well as the rules and policies adopted by the Colorado Medical Board and the Colorado Board of Psychologist Examiners, and shall follow applicable laws, rules, and regulations for informed consent.
* A Hospital (inpatient or outpatient)
* A Critical Access Hospital (CAH)
* A Rural Health Clinic (RHC)
* A federally qualified health center (FQHC)
* A hospital based renal dialysis center (including satellites)
* A Skilled Nursing Facility (SNF)
* A community mental health center (CMHC)
Maximum allowance for Q3014 is $35.00 per 15 minutes. (Equipment, supplies, and professional fees of supporting providers at the originating site are not separately payable.)
Documentation requirements are the same as for a face-to-face encounter and shall also include the location of both the rendering provider and the injured worker at the time of service, and a statement on how the treatment was rendered through telemedicine (such as secured video).
7 CCR 1101-3-18-4