7 Colo. Code Regs. § 1101-3-18-5
The provider has the burden of proving reasonableness of reimbursement sought. Veterans Administration Hospital payments must comply with applicable rules promulgated by the United States Department of Veterans Affairs.
Each of the daily rates listed above is all-inclusive for services related to the injured worker's compensable conditions. Physician's professional services, ambulance services, and chemotherapy drugs or radioisotopes may be billed separately. In the rare case extraordinary medical care is required, or for treatment of traumatic brain injuries or spinal cord injuries, there shall be an additional payment of $306 on a per day basis.
All charges shall be submitted on a final bill unless the parties agree on interim billing. The rate in effect on the last date of service covered by an interim or final bill shall determine payment.
The total length of stay includes the date of admission but not the date of discharge. Typically, bed hold days or temporary leaves are not subtracted from the total length of stay.
The maximum allowance is determined by the relative weights for the assigned MS-DRG from Table 5 in effect per section 18-2 at the time of discharge and the hospital's base rate in Exhibit #2, calculated as follows:
(MS-DRG Relative Wt x Specific hospital base rate x 160%) + (trauma center activation allowance) + (organ acquisition, when appropriate)
Table 5 establishes the maximum length of stay (LOS) using the "arithmetic mean LOS." However, there is no additional allowance for exceeding this LOS, other than through the cost outlier criteria.
An admission requiring the use of both an acute care hospital (admission/discharge) and its Rehabilitation Hospital (admission/discharge) is considered as one admission and MS-DRG.
Outliers are admissions with extraordinary cost warranting additional reimbursement beyond the maximum allowance. To calculate the additional reimbursement, if any:
The MS-DRG adjusted billed charges are determined by subtracting the trauma center activation billed charge and the organ acquisition billed charges from the total billed charges. The final payment is the sum of the lesser of each of these comparisons.
The organ acquisition allowance is calculated using the most recent filed computation of organ acquisition costs and charges for hospitals that are certified transplant centers (CMS Worksheet D-4 or subsequent form) plus 20%.
The Provider has the burden of proving reasonableness of reimbursement sought. Veterans Administration Hospital payments must comply with applicable rules promulgated by the United States Department of Veterans Affairs.
To identify which APC grouper is aligned with a CPT® code and dollar value, use Medicare's Addendum B, as incorporated by 18-2. For comprehensive APCs (C-APCs), see 18-5(B)(6).
Services and items included in the APC value:
Indicator | Meaning |
A | Use another fee schedule instead of Addendum B, such as conversion factors listed in section 18-4, RBRVS RVUs, Ambulance Fee Schedule, or section 18-4(F)(2). |
B | Is not recognized for Outpatient Hospital Services bill type (12x and 13x) and therefore is not separately payable unless separate fees are applicable under another section of this Rule. |
C | The Division recognizes these procedures on an outpatient basis with prior authorization. |
E | Not generally reimbursable when submitted on any outpatient bill type. However, services could still be reasonable and necessary, thus requiring hospital or ASC level of care. The billing party shall submit documentation to substantiate the billed service codes and any similar established codes with fees in Addendum A, as incorporated by 18-2. |
F | Corneal tissue acquisition, certain CRNA services, and Hepatitis B vaccines are allowed at a reasonable cost to the facility. The facility must provide a separate invoice identifying its cost. |
G | "Pass-Through Drugs and Biologicals"; separate APC payment. |
H | "Pass-Through Device"; separate APC payment based on cost to the facility. |
J1 or J2 | The services are paid through a comprehensive APC. |
K | "Nonpass-Through Drug or Biological or Device" for therapeutic radiopharmaceuticals, brachytherapy sources, blood and blood products; separate APC payment. |
L | Influenza Vaccine/Pneumococcal Pneumonia Vaccine and therefore is generally considered to be unrelated to work injuries. |
M | Not separately payable. |
N | Items and services packaged into APC rates; not separately payable. |
P | Partial hospitalization paid based on observation fees outlined in this section. |
Q1-Q4 | Packaged services subject to separate payment criteria. |
R | Blood and blood products; separate APC payment. |
S | Significant procedure, not discounted when multiple. |
T | Significant procedure, multiple procedure reduction applies. |
U | Brachytherapy source; separate APC payment. |
V | Clinic or an ED visit; separate APC payment. |
Y | Non-implantable Durable Medical Equipment paid pursuant to Medicare's Durable Medical Equipment Regional Carrier fee schedule for Colorado. |
As defined by status indicator J1, all covered outpatient services on the claim are packaged with the primary J1 service for payment, except services with a status indicator of F, G, H, L, or U; ambulance services; diagnostic and screening mammography; rehabilitation therapy services reported on a separate claim; new technology services; and self-administered drugs.
When multiple codes with J1 status indicators are included on the claim, services are packaged with the primary (highest APC value) J1 code. Certain J1 codes, when billed together, may be eligible for a complexity adjusted APC payment listed on Medicare's Addendum J, as incorporated by 18-2.
Services with a status indicator J2 are assigned to a comprehensive APC (8011) when specific combinations of services are reported on the claim. All levels of emergency department (ED) and clinic visits, if billed in combination with observation time, can trigger this comprehensive composite rate. Payment of APC 8011 requires a minimum of eight units of G0378 hospital observation service, per liour, no status T procedure on the claim; and either an E&M visit on the same day or day before the G0378 date of service; or G0379 direct admit to observation.
All covered services on the claim shall be considered adjunct to APC 8011 and packaged into a single payment, except those items excluded by rule. Other excluded services include covered screening procedures, preventative services, pass-through drugs and devices (status indicator G or H), PT, OT, and SLP services reported on a separate claim, certain vaccines (status indicator L or F), cornea tissue acquisition, and new technology APCs with status indicator S. If the claim contains a J1 primary service, the J1 C-APC will be the composite under which the services will be paid. There is no complexity adjustment for J2 occurring on the same claim as J1.
If services with a J2 status indicator are provided during an extended assessment and management encounter, including observation care, and do not meet all the requirements for APC 8011 listed above, the usual APC logic will apply.
Codes with a Q2 indicator are packaged with the APC payment if billed on the same claim as a HCPCS code assigned status indicator T. Otherwise, payment is made through a separate APC. When multiple codes with status Q1 or Q2 are billed together, only one unit of the highest-valued Q1 or Q2 code is payable.
Codes with a status Q3 indicator may be paid through a composite APC if billed with another code in the same family listed in Table 3 of the OPPS Imaging Families and Multiple Procedure Composite APCs, of the 2023 OPPS Final Rule. The five multiple imaging composite APCs are:
* APC 8004 (Ultrasound Composite);
* APC 8005 (CT and CTA without Contrast Composite);
* APC 8006 (CT and CTA with Contrast Composite);
* APC 8007 (MRI and MRA without Contrast Composite); and
* APC 8008 (MRI and MRA with Contrast Composite).
Each imaging composite APC is defined as having two or more imaging procedures from the same family performed on the same date of service. If a "without contrast" procedure is performed during the same session as a "with contrast" procedure from the same family, payment would be based on the "with contrast" composite APC. Standard APC assignments apply for single imaging procedures and multiple imaging procedures performed across families.
Codes with a status Q4 indicator are packaged with the APC payment if billed on the same claim as a HCPCS code assigned status indicator S, T, V, Q1, Q2, or Q3. Otherwise, payment is made through a separate APC.
Trauma activation allowances are as follows:
Revenue Code 681 | $5,534.00 |
Revenue Code 682 | $2,298.00 |
Revenue Code 683 | $1,289.00 |
Revenue Code 684 | $954.00 |
Rural Health Clinics are allowed a single separate clinic facility fee at 80% of billed charges per date of service.
Allowed revenue codes for clinic fees are 521 for physical health services and 900 for behavioral health services.
Facility fees are only payable if the facility qualifies as an Urgent Care facility. All Urgent Care facilities shall be accredited or certified by the Urgent Care Association (UCA) or accredited by the Joint Commission to be recognized for a separate facility payment for the initial visit.
7 CCR 1101-3-18-5