7 Colo. Code Regs. § 1101-3-18-6
DME equipment withstands repeated use and allows injured workers accessibility in the home, work, and community. DME can be categorized as:
Items with a total invoice cost of $50 or less may be billed using A9300 at no more than 120% of actual cost, without an invoice. Reimbursement shall be based on billed charges. Payers reserve the right to retroactively review invoices to validate the provider's cost, per Rule 16. Home exercise supplies can include, but are not limited to the following items: therabands, theratubes, band/tube straps, theraputty, bow-tie tubing, fitness cables/trainers, overhead pulleys, exercise balls, cuff weights, dumbbells, ankle weight bands, wrist weight bands, hand squeeze balls, flexbars, digiflex hand exercisers, power webs, plyoballs, spring hand grippers, hand helper rubber band units, ankle stretchers, rocker boards, balance paws, and aqua weights.
Electrical stimulators are bundled kits that include the portable unit(s), two to four leads and pads, initial battery, electrical adapters, and carrying case. Kits that cost more than $300.00 shall be rented for the first month of use and require documentation of effectiveness prior to purchase (effectiveness means functional improvement and decreased pain).
A4595 - electrical stimulator supplies, two leads.
A4557 - lead wires, pair (reimbursable once every 12 months).
These devices are bundled into the facility fees and not separately payable, unless the MTGs recommend their use after discharge for the particular condition.
E0935 - continuous passive motion exercise device for use on the knee only.
E0936 - continuous passive motion exercise device for use on body parts other than knee.
These devices (including, but not limited to, cold with compression) are bundled into facility fees and are not separately payable. The use of these devices after discharge requires prior authorization.
E0650-E0676 - Codes based on body part(s), segmental or not, gradient pressure and cycling of pressure, and purpose of use.
A4600 - Sleeve for intermittent limb compression device, replacement only, per each limb.
These items are purchased. The maximum allowance is 120% of the cost to the provider as indicated by invoice. The maximum allowance for V2623 (prosthetic eye) and L8045 (auricular prosthesis) shall be based on 120% of the cost of the item as indicated by invoice.
Maximum allowance for any orthotic created using casting materials shall be determined using Medicare's Q codes and values listed under Medicare's DMEPOS fee schedule. The therapist time necessary to create the orthotic shall be billed using CPT® 97760.
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.
Supplies necessary to perform a service or procedure are not separately reimbursable. Only supplies that are not an integral part of a service or procedure are considered to be over and above those usually included in the service or procedure. Allowances for supplies to facilities shall comply with the appropriate section of this Rule.
Unless other limitations exist in this Rule, the maximum allowance for DMEPOS suppliers and medical providers shall be based on Medicare's HCPCS Level II codes, when one exists, as established in the January 2023 DMEPOS schedule for rural (R) or non-rural (NR) areas.
If no Medicare value exists, the maximum allowance shall be based on the total allowable amount listed in Medicaid's Health First Colorado Fee Schedule Effective January 1, 2023.
If no Medicaid fee schedule value exists, the maximum allowance is based on 120% of the cost of the item as indicated by invoice. For inventorial items, "invoice" means a statement given to the Provider by its supplier showing the Provider's cost of obtaining the item. For fabricated/customized items, "invoice" means a statement prepared by the Provider showing the amount due after accounting for fabrication and necessary customization. Shipping and handling charges are not separately payable. Payers shall not recognize the KE modifier.
Auto-shipping of monthly DMEPOS is not allowed. An affirmative request by the injured worker or prescribing provider is required.
Prior authorization is required for all home care-services, unless otherwise specified. All skilled home care service providers shall be licensed by the Colorado Department of Public Health and Environment (CDPHE) as Type A or B providers. The Payer and the home health entity should agree in writing on the type of care, the type and skill level of provider, frequency of care, duration of care at each visit, and any financial arrangements to prevent disputes.
The per day or refill rates for home infusion therapy shall include all reasonable and necessary products, equipment, IV administration sets, supplies, supply management, and delivery services necessary to perform the infusion therapy. Per diem rates are only payable when licensed professionals (RNs) are providing "reasonable and necessary" skilled assessment and evaluation services in the injured worker's home.
Skilled Nursing fees are separately payable when the nurse travels to the injured worker's home to perform initial and subsequent evaluation(s), education, and coordination of care.
Code | Quantity | Max Bill Frequency | Daily Rate |
S9364 | < Liter | once per day | $160.00 |
S9365 | 1 liter | once per day | $174.00 |
S9366 | 1.1 - 2.0 liter | once per day | $200.00 |
S9367 | 2.1 - 3.0 liter | once per day | $227.00 |
S9368 | > 3.0 liter | once per day | $254.00 |
The daily rate includes the standard total parenteral nutrition (TPN) formula. Lipids, specialty amino acid formulas, and drugs other than those in standard formula are separately payable under section 18-6(C).
Code | Time | Max Bill Frequency | Daily Rate |
S9494 | Per diem | once per day | $158.00 |
S9497 | once every 3 hours | once per day | $152.00 |
S9500 | every 24 hours | once per day | $97.00 |
S9501 | once every 12 hours | once per day | $110.00 |
S9502 | once every 8 hours | once per day | $122.00 |
S9503 | once every 6 hours | once per day | $134.00 |
S9504 | once every 4 hours | once per day | $146.00 |
Code | Description | Max Bill Frequency | Daily Rate |
S9329 | Administrative Services | once per day | $0.00 |
S9330 | Continuous (24 hrs. or more) chemotherapy | once per day | $91.00 |
S9331 | Intermittent (less than 24 hrs.) | once per day | $103.00 |
Code | Description | Max Bill Frequency | Daily Rate |
S9341 | Via Gravity | once per day | $44.09 |
S9342 | Via Pump | once per day | $24.23 |
S9343 | Via Bolus | once per day | $24.23 |
Code | Description | Max Bill Frequency | Daily Rate |
S9326 | Continuous (24 hrs. or more) | once per day | $79.00 |
S9327 | Intermittent (less than 24 hrs.) | once per day | $103.00 |
S9328 | Implanted pump | per diem | $116.00/refill. |
Code | Quantity | Max Bill Frequency | Daily Rate |
S9373 | < 1 liter per day | once per day | $61.00 |
S9374 | 1 liter per day | once per day | $85.00 |
S9375 | >1 but < liters per day | once per day | $85.00 |
S9376 | >2 liters but < liters | once per day | $85.00 |
S9377 | >3 liters per day | once per day | $85.00 |
Highest cost per day or refill only + drug cost at ASP, as incorporated by Rule 18-2. If ASP is not available, use AWP.
Code | Type of Nurse | Max Bill Frequency | Hourly Rate |
59123 | RN | 2 hours | $127.50 |
59124 | LPN | 2 hours | $127.50 |
S9122 | CNA | The amount of time spent with the injured worker must be specified in the medical records and on the bill. | $51.00 |
The parties should agree upon travel allowances and the mileage rate shall not exceed 59 cents per mile, portal to portal. DoWC Z0772.
Travel is typically included in the fees listed. Travel time greater than one hour oneway is allowed additional reimbursement not to exceed $35.37 per hour. DoWC Z0773.
As defined in section 18-6(A), any drugs/supplies/DME/Orthotics/Prosthetics integral to a professional's service are not separately payable.
The maximum allowance for non-integral drugs/supplies/DME/Orthotics/Prosthetics used during a professional's home care visits are listed in section 18-6(A). All IV infusion supplies are included in the per diem or refill rates listed in this Rule.
In order to qualify as a compound under this section, the medication must require a prescription; the ingredients must be combined, mixed, or altered by a licensed pharmacist or a pharmacy technician being overseen by a licensed pharmacist, a licensed physician, or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist; and it must create a medication tailored to the needs of an individual patient. All topical compounds shall be billed using the DoWC Z code corresponding with the applicable category as follows:
Category I Z0790, $83.23 per 30 day supply
Any anti-inflammatory medication or any local anesthetic single agent. Category II Z0791, $166.46 per 30 day supply
Any anti-inflammatory agent or agents in combination with any local anesthetic agent or agents.
Category III Z0792, $275.71 per 30 day supply
Any single agent other than anti-inflammatory agent or local anesthetic, either alone, or in combination with anti-inflammatory or local anesthetic agents.
Category IV Z0793, $384.95 per 30 day supply
Two or more agents that are not anti-inflammatory or local anesthetic agents, either alone or in combination with other anti-inflammatory or local anesthetic agents.
All ingredient materials must be listed by quantity used per prescription. If the MTGs approve some but not all of the active ingredients for a particular diagnosis, the insurer shall count only the number of the approved ingredients to determine the applicable category. In addition, initial prescription containing the approved ingredients shall be reimbursed without a medical review. Continued use (refills) may require documentation of effectiveness including functional improvement.
Category allowances include materials, shipping and handling, and time. Regardless of how many ingredients or what type, compounded drugs cannot be reimbursed higher than the Category IV allowances. The 30 day maximum allowance value shall be fractioned down to the prescribed and dispensed amount given to the injured worker. Automatic refilling is not allowed.
DoWC Z0794 per 30 day supply for any application (excludes patches).
DoWC Z0795 per 30 day supply for patches.
See subsection (6) for prescription-strength topicals and patches.
Reimbursement for outpatient dietary supplements, vitamins, and herbal medicines is authorized only by prior agreement of the Payer or if specifically indicated in the MTGs. Reimbursement shall be at cost to the injured worker (see subsection (9) below).
In the event the injured worker has directly paid for authorized medications (prescription or over-the-counter), the Payer shall reimburse the injured worker for the amount actually paid within 30 days after submission of the injured worker's receipt. See Rule 16.
Complementary integrative medicine describes 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. Non-physician providers of complementary integrative medicine that are not listed in Rule 16 must have completed training in one or more forms of therapy and certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in Chinese herbology.
The maximum allowance for medical transportation consists of a base rate and a payment for mileage. Both the transport of the injured worker and all items and services associated with such transport are included in the base rate and mileage rate.
The selection of the base code is based upon the condition of the injured worker at the time of transport, not the vehicle used, and includes services and supplies used during the transport.
HCPCS | Base Rate | URBAN BASE RATE/ URBAN MILEAGE | RURAL BASE RATE/ RURAL MILEAGE | RURAL BASE RATE/ SUPER RURAL MILEAGE | RURAL GROUND MILES |
A0425 | $17.08 | $17.42 | $17.60 | n/a | $26.40 |
A0426 | $531.08 | $672.80 | $679.38 | $832.92 | n/a |
A0427 | $531.08 | $1,065.26 | $1,075.70 | $1,318.80 | n/a |
A0428 | $531.08 | $560.66 | $566.16 | $694.12 | n/a |
A0429 | $531.08 | $897.06 | $905.86 | $1,110.58 | n/a |
A0432 | $531.08 | $981.16 | $990.78 | n/a | n/a |
A0433 | $531.08 | $1,541.82 | $1,556.94 | $1,908.80 | n/a |
A0434 | $531.08 | $1,822.14 | $1,840.02 | $2,255.86 | n/a |
The "urban" base rate(s) and mileage rate(s) shall apply to all relevant/applicable ambulance services unless the zip code range area is "Rural" or "Super Rural." Medicare MSA zip code grouping is listed on Medicare's webpage with an "R" indicator for "Rural" and "B" indicator for "Super Rural." See Medicare's Zip Code to Carrier Locality File, revised May 2023.
HCPCS modifiers identify place of origin and destination of the trip. The modifier is to be placed next to the HCPCS code billed. Each of the modifiers may be utilized to make up the first and/or second half of a two-letter modifier. The first letter describes the origin of the transport, and the second letter describes the destination.
Charges for mileage must be based on loaded mileage only, i.e., from pickup to destination.
7 CCR 1101-3-18-6