colorado workers' compensation medical fee schedules: ppo

Colorado Workers’ Colorado Workers’ Compensation Medical Fee Compensation Medical Fee

Schedules: PPO Schedules: PPO Contracts, Billing, Fee Contracts, Billing, Fee

Calculations, and UpdatesCalculations, and Updates

Debra J. Northrup, RNDebra J. Northrup, RN

Colorado Medical SocietyColorado Medical Society

“ “Brown Bag Teleconference” Brown Bag Teleconference”

November 18, 2008November 18, 2008

ObjectivesObjectives

• Preferred Provider Contracts (PPO) and Preferred Provider Contracts (PPO) and Workers’ Compensation feesWorkers’ Compensation fees

• A/R requirements, and timely payment of A/R requirements, and timely payment of medical benefits in Colorado Workers’ medical benefits in Colorado Workers’ Compensation Compensation

• How to calculate the maximum medical fees in How to calculate the maximum medical fees in Colorado Workers’ CompensationColorado Workers’ Compensation

• How Botox is reimbursed under Colorado How Botox is reimbursed under Colorado Workers’ CompensationWorkers’ Compensation

• Brief updates on Rule 16 and Rule 18 changes: Brief updates on Rule 16 and Rule 18 changes: effective 1/1/2009effective 1/1/2009

PPO Contracts and PPO Contracts and Workers’ CompensationWorkers’ Compensation

““Know what you are legally Know what you are legally agreeing to before you sign agreeing to before you sign

any contract”any contract”

PPO contracts and SB PPO contracts and SB 7979

• SB79 applies to Workers’ Compensation.SB79 applies to Workers’ Compensation.• Identify and review all of your contracts to Identify and review all of your contracts to

ensure they are in compliance with SB79 ensure they are in compliance with SB79 and everything is “Transparent”, including and everything is “Transparent”, including any applications to Workers’ Compensation any applications to Workers’ Compensation bills.bills.• If you don’t nobody else will.If you don’t nobody else will.

• Colorado Medical Society (CMS) Colorado Medical Society (CMS) • Use “The Practical Application of C.R.S. 25-37-Use “The Practical Application of C.R.S. 25-37-

101 (SB79) to evaluate 101 (SB79) to evaluate all your PPO all your PPO contractscontracts..

PPO contractsPPO contracts• What I’ve found out:What I’ve found out:

• The “Plan Participation” clause in your The “Plan Participation” clause in your commercial health contract can too broad.commercial health contract can too broad.

• Does your commercial health care plan PPO Does your commercial health care plan PPO contract allow them to apply that signed contract allow them to apply that signed contract to “all other plans” at the contractors' contract to “all other plans” at the contractors' discretion discretion

• Aetna commercial PPO contract can possibly Aetna commercial PPO contract can possibly be applied to Coventry Workers’ Compensation be applied to Coventry Workers’ Compensation or First Health/Coventry commercial plan to or First Health/Coventry commercial plan to the Coventry WCs the Coventry WCs

PPO contractsPPO contracts• What I’ve found out:What I’ve found out:

• PPO company says you’re participating if PPO company says you’re participating if you you don’t contact themdon’t contact them

• Aetna sends out a “Dear Health Care Provider” Aetna sends out a “Dear Health Care Provider” letter requesting participation in their W/C letter requesting participation in their W/C Access Network and considers the provider Access Network and considers the provider participating participating if her/she does not respondif her/she does not respond to to their solicitation.their solicitation.

• Signed PPO contract bought out by another Signed PPO contract bought out by another entity (Coventry buys the Focus Network and entity (Coventry buys the Focus Network and many other smaller networks.) many other smaller networks.)

PPO contractsPPO contracts

• What I’ve found out:What I’ve found out:• Coventry purchased Concentra’s non-Coventry purchased Concentra’s non-

medical products:medical products:• Concentra Medical Bill Review is now Concentra Medical Bill Review is now

Coventry W/C Services.Coventry W/C Services.• Focus Network is now owned by Coventry. Focus Network is now owned by Coventry.

Focus may include or be associated with Focus may include or be associated with in some way with the commercial in some way with the commercial networks - Mountain Medical Affiliate networks - Mountain Medical Affiliate (MMA) and/or Sloan’s Lake(MMA) and/or Sloan’s Lake


• Bottom Line:Bottom Line:

““If you signed a contact you If you signed a contact you agreed to its content.”agreed to its content.”


• What I’ve found out:What I’ve found out:• ““Evergreen Clause” in the Evergreen Clause” in the

contract allows the contract to contract allows the contract to be automatically updated every be automatically updated every year without noticeyear without notice

Account Receivable Account Receivable RequirementsRequirements


• Bill professional fees on a CMS Bill professional fees on a CMS 1500 form 1500 form (formally the HCFA 1500) (formally the HCFA 1500) Rule 16-7(B)(1-4)Rule 16-7(B)(1-4)

• Billed facility fees on a UB04 form Billed facility fees on a UB04 form • In Colorado it is Illegal to bill the In Colorado it is Illegal to bill the

injured worker for any hospital or injured worker for any hospital or medical services related to a medical services related to a workers’ compensation claim.workers’ compensation claim.


• Bill for services within 120 days Bill for services within 120 days from date of service, unless from date of service, unless unusual circumstances justify unusual circumstances justify delay. delay. Rule 16-11(A)(1)Rule 16-11(A)(1)

• ““denied claim” can take two years denied claim” can take two years to get final resolutionto get final resolution


• Providers, except hospitals, must Providers, except hospitals, must submit copy of supporting submit copy of supporting documentation with the bill, unless documentation with the bill, unless otherwise agreed upon with payer.otherwise agreed upon with payer.

• Hospital must submit copies of Hospital must submit copies of supporting documentation upon supporting documentation upon request. request. Rule 16-7 E.4-6Rule 16-7 E.4-6


• Payers must pay within 30 days from Payers must pay within 30 days from receipt of bill and/or send EOB outlining receipt of bill and/or send EOB outlining reasons for denying any billed line. reasons for denying any billed line. Rule 16-Rule 16-11(A)(2)11(A)(2)

• Contesting payment of billed service:Contesting payment of billed service:• Clear explanation of reason for denialClear explanation of reason for denial• If contesting for medical reasons a physician If contesting for medical reasons a physician

review and report must be submitted with review and report must be submitted with EOBEOB

• Can not change codes - must deny or call Can not change codes - must deny or call and document agreement with provider and document agreement with provider office and document on EOB. office and document on EOB. Rule 16-11(B) “Contested Rule 16-11(B) “Contested Payment for Billed Services Based uppn Non-Medical Issues” or (C) “Contested Payment Payment for Billed Services Based uppn Non-Medical Issues” or (C) “Contested Payment for Billed Services Based upon Medical Issues”for Billed Services Based upon Medical Issues”


• Only required to pay the billed Only required to pay the billed amount or the maximum fee amount or the maximum fee schedule allowance, whichever is schedule allowance, whichever is less. less. Rule 16-6(B)Rule 16-6(B)


• Respond to any disputed or denied payment Respond to any disputed or denied payment amounts within 60 days from receipt of the amounts within 60 days from receipt of the EOB and/or check. EOB and/or check. Rule 16-11(D)(1)Rule 16-11(D)(1)

• Have clear and well organized collection Have clear and well organized collection procedures for all billed services to all types procedures for all billed services to all types of payers, not just workers compensation.of payers, not just workers compensation.

• Know what you are collecting – is it a denial that Know what you are collecting – is it a denial that is not justified by CPT or Rule 18is not justified by CPT or Rule 18

• Collection letters should clearly outline the Collection letters should clearly outline the correct calculation and or why the service is correct calculation and or why the service is payable per CPT and/or Rule 18 – we’ve payable per CPT and/or Rule 18 – we’ve incorporated by reference both CPT and RVP. incorporated by reference both CPT and RVP. Rule Rule 18-118-1

• Document all phone calls to whom you spoke to Document all phone calls to whom you spoke to etc..etc..


• Contact the Division only after you have Contact the Division only after you have tried to collect the disputed payment or tried to collect the disputed payment or denial your self. denial your self. • Contact the Carrier Practice Unit if you have Contact the Carrier Practice Unit if you have

not received any payment at allnot received any payment at all• Contact the Medical Policy Unit if you are Contact the Medical Policy Unit if you are

disputing the paid amount due to coding or disputing the paid amount due to coding or rule interpretation.rule interpretation.

Calculating Calculating Professional Workers’ Professional Workers’

Compensation Compensation Maximum FeesMaximum Fees

Calculating Workers’ Calculating Workers’ Compensation Medical Compensation Medical

FeesFees

• ““Relative Values for Relative Values for Physicians”Physicians” (RVP) – specific (RVP) – specific editions are incorporated by editions are incorporated by reference in Rule 18 reference in Rule 18 •RVP contains all of the CPT RVP contains all of the CPT

codes and assigns a relative codes and assigns a relative value weight (RVUs) to each value weight (RVUs) to each CPT code. RVU is used to CPT code. RVU is used to determine the reimbursement. determine the reimbursement.


FeesFees

• ““Current Procedural Current Procedural Terminology”Terminology” ( (CPT) – specific CPT) – specific editions are “incorporated by editions are “incorporated by reference” in Rule 18reference” in Rule 18• AMA CPT code descriptions, AMA CPT code descriptions,

coding requirements, coding requirements, parenthetical notes, etc are parenthetical notes, etc are maintained unless the Division maintained unless the Division deviates by rule.deviates by rule.

CPT® only copyright 2007 American Medical Association. All rights reserved.


FeesFees

• Division of Workers’ Division of Workers’ Compensation Rule 16 Compensation Rule 16 requirements:requirements:• Billing forms, Billing forms, • Billing and payment timelines,Billing and payment timelines,• Documentation Documentation • Prior authorization proceduresPrior authorization procedures• Contest procedures for prior Contest procedures for prior

authorization and bill paymentauthorization and bill payment


FeesFees• Division of Workers’ Division of Workers’

Compensation Rule 18 and Compensation Rule 18 and applicable exhibits:applicable exhibits:•Effective date of fee schedule – Effective date of fee schedule –

based upon the date of service.based upon the date of service.•Conversion Factors for code setsConversion Factors for code sets•Any deviation from CPTAny deviation from CPT©©

•Services/Workers’ Services/Workers’ Compensation specific codes Compensation specific codes and feesand fees


FeesFees• Division of Workers’ Division of Workers’

Compensation Compensation Interpretative Bulletin #13:Interpretative Bulletin #13:•Clarifies what codes are Clarifies what codes are being referred to in Rule 18.being referred to in Rule 18.


FeesFeesRVP© and CPT Code Ranges per Conversion

Factor

• Anesthesia (CPT® 00100 –01999 and 99100-99140)

• Surgery (CPT® 10021-69990)• Surgery X Codes (See Rule 18-5(D)(1)(d)) and

Interpretive Bulletin for codes • Radiology (CPT® 70010-79999)• Pathology (CPT® 80047-89356) • Medicine (CPT® 90281 - 96999 and 98925 –

99199 and 99500-99607)• Physical Medicine (CPT® 97001-97814)• Evaluation & Management (CPT® 99201 –

99499)

CPT® only copyright 2007 American Medical Association. All rights reserved.

Surgery X-Codes Surgery X-Codes The surgery-X codes, referred to in section 18-5(D)(1)(d)

(1) are:• 01996 31500 36400 36420 36425 36600 36620 36625 36660

62273 62280 62281,62282 62310 62311 62318 62319 64400 64402 64405 64408 64410 64412 , 64413,64415 64416 64417 64418 64420 64421 64425 64430 64435 64445 64446 64447,64448 64449 64450 64470 64472 64475 64476 64479 64480 64483 64484 64505,64508 64510 64520 64530 64600 64605 64610 64620 64622 64623 64626 64627,64630 64640 64680

• It is recommended that providers use codes 77012 or 77021 when billing for CT or MRI fees involved with IDEA.


FeesFees• Example Effective 1/1/2008: Example Effective 1/1/2008:

Surgery X-CodeSurgery X-Code 6447564475• 8 RVUs x $37.698 RVUs x $37.69 = $301.52= $301.52

• 8 RVUs are from Relative Values for 8 RVUs are from Relative Values for Physicians (RVP) 2007 edition that is Physicians (RVP) 2007 edition that is incorporated by reference under Rule 18-1.incorporated by reference under Rule 18-1.

• $37.69 Surgery X-code conversion factor is $37.69 Surgery X-code conversion factor is under Rule 18-4, effective 1/1/2008.under Rule 18-4, effective 1/1/2008.

• No Time Units are allowedNo Time Units are allowed


FeesFees• Example, Effective 1/1/2009: E&M Example, Effective 1/1/2009: E&M

office visitoffice visit 9920599205• 26 RVUs x $8.8126 RVUs x $8.81 = $229.06= $229.06

• 26 units are from Relative Values for 26 units are from Relative Values for Physicians (RVP) Physicians (RVP) 2008 edition2008 edition that is that is incorporated by reference under Rule 18-1.incorporated by reference under Rule 18-1.

• $$8.81 E&M conversion factor8.81 E&M conversion factor under Rule under Rule 18-418-4

Billing and Calculating Billing and Calculating Maximum fees for Botox Maximum fees for Botox

InjectionInjection

Rule 18-6(H)(1)-(5) Rule 18-6(H)(1)-(5) Payment for the Botox Payment for the Botox

DrugDrug• Rule 18-6(O)(12), second paragraph Rule 18-6(O)(12), second paragraph

allows providers to be paid their actual allows providers to be paid their actual cost for a drug if it is given during the cost for a drug if it is given during the course of care – ie Botox injections.course of care – ie Botox injections.

• Payers should pay providers whatever Payers should pay providers whatever their actual cost was for the drug their actual cost was for the drug Botox.Botox.• Botox is somewhere around $550.00 for Botox is somewhere around $550.00 for

one bottle. one bottle.

Rule 18-6(H)(1)-(5) Billing Rule 18-6(H)(1)-(5) Billing for the drug, Botoxfor the drug, Botox

• Bill using Medicare’s HCPCS Level II Bill using Medicare’s HCPCS Level II codes codes • Botulinum Toxin Type A - J0585 - 1 UBotulinum Toxin Type A - J0585 - 1 U• Botulinum Toxin Type B - J0587 – 100 UBotulinum Toxin Type B - J0587 – 100 U

OrOr• General supply code 99070 General supply code 99070

• Regardless how you bill always submit a Regardless how you bill always submit a copy of your invoice showing the actual copy of your invoice showing the actual cost your office incurred for this drugcost your office incurred for this drug

Rule 18-6(H)(1)-(5)Botox Rule 18-6(H)(1)-(5)Botox Injection Billing and Injection Billing and

PaymentPayment• Bill according to CPT - each code can only be Bill according to CPT - each code can only be

billed once.billed once.• 64612 – Chemodenervation of muscle(s); 64612 – Chemodenervation of muscle(s);

muscle(s) innervated by facial nerve(eg. For muscle(s) innervated by facial nerve(eg. For blepharospasm, hemifacial spasm)blepharospasm, hemifacial spasm)

• 64613 -64613 - neck muscle(s), (eg. For neck muscle(s), (eg. For spasmodic torticollis, spasmodic torticollis, spasmodic dysphonia)spasmodic dysphonia)

• 64614 - 64614 - extremity(s) and/or trunk extremity(s) and/or trunk muscle(s), (eg. For dystonia, muscle(s), (eg. For dystonia, cerebral cerebral palsy, multiple palsy, multiple sclerosis)sclerosis)

Rule 18-6(H)(1)-(5)Botox Rule 18-6(H)(1)-(5)Botox Injection Billing and Injection Billing and

PaymentPayment• Example of maximum fees for a Botox injection into Example of maximum fees for a Botox injection into the neck:the neck:• 64613 -Chemodenervation of muscle(s); neck muscle(s), (eg. 64613 -Chemodenervation of muscle(s); neck muscle(s), (eg.

For spasmodic For spasmodic torticollis, spasmodic dysphonia)torticollis, spasmodic dysphonia)• 2.4 RVUs x $90.97 = 2.4 RVUs x $90.97 = $218.33 for injection into the neck$218.33 for injection into the neck• 2.4 RVUs from RVP, 2007 edition2.4 RVUs from RVP, 2007 edition• $90.97 conversion factor- Rule 18-4, effective 1/1/2008$90.97 conversion factor- Rule 18-4, effective 1/1/2008

• Invoice for 1 bottle of Botox shows cost at Invoice for 1 bottle of Botox shows cost at $550.00 for the $550.00 for the cost of the Botox drug itself.cost of the Botox drug itself.

• Total Maximum reimbursement for both = Total Maximum reimbursement for both = approximately $768.33approximately $768.33

Significant Adopted Significant Adopted Changes to Rule 16 Changes to Rule 16

Effective: 1/1/09Effective: 1/1/09

Rule 16Rule 16

• Rule 16-1 Statement of Rule 16-1 Statement of Purpose was Purpose was modifiedmodified::

Change the effective date from Change the effective date from 1/1/2008 to 1/1/2009.1/1/2008 to 1/1/2009.

Rule 16Rule 16

• Rule 16-3 “Required Use of The Rule 16-3 “Required Use of The Medical Treatment Guidelines Medical Treatment Guidelines AND AND PAYMENT FOR SERVICEPAYMENT FOR SERVICE” ” modifiedmodified::• ““A payer may not dictate the type or A payer may not dictate the type or

duration of medical treatment. Nor duration of medical treatment. Nor may a payer apply its own internal may a payer apply its own internal guidelines or other standards for guidelines or other standards for medical treatment if they conflict medical treatment if they conflict with Rule 17 and its exhibits.”with Rule 17 and its exhibits.”

Rule 16Rule 16

• Rule 16-5(4)(A) “Referrals”, Rule 16-5(4)(A) “Referrals”, added added languagelanguage::

“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.”

Rule 16Rule 16

• Rule 16-7 (E) (1) (a) “Required Billing Forms Rule 16-7 (E) (1) (a) “Required Billing Forms and Accompanying Documentation” and Accompanying Documentation” Modified sentenceModified sentence::

• ““The (WC 164 Form) report type as The (WC 164 Form) report type as “initial” when the injured worker “initial” when the injured worker has their initial visit with the has their initial visit with the designated or selecteddesignated or selected authorized treating physician for authorized treating physician for this workers’ compensation injury.”this workers’ compensation injury.”

Rule 16Rule 16

• Rule 16-8 (A) “Required Medical Rule 16-8 (A) “Required Medical Record Documentation” Record Documentation” Modified sentenceModified sentence::

A A treatingtreating provider shall maintain provider shall maintain medical records for each injured medical records for each injured worker when the provider intends worker when the provider intends to bill of the provided service.to bill of the provided service.

Rule 16Rule 16

• Rule 16-(7)(E)(1)(a) “Required Rule 16-(7)(E)(1)(a) “Required Billing Forms and Accompanying Billing Forms and Accompanying Documentation” Documentation” modifiedmodified::

• Authorized treating physicians Authorized treating physicians sign (orsign (or countersign)countersign) and submit to the payer, and submit to the payer, with their initial and final visit billings, a with their initial and final visit billings, a completed “Physician’s Report of completed “Physician’s Report of Workers’Compensation Injury” (Form WC Workers’Compensation Injury” (Form WC 164) specifying:…164) specifying:…

Rule 16Rule 16

• Rule 16-9(D)Rule 16-9(D) “Prior Authorization” “Prior Authorization” adds a adds a modified sentencemodified sentence::

• ““The payer, unless they have The payer, unless they have previously notified said provider, shall previously notified said provider, shall give notice to the provider of these give notice to the provider of these procedures of obtaining prior procedures of obtaining prior authorization for payment upon receipt authorization for payment upon receipt of of the initial bill from that the initial bill from that providerprovider.”.”

Rule 16Rule 16

• Rule 16-10(E) “Contest of a Request for Prior Rule 16-10(E) “Contest of a Request for Prior Authorization” Authorization” adds a new paragraphadds a new paragraph::

• Failure of the payer to timely comply in full Failure of the payer to timely comply in full with the requirements of Rule 16-10(A) or with the requirements of Rule 16-10(A) or (B) shall be deemed authorization for (B) shall be deemed authorization for payment of the requested treatment unless:payment of the requested treatment unless:• (1)(1) A hearing is requested within the time A hearing is requested within the time

prescribed for responding as set forth prescribed for responding as set forth in Rule in Rule 16-10(A) or (B), 16-10(A) or (B), andand

• (2)(2) The requesting provider is notified that the The requesting provider is notified that the request is being contested and the request is being contested and the

matter is matter is going to hearing.”going to hearing.”

Significant Adopted Significant Adopted Changes to Rule 18 Changes to Rule 18

“Medical Fee Schedule”“Medical Fee Schedule”Effective: 1/1/09Effective: 1/1/09

Rule 18-1&2Rule 18-1&2• Updated “incorporated by reference” Updated “incorporated by reference”

documentsdocuments• 2008 edition of the “2008 edition of the “Relative Values for Relative Values for

PhysiciansPhysicians”” (RVP) (RVP) from the 2007 editionfrom the 2007 edition• Version 26 of the “Version 26 of the “Medicare Severity Diagnosis Medicare Severity Diagnosis

Related Groups (MS-DRG) Definitions Manual”Related Groups (MS-DRG) Definitions Manual” from version 25.from version 25.

• First “Incorporation by reference” of First “Incorporation by reference” of American Medical Association’s American Medical Association’s “Current “Current Procedural Terminology (CPT)”Procedural Terminology (CPT)” 2008 2008 Professional Edition. Professional Edition.

Rule 18-1Rule 18-1

• Effective date for Rule 18 Effective date for Rule 18 changed from dates of changed from dates of service occurring on and service occurring on and after 1/1/2008 to 1/1/2009 after 1/1/2008 to 1/1/2009

Rule 18-4 Conversion Rule 18-4 Conversion FactorsFactors

SectionSection Effective 1/1/08Effective 1/1/08 Effective 1/1/09Effective 1/1/09MedicineMedicine $ 7.56$ 7.56 $ 7.56$ 7.56E&ME&M $ 8.47$ 8.47 $ 8.81$ 8.81PM&RPM&R $ 5.57$ 5.57 $ 5.57$ 5.57Anes.Anes. $48.89$48.89 $49.87$49.87X-CodeX-Code $37.69$37.69 $38.07$38.07SurgerySurgery $90.97$90.97 $92.79$92.79RadiologyRadiology $17.26$17.26 $17.43$17.43PathologyPathology $12.99$12.99 $12.99$12.99

Rule 18-5Rule 18-5• Title of section was modified: “ Title of section was modified: “

Instructions and/or Modifications to the Instructions and/or Modifications to the Documents Incorporated by Reference in Documents Incorporated by Reference in Rule 18-1Rule 18-1””

• (B) Modified: “(B) Modified: “Unless modified here, the Unless modified here, the RVP is adopted for RVU’s and RVP is adopted for RVU’s and reimbursementreimbursement…..…..The CPT The CPT ®2008 is ®2008 is adopted for codes, descriptions, adopted for codes, descriptions, parenthetical notes and coding guidelines, parenthetical notes and coding guidelines, unless modified in this ruleunless modified in this rule.”.”

New DoWC Code New DoWC Code FormatFormat

• Alpha numericAlpha numeric• Begins with a “Z”Begins with a “Z”• 3 numbers following “Z”3 numbers following “Z”

• All previous DoWC codes were replaced with All previous DoWC codes were replaced with the new codesthe new codes

• Several new DoWC codes were added due to Several new DoWC codes were added due to necessity.necessity.

• Two page handout listing all of the new “Z” Two page handout listing all of the new “Z” codes.codes.• Previous DoWC codes crossed walked to new codes. Previous DoWC codes crossed walked to new codes.

Rule 18-5(G)(3) Rule 18-5(G)(3) BiofeedbackBiofeedback

• First paragraph modified: Prior First paragraph modified: Prior authorization for payment shall be required authorization for payment shall be required from the payer from the payer for any treatment for any treatment exceeding the treatment guidelinesexceeding the treatment guidelines. . (deleted the 12 visit limit).(deleted the 12 visit limit).

• The second sentence was modified: The second sentence was modified: “Session notes shall be periodically “Session notes shall be periodically reviewed by the prescribing physicianreviewed by the prescribing physician or or psychologistpsychologist to determine the continued to determine the continued need for the service.”need for the service.”

Rule 18-5(G)(6) Rule 18-5(G)(6) Psychiatric/Psychological Psychiatric/Psychological

CNS Tests and CNS Tests and Assessment ServiceAssessment Service• Modified the first sentence in Modified the first sentence in

paragraph (a):paragraph (a):• “ “A licensed psychologist A licensed psychologist (PsyD, PhD, (PsyD, PhD,

EdD)EdD) is reimbursed a maximum of is reimbursed a maximum of 100%100% of the medical fee listed in the of the medical fee listed in the RVPRVP©.”©.”

• Deleted paragraph (d) - for all CNS Deleted paragraph (d) - for all CNS assessments and tests use the RVP assessments and tests use the RVP relative value units relative value units (96101-96120 CPT® codes)(96101-96120 CPT® codes)

Rule 18-5(G)(8) Rule 18-5(G)(8) Qualified Qualified Non-Physician ProviderNon-Physician Provider Telephone or On-Line Telephone or On-Line

Services Services • Added new paragraph to address the Added new paragraph to address the separation of physician and non-physician separation of physician and non-physician telephone call created by 2008 CPTtelephone call created by 2008 CPT®® : :• ““Reimbursement to qualified non-physician Reimbursement to qualified non-physician

provider for coordination of care with provider for coordination of care with professionals shall be based upon the professionals shall be based upon the telephone codes for qualified non-physician telephone codes for qualified non-physician providers found in the RVPproviders found in the RVP© Medicine © Medicine Section. Coordination of care reimbursement Section. Coordination of care reimbursement is limited to telephone calls made to is limited to telephone calls made to professionals outside of the non-physician professionals outside of the non-physician provider’s employment facility(ies) and/or to provider’s employment facility(ies) and/or to the injured worker or their family.”the injured worker or their family.”

Rule 18-5(H)(PMR) Rule 18-5(H)(PMR) SectionSection

• Clarified Clarified Interdisciplinary Rehabilitation Interdisciplinary Rehabilitation ProgramsPrograms definition is found in the definition is found in the Division’s Medical Treatment Guidelines.Division’s Medical Treatment Guidelines.

• Added two new paragraphs. New Added two new paragraphs. New paragraph #1: paragraph #1: “If there is a single “If there is a single billing provider for the billing provider for the entire entire interdisciplinary rehabilitation interdisciplinary rehabilitation program:program:

• Mutually agree upon a daily per diem rateMutually agree upon a daily per diem rate• Bill using DoWC code Z500.”Bill using DoWC code Z500.”

Rule 18-5(H)(4) Physical Rule 18-5(H)(4) Physical Medicine and Medicine and

Rehabilitation (PMR)Rehabilitation (PMR)• New Paragraph #2:New Paragraph #2:

• ““If the individual interdisciplinary If the individual interdisciplinary rehabilitation professionals bill rehabilitation professionals bill separately for their participation in separately for their participation in an interdisciplinary rehabilitation an interdisciplinary rehabilitation program:program:

• the applicable CPTthe applicable CPT® codes shall be used ® codes shall be used to bill for their services. to bill for their services.

• Demonstrated participation in an Demonstrated participation in an interdisciplinary rehabilitation program interdisciplinary rehabilitation program allows the use of he frequencies and allows the use of he frequencies and durations listed in the relevant medical durations listed in the relevant medical treatment guidelines rehabilitation treatment guidelines rehabilitation program.”program.”

Rule 18-5(H)(6) Physical Rule 18-5(H)(6) Physical Medicine and Medicine and

Rehabilitation (PMR)Rehabilitation (PMR)• ModalitiesModalities

• Changed billing codes for Dry Needling: Changed billing codes for Dry Needling: • Z501Z501 Single or multiple needles , one or two Single or multiple needles , one or two

musclesmuscles• Z502Z502 three or more musclesthree or more muscles

• Added Added “Bill only one of the Dry “Bill only one of the Dry Needling modality codes (See relevant Needling modality codes (See relevant treatment guidelines for limitation on treatment guidelines for limitation on frequency)frequency)

Rule 18-5(H)(7)(a) Rule 18-5(H)(7)(a) Physical Medicine and Physical Medicine and Rehabilitation (PMR)Rehabilitation (PMR)

• Evaluation Services for TherapistsEvaluation Services for Therapists

• Modified last sentence in paragraph Modified last sentence in paragraph to read: “These to read: “These re-evaluation re-evaluation codes codes shall not be billed for shall not be billed for routineroutine pre- pre-treatment patient assessment. treatment patient assessment.

Rule 18-5(H)(7)(d) Rule 18-5(H)(7)(d) Physical Medicine and Physical Medicine and Rehabilitation (PMR)Rehabilitation (PMR)

• Paragraph (d) sentence was modified: Paragraph (d) sentence was modified:

• ““Reimbursement to PT’s, OTs, speech Reimbursement to PT’s, OTs, speech language pathologists and audiologists language pathologists and audiologists for coordination of care with for coordination of care with professionals shall be based upon the professionals shall be based upon the telephone codes telephone codes for qualified non-for qualified non-physician providers found in the physician providers found in the RVPRVP© Medicine Section© Medicine Section. .

Rule 18-5(H)(8) Special Rule 18-5(H)(8) Special Tests and (11) Tests and (11)

Unattended TreatmentUnattended Treatment• Separate billing codes and prior Separate billing codes and prior authorization is required when:authorization is required when:• Computer Enhanced Evaluation Computer Enhanced Evaluation (DoWC Z503) (DoWC Z503)

- > 4 hrs or more than 6 tests per claim- > 4 hrs or more than 6 tests per claim• Work Tolerance Screening (DoWC Z504) -Work Tolerance Screening (DoWC Z504) -> 4 > 4

hrs or more than 6 tests per claimhrs or more than 6 tests per claim • Remaining types of special tests are billed Remaining types of special tests are billed

under their applicable CPT codesunder their applicable CPT codes• FCE 97750 - FCE 97750 - >4 hours or 2 tests per claim>4 hours or 2 tests per claim• Job Site Evaluation 97537 - Job Site Evaluation 97537 - > 2 hrs> 2 hrs• Assistive Technology Assessment – 97755Assistive Technology Assessment – 97755

• New billing code for Unattended Therapy – New billing code for Unattended Therapy – Z505Z505

Rule 18-6(G) Report Rule 18-6(G) Report PreparationPreparation

• Paragraph (4) Special Reports has new Paragraph (4) Special Reports has new billing codes to represent the various billing codes to represent the various types of requests:types of requests:• Billing Codes Billing Codes

• Written Report OnlyWritten Report Only Z755Z755• IME/Report with patient examIME/Report with patient exam Z756Z756• Lengthy Form Completion Lengthy Form Completion

Z757Z757• Face-to-Face or telephonic meeting Face-to-Face or telephonic meeting

with Non-Tx Dr. with Non-Tx Dr. Z758Z758

Rule 18-6(H)(1)-(5) Rule 18-6(H)(1)-(5) Supplies, DME, and Supplies, DME, and

Orthotics and ProsthesesOrthotics and Prostheses• Allow providers to bill using Allow providers to bill using

Medicare’s HCPCS Level II codes Medicare’s HCPCS Level II codes • Allow payers to use Medicare’s HCPCS Allow payers to use Medicare’s HCPCS

Level II maximum fee values, unless Level II maximum fee values, unless the provider indicates that the items is the provider indicates that the items is to be paid at cost plus 20%.to be paid at cost plus 20%.• Provider has 60 days from receipt of the Provider has 60 days from receipt of the

EOB and payment to notify the payer EOB and payment to notify the payer they wish to be paid at cost plus 20% they wish to be paid at cost plus 20%

Rule 18-6(R) Use of Rule 18-6(R) Use of InterpreterInterpreter

• New section on InterpretersNew section on Interpreters• States: “Rates and terms shall be States: “Rates and terms shall be

negotiated and prior authorization is negotiated and prior authorization is required.”required.”

• Bill using code Z724Bill using code Z724

ResourcesResources• ““Resource Tools for Colorado Workers’ Resource Tools for Colorado Workers’

Compensation”Compensation”• Division Rules, contacts, phone #s Division Rules, contacts, phone #s • Relevant website addresses, Relevant website addresses,

• List of all new DoWC “Z” codesList of all new DoWC “Z” codes• Table of new telephone, on-line evaluation, and Medical Table of new telephone, on-line evaluation, and Medical

Team conferences for Tx, Non-Tx and qualified non-Team conferences for Tx, Non-Tx and qualified non-physician providers.physician providers.

• Division Web AddressDivision Web Address• http://www.coworkforce.com/dwc/http://www.coworkforce.com/dwc/

• Interpretative BulletinInterpretative Bulletin• Rule 16 and 18 , current rules, archivesRule 16 and 18 , current rules, archives• New 1/1/09 Rule 16 and 18 are under the “Rules of Procedure” New 1/1/09 Rule 16 and 18 are under the “Rules of Procedure”

icon, then click the “icon, then click the “Proposed/Adopted Rules/Notices of Rule HearingsProposed/Adopted Rules/Notices of Rule Hearings

Thank You!Thank You!

Any questions????Any questions????

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