Code of Colorado Regulations
1100 - Department of Labor and Employment
1101 - Division of Workers' Compensation
7 CCR 1101-3 R18 Exhibits - Rule 18, Exhibits
Exhibit #1 - Evaluation and Management - Medical Decision Making - Effective 1/1/2024
Number/Complexity of Problems Addressed (Chart A)
Only problems directly related to the injury and pertinent to the visit or treatment are counted.
Amount and/or Complexity of Data to be Reviewed and Analyzed (Chart B)
*Each unique test, order, or document contributes to the combination of T&D category below. If the test is being billed on the same date, T&D does not apply
Test - Laboratory services, diagnostic imaging, psychometric, or physiologic data. A clinical laboratory panel (e.g., basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT® code set.
External - External records, communications and/or test results are from an external physician, other qualified health care professional, facility or health care organization.
External Physician or Other Qualified Healthcare Professional - An individual who is in a different group practice or who is of a different specialty or subspecialty. It includes licensed professionals that are practicing independently (e.g. PT, OT, nurse case manager.) It may also be a facility or organizational provider such as a hospital, nursing facility, or home health care agency.
Independent Historian(s) - An individual such as a parent, guardian, surrogate, spouse, caregiver, witness, supervisor, or co-worker who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history due to developmental stage of the patient, or another mental condition(s) or because a confirmatory history is determined to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian(s) is needed, the independent historian(s) requirement is met.
Independent Interpretation - The interpretation of a test for which there is a CPT® code and an interpretation or report is expected. This does not apply when the provider is reporting the service or has previously reported the service for the patient. A form of interpretation should be documented, but need not conform to the usual standards of a complete report for the test.
Appropriate Source - Individuals who are not health care professionals, but may be involved in the management of the patient (e.g., lawyer, parole officer, power of attorney, case manager, clergy, teacher). It does not include discussion with family or informal caregivers.
Risk of complications and/or Morbidity or Mortality of Patient Management (Chart C) see examples on following page
Time-Based Coding
Total Time on the Date of the Visit - (99202-99205, 99212-99215) - For calculation purposes, time for these services is the total time on the date of the visit. It includes both the face-to-face and non-face-to-face time personally spent by the provider(s) on the day of the visit and includes time in activities that require the provider but does not include time in activities normally performed by clinical staff.
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Provider time includes the following activities, when performed and documented: |
Provider time does not include: |
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* Preparing to see the patient such as reviewing the pt's record |
* Completing a WC-164 |
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* Obtaining and/or reviewing separately obtained history |
* Activities related to QPOP |
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* Performing a medically appropriate history and examination |
* Activities not included in the documentation |
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* Counseling and educating the patient, family, and/or caregiver |
* Time associated with any other billed code |
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* Ordering prescription medications, tests, or procedures |
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* Referring and communicating with other health care providers when not separately reported during the visit * Documenting clinical information in the electronic or other health record |
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* Independently interpreting and communicating results to the patient/family/caregiver |
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* Coordinating the care of the patient (case manager; discharge; instructions for post-op care) |
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* Time spent communicating with patient, family and/or caregiver through an interpreter |
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* Time spent on causation or apportionment analysis |
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Code |
Time |
Code |
Time |
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99202 |
15-29 |
99212 |
10-19 |
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99203 |
30-44 |
99213 |
20-29 |
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99204 |
45-59 |
99214 |
30-39 |
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99205 |
60-74 |
99215 |
40-54 |
