Code of Colorado Regulations
1100 - Department of Labor and Employment
1101 - Division of Workers' Compensation
7 CCR 1101-3 Rule 18 - Rule 18, MEDICAL FEE SCHEDULE (Rule 18 exhibits published separately)
Section 7 CCR 1101-3-18-6 - ANCILLARY SERVICES

Universal Citation: 1100 CO Code Regs 7 CCR 1101-3-18-6

Current through Register Vol. 47, No. 17, September 10, 2024

(A) DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES (DMEPOS)

(1) Durable Medical Equipment (DME):

DME equipment withstands repeated use and allows injured workers accessibility in the home, work, and community. DME can be categorized as:

(a) Purchased Equipment/Capped Rental:

(i) Items that cost $100.00 or less may not be rented.

(ii) Rented items must be purchased or discontinued after ten months of continuous use or once the total fee schedule allowance has been reached.

(iii) The monthly rental rate cannot exceed 10% of the DMEPOS fee schedule, or if not available, the cost of the item to the provider or the supplier (after taking into account any discounts/rebates the supplier or the provider may have received). When the item is purchased, all rental fees shall be deducted from the total fee scheduled price. If necessary, the parties should use an invoice to establish the purchase price.

(iv) Purchased items may require maintenance/servicing agreements or fees. The fees are separately payable. Rented items typically include these fees in the monthly rental rates.

(v) Modifier NU shall be appended for new items, UE for used purchased items or modifier RR for rented items.

(b) Take Home Exercise Equipment:

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).

(i) TENS (Transcutaneous Electric Nerve Stimulator) machines/kits, IF (Interferential) machines/kits, and any other type of electrical stimulator combination kits: E0720 for a kit with two leads or E0730 for a kit with four leads.

(ii) Electrical Muscle Stimulation machines/kits: E0744 for scoliosis; or E0745 for neuromuscular stimulator, electric shock unit.

(iii) Osteogenesis electrical stimulators (E0747-E0760) are not required to be rented before purchase when used in accordance with MTG recommendations.

(iv) Replacement supplies are limited to once per month and are not eligible with a first month rental.

A4595 - electrical stimulator supplies, two leads.

A4557 - lead wires, pair (reimbursable once every 12 months).

(v) Conductive Garments: E0731.

(d) Continuous Passive Motion Devices (CPMs):

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.

(e) Intermittent Pneumatic Devices:

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.

(f) Hearing and Vision Supplies:

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.

(2) Orthotics:

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.

(3) Supplies:

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.

(4) Reimbursement:

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.

(5) Complex Rehabilitation Technology dispensed and billed by Non-Physician DMEPOS Suppliers:

(a) Complex rehabilitation technology (CRT) items, including complex rehabilitation power wheelchairs, highly configurable manual wheelchairs, adaptive seating and positioning systems, standing frames, and gait trainers enable individuals to maximize their function and minimize the extent and costs of their medical care.

(b) Complex Rehabilitation Technology products must be provided by suppliers who are specifically accredited by a Center for Medicare and Medicaid Services (CMS) deemed accreditation organization as a supplier of CRT and licensed as a DMEPOS Supplier with the Colorado Secretary of State.

(B) HOME CARE SERVICES

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.

(1) Home Infusion Therapy:

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.

(a) Parenteral Nutrition:

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).

(b) Antibiotic Therapy is allowed a daily rate by professional + drug cost at Medicare's Average Sale Price (ASP), as incorporated by Rule 18-2. If ASP is not available, use Average Wholesale Price (AWP) (see 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

(c) Chemotherapy is allowed a daily rate + drug cost at ASP, as incorporated by Rule 18-2. If ASP is not available, use AWP.

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

(d) Enteral nutrition (enteral formula and nursing services are separately payable):

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

(e) Pain Management per day or refill + drug cost at ASP, as incorporated by Rule 18-2. If ASP is not available, use AWP.

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.

(f) Fluid Replacement is allowed a daily rate + drug cost at ASP, as incorporated by Rule 18-2. If ASP is not available, use AWP.

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

(g) Multiple Therapies:

Highest cost per day or refill only + drug cost at ASP, as incorporated by Rule 18-2. If ASP is not available, use AWP.

(2) Nursing Services are limited to two hours without prior authorization, unless otherwise indicated in the MTGs:

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

(3) Physical medicine procedures are payable in accordance with section 18-4(H).

(4) Mileage:

The parties should agree upon travel allowances and the mileage rate shall not exceed 59 cents per mile, portal to portal. DoWC Z0772.

(5) Travel Time:

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.

(6) Drugs/Supplies/DME/Orthotics/Prosthetics Used For At-Home Care:

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.

(1) All medications must be reasonably needed to cure and relieve the injured worker from the effects of the injury. Prior authorization is required for:

(a) Medications "not recommended" in the MTGs for a particular diagnosis; or

(b) Any non-steroidal anti-inflammatory drug (NSAID), muscle relaxant, or topical agent for which a significantly lower-cost therapeutic equivalent is available, including commercially or over-the-counter (OTC), even in a different strength/dosage. Significantly lower cost means the therapeutic equivalent costs at least $100 less, for the same number of days' supply. For example, prior authorization would be required to dispense diclofenac gel 1.5% at an average wholesale price (AWP) of $689 when diclofenac 1% is available OTC for $10, or to dispense more than one unit of lidocaine 4.5%-menthol 5% patch at an AWP of $49 when a lidocaine 4%-menthol 5% patch can be obtained OTC for $2.

(2) Prescription Writing:

(a) This Rule applies to all pharmacies, whether located in or out of state.

(b) Physicians shall indicate on the prescription form that the medication is related to a workers' compensation claim.

(c) All prescriptions shall be filled with bio-equivalent generic drugs unless the physician indicates "Dispense As Written" (DAW) on the prescription. In addition to the Rule 16 requirements, providers prescribing a brand name with a DAW indication shall provide a written medical justification explaining the reasonableness and necessity of the brand name over the generic equivalent.

(d) The provider shall not exceed a 60-day supply per prescription.

(e) Opioids/scheduled controlled substances, including benzodiazepines, shall only be provided through a pharmacy. The prescriber shall comply with applicable provisions of Title 12 and other statutes and rules.

(3) Billing:

(a) Drugs (brand name or generic) shall be reported on bills using the applicable identifier from the National Drug Code (NDC) Directory as published by the Food and Drug Administration (FDA).

(b) All parties shall use one (1) of the following forms:

(i) CMS-1500 - dispensing provider shall bill by using the metric quantity (number of tablets, grams, or mls) in column 24.G and NDC number of the drug being dispensed or, if one does not exist, the HCPCS supply code. For repackaged drugs, dispensing provider shall list the "repackaged" and the "original" NDC numbers in field 24 of the CMS-1500. The dispensing provider shall list the "repackaged" NDC number of the actual dispensed medication first and the "original" NDC number second, with the prefix 'ORIG' appended. Billing providers shall include the units and days supply for all dispensed medications in field 19, example: '60UN/30DY.'

(ii) With the agreement of the Payer, the National Council for Prescription Drug Programs (NCPDP) or ANSI ASC 837 (American National Standards Institute Accredited Standards Committee) electronic billing transaction containing the same information as above may be used for billing. NCPDP Workers' Compensation/Property and Casualty (P&C) Universal Claim Form, version 1.1, for prescription drugs billed on paper shall be used by dispensing pharmacies and pharmacy benefit managers.

(c) Dispensing provider shall keep a signature on file indicating the injured worker or the injured worker's authorized representative has received the prescription.

(4) Average Wholesale Price (AWP):

(a) AWP for brand name and generic pharmaceuticals may be determined using such monthly publications as Red Book Online or Medispan. In case of a dispute on AWP values for a specific NDC, the parties shall take the lower of their referenced published values.

(b) If published AWP data becomes unavailable, substitute Wholesale Acquisition Cost (WAC) + 20% for AWP everywhere in this Rule.

(5) Reimbursement for Prescription Drugs & Medications:

(a) For prescription medications, except topical compounds, reimbursement shall be AWP + $4.00. If drugs have been repackaged, use the original AWP and NDC that was assigned by the source of the repackaged drugs to determine reimbursement.

(b) The entity packaging two or more products together makes an implied claim that the products are safe and effective when used together and shall be billed as individual line items identified by their original AWP and NDC. This original AWP and NDC shall be used to determine reimbursement. Supplies are considered integral to the package are not separately reimbursable.

(c) Reimbursement for an opiate antagonist prescribed or dispensed under § 12-30-110 to an injured worker at risk of experiencing an opiate-related drug overdose event, or to a family member, friend, an employee or volunteer of a harm reduction organization, or other person in a position to assist the injured worker shall be AWP plus $4.00.

(d) Injectables shall be reimbursed at Medicare's Part B Drug Average Sale Price (ASP), as incorporated by Rule 18-2, unless the ASP value does not exist for the drug or the provider's actual cost exceeds the ASP. In this circumstance, provider may request reimbursement based on the actual cost, after taking into account any discounts/rebates the provider may have received.

(e) The provider may bill for the discarded portion of drug from a single use vial or a single use package, appending the JW modifier to the HCPCS Level II code. The provider shall bill for the discarded drug amount and the amount administered to the injured worker on two separate lines. The provider must document the discarded drug in the medical record.

(6) Prescription-Strength Topical Compounds:

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.

(7) Over-the-Counter Medications:

(a) Medications that are available for purchase by the general public without a prescription and listed as over-the-counter in publications such as RedBook Online or Medispan, are reimbursed at NDC/AWP and are not eligible for dispensing fees. If drugs have been repackaged, use the original AWP and NDC that was assigned by the source of the repackaged drugs to determine reimbursement.

(b) The maximum allowance for any topical agent containing only active ingredients available without a prescription shall be at cost to the billing provider up to $30.60 per 30 day supply for any application (excludes patches). The maximum allowance for a patch is cost to the billing provider up to $71.40 per 30 day supply. When less than a 30 day supply is prescribed, these allowances shall be pro-rated to the amount dispensed to the injured worker.

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.

(8) Dietary Supplements, Vitamins, and Herbal Medicines:

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).

(9) Injured Worker Reimbursement:

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.

(D) COMPLEMENTARY INTEGRATIVE MEDICINE

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.

(E) AMBULANCE TRANSPORTATION

(1) Maximum Allowance:

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.

(2) General Claims Submission:

(a) All hospitals billing for ground or air ambulance services shall bill on the UB-04. All other providers shall bill on the CMS-1500.

(b) Providers shall use HCPCS codes and origin/destination modifiers.

(d) Providers shall list the zip code for the place of origin in Item 23 of the CMS- 1500 or FL 39-41 of the UB-04 with an "AO" code. If billing for multiple trips and the zip code for each origin is the same, services can be submitted on the same claim. If the zip codes are different, a separate claim must be submitted for each trip.

(3) Ground Ambulance Services Billing Codes and Fees:

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.

(4) Modifiers:

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.

(5) Mileage:

Charges for mileage must be based on loaded mileage only, i.e., from pickup to destination.

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Code of Colorado Regulations1100 - Department of Labor and Employment1101 - Division of Workers' Compensation7 CCR 1101-3 Rule 18 - Rule 18, MEDICAL FEE SCHEDULE (Rule 18 exhibits published separately)Section 7 CCR 1101-3-18-6 - ANCILLARY SERVICES

Code of Colorado Regulations
1100 - Department of Labor and Employment
1101 - Division of Workers' Compensation
7 CCR 1101-3 Rule 18 - Rule 18, MEDICAL FEE SCHEDULE (Rule 18 exhibits published separately)
Section 7 CCR 1101-3-18-6 - ANCILLARY SERVICES