Code of Colorado Regulations, Rule 7 CCR 1101-3 Rule 18, Section 7 CCR 1101-3-18-7 - DIVISION-ESTABLISHED CODES AND VALUES | Code of Colorado Regulations

(A) FACE-TO-FACE OR TELEPHONIC MEETINGS

(1) Face-to-face or telephonic meeting by a treating Physician or a Psychologist with an employer, claim representative, or any attorney, and with or without the injured worker. Claim representatives include physicians or other qualified medical personnel performing Payer-initiated medical treatment reviews, but this Rule does not apply to provider-initiated requests for prior authorization. The Physician or Psychologist may bill for the time spent attending the meeting and preparing the report (no travel time or mileage is separately payable). The fee includes the cost of the report for all parties, including the injured worker.

Before a meeting is separately payable, the following requirements must be met:

(a) Each meeting (including the time to document) shall be a minimum of 8 minutes.

(b) A report or written record signed by the Physician or Psychologist is required and shall include the following:

(i) Who was present at the meeting and their role at the meeting;

(ii) Purpose of the meeting;

(iii) A brief statement of recommendations and actions at the conclusion of the meeting;

(iv) Documented time (both start and end times).

(c) DoWC Z0701, $44.22, is payable in 8-minute increments. The CPT® midpoint rule for attaining a unit of time does not apply to this code. The Physician or Psychologist may bill multiple units of this code per date of service.

(d) For reimbursement to qualified non-physician providers for coordination of care with medical professionals, see section 18-4(H).

(2) Face-to-face or telephonic meeting by a non-treating physician with the employer, claim representatives, or any attorney in order to provide a medical opinion on a specific workers' compensation case, which is not accompanied by a specific report or written record.

DoWC Z0601, $76.99 per 15 minutes billed to the requesting party.

(3) Face-to-face or telephonic meeting by a non-treating physician with the employer, claim representatives, or any attorney to provide a medical opinion on a specific workers' compensation case, which is accompanied by a report or written record, shall be billed as a special report (see section 18-7(G)(4)).

(4) Peer-to-peer review by a treating physician with a medical reviewer, following the treating physician's complete prior authorization request pursuant to Rule 16.

DoWC Z0602, $76.99 per 15 minutes billed to the requesting party.

(B) CANCELLATION FEES FOR PAYER-MADE APPOINTMENTS

(1) A cancellation fee is payable only when a Payer schedules an appointment the injured worker fails to keep, and the Payer has not canceled five days prior to the appointment.

The Payer shall pay one-half of the usual fee for the scheduled services, or $187.27, whichever is less:

DoWC Z0720. The provider shall indicate the code corresponding to the service that has been cancelled in Box 19 of the CMS-1500 form or electronic billing equivalent.

For Payer-made appointments scheduled for four hours or longer, the Payer shall pay one-half of the usual fee for the scheduled service.

DoWC Z0740. The Provider shall indicate the code corresponding to the service that has been cancelled in Box 19 of the CMS-1500 form or electronic billing equivalent.

(2) Missed Appointments:

When an injured worker fails to keep a scheduled appointment, the Provider should contact the Payer within five days. Upon reporting the missed appointment, the Provider may inquire if the Payer wishes to reschedule the appointment for the injured worker. If the injured worker fails to keep the Payer's rescheduled appointment, the Provider may bill for a cancellation fee according to this section.

(C) REQUESTS FOR MEDICAL RECORDS AND COPYING FEES

The Payer, Payer's representative, injured worker, and injured worker's representative shall pay a reasonable fee for the reproduction of the injured worker's medical record. Copying charges do not apply for the initial submission of records that are part of the required documentation for billing. If records are readily producible electronically and appropriate security is in place, including but not limited to compatible encryption, the provider shall provide the requestor with an electronic copy (e.g., email). If the requester and Provider agree, the copy may be provided by fax, on paper, or by disc. Provider may not charge a fee for a records search and retrieval. All records shall be provided no later than 30 days from the date the request is received.

Copying Fee Billing Codes and Maximum Fees:

DoWC Z0721, $18.53 for first 10 or fewer paper page(s), including faxed documents

DoWC Z0725, $0.85 per paper page for the next 11-40 paper page(s), including faxed documents

DoWC Z0726, $0.57 per paper page for remaining paper page(s), including faxed documents

DoWC Z0727, $1.50 per microfilm page

DoWC Z0728, $14.00 per computer disc

DoWC Z0729, $6.50 per electronic copy

DoWC Z0802, actual postage paid

(D) DEPOSITION AND TESTIMONY FEES

(1) When requesting deposition or testimony from any Provider, guidance should be obtained from the Interprofessional Code, endorsed by the Colorado Bar Association, the Denver Bar Association, the Colorado Medical Society, and the Denver Medical Society. If the parties cannot agree upon lesser fees for the deposition or testimony services, or cancellation time periods and/or fees, the deposition and testimony rules and fees listed below shall be used.

If a party shows good cause to an Administrative Law Judge (ALJ) for exceeding the Medical Fee Schedule allowance, that ALJ may allow a greater fee.

(2) Preparation Time:

By prior agreement, the Provider may charge for preparation time for a deposition or testimony, for reviewing and signing the deposition, or for preparation time for testimony.

Treating or non-treating Physician or Psychologist:

DoWC Z0730, $190.74, billed in half-hour increments. Other Providers are allowed 85% of this fee.

(3) Deposition:

Payment for testimony at a deposition shall not exceed $190.74, billed in half-hour increments, for a treating or non-treating Physician or a Psychologist. DoWC Z0734, calculating the Provider's time from "portal to portal." Other Providers are allowed 85% of this fee.

If requested, the Provider is entitled to a full hour deposit in advance in order to schedule the deposition.

If the Provider is notified of the cancellation of the deposition at least ten days prior to the scheduled deposition, the Provider shall be paid the number of hours that have been reasonably spent in preparation, less any deposit paid by the deposing party. DoWC Z0731, $190.74, in half-hour increments.

If the Provider is notified less than ten days in advance of a cancellation or rescheduling, or the deposition is shorter than the time scheduled, the Provider shall be paid the number of hours that have been reasonably spent in preparation and have been scheduled for the deposition. DoWC Z0733, $190.74, in half-hour increments.

(4) Testimony:

Treating or non-treating Physician or Psychologist:

DoWC Z0738, $264.18, billed in half-hour increments. Other Providers are allowed 85% of this fee.

Calculation of the Provider's time shall be "portal to portal" (includes travel time and mileage in both directions).

For testifying at a hearing, if requested, the Provider is entitled to a four-hour deposit in advance in order to schedule the testimony.

If the Provider is notified of the cancellation of the testimony at least ten days prior to the scheduled testimony, the Provider shall be paid the number of hours that have been reasonably spent in preparation, less any deposit paid by the requesting party. DoWC Z0735, $264.18, in half-hour increments.

If the Provider is notified less than ten days in advance of a cancellation or rescheduling, or the testimony is shorter than the time scheduled, the Provider shall be paid the number of hours that have been reasonably spent in preparation and has scheduled for the testimony. DoWC Z0737, $264.18, in half-hour increments.

(E) INJURED WORKER TRAVEL EXPENSES

The Payer shall advance or reimburse the injured worker for reasonable and necessary mileage expenses for travel to and from medical appointments. The injured worker shall submit a request to the Payer showing the date(s) of travel and mileage, incurred or anticipated, and explain any other reasonable and necessary travel expenses. The number of miles shall be in whole numbers and calculated using the most direct route available on the date of service. Advance mileage is available for eligible travel greater than 100 miles round trip, and shall be approved when requested by the injured worker at least seven days in advance.

Mileage Pre-paid Expense:	DoWC Z0722, 59 cents per mile
Mileage Expense:	DoWC Z0723, 59 cents per mile
Other Travel Expenses:	DoWC Z0724, actual paid

(F) PERMANENT IMPAIRMENT RATING

(1) The Payer is only required to pay for one combined whole-person permanent impairment rating per claim, except as otherwise provided in the Workers' Compensation Rules of Procedures. Exceptions that may require payment for an additional impairment rating include, but are not limited to, reopened cases, as ordered by the Director or an Administrative Law Judge, or a subsequent request to review apportionment. The ATP is required to submit in writing all permanent restrictions and future maintenance care related to the injury or occupational disease.

(2) Provider Restrictions:

The Physician determining the permanent impairment rating must be Level II accredited and comply with Rule 5 as applicable.

(3) Maximum Medical Improvement (MMI) Determined Without any Permanent Impairment:

If a Physician determines the injured worker is at MMI and has no permanent impairment, the Physician should be reimbursed for the examination at the appropriate level of E&M service. The ATP managing the total workers' compensation claim should complete the Physician's Report of Workers' Compensation Injury (Closing Report), WC 164 (see section 18-7(G)(2)).

(4) MMI Determined with a Calculated Permanent Impairment Rating

(a) Calculated Impairment: The total fee includes the office visit, a complete physical examination, complete history, review of all medical records except when the amount of medical records is extensive (see below), determining MMI, completing all required measurements, referencing all tables used to determine the rating, using all report forms from the AMA's Guide to the Evaluation of Permanent Impairment, Third Edition (Revised), (AMA Guides), and completing the Physician's Report of Workers' Compensation Injury (Closing Report) WC 164.

Extensive medical records take longer than one hour to review and require a separate report. The separate report must document each record reviewed, specific details of the records reviewed, and the dates represented by the records reviewed. The separate record review can be billed as a special report and requires prior authorization.

(b) Impairments Requiring Multiple Providers:

All Physicians and Psychologists (including Level II Accredited Physicians) providing consulting services for the completion of a whole person impairment rating shall bill using the appropriate E&M consultation code, or psychological diagnostic evaluation code, and shall forward their portion of the rating to the Physician determining the combined whole person rating.

A return visit for a range of motion (ROM) validation shall be billed with the appropriate code in the Medicine Section of CPT®.

The date the Physician sees the injured worker shall be the date of service billed.

DoWC Z0759, $612.00, for the Level II Accredited Authorized Treating Physician providing primary care.

DoWC Z0760, $822.12, for the Referral, Level II Accredited Authorized Physician (the claimant is not a previously established patient to that physician for that workers' compensation injury).

DoWC Z0764, If the injured worker fails to attend the impairment rating appointment or if the parties notify the Physician of a cancellation or rescheduling five days or less prior to the appointment, the Physician shall be paid one-half of the fee for the scheduled service. The Physician shall indicate the code corresponding to the scheduled service in Box 19 of the CMS-1500 form or electronic billing equivalent.

(G) REPORT PREPARATION

(1) Routine Reports:

Providers shall submit routine reports free of charge as directed in Rule 16 and by statute. Requests for additional copies of routine reports and for reports not in Rule 16 or statute are reimbursable under the copying fee section of this Rule. Routine reports include:

(a) Diagnostic testing

(b) Procedure reports

(c) Progress notes

(d) Office notes

(e) Operative reports

(f) Supply invoices, if requested by the Payer

(2) Completion of the Physician's Report of Workers' Compensation Injury:

(a) Initial Report WC 164:

The ATP and ED/urgent care physician, when applicable, shall complete the first report of injury. Items 1-7 and 11 must be complete. However, item 2 may be omitted if not known by the Provider. If completed by a PA or NP, the ATP must countersign the form.

DoWC Z0750 Initial Report

$51.00

(b) Closing Report WC 164:

The ATP managing the workers' compensation claim must complete the WC 164 closing report when the injured worker is at maximum medical improvement (MMI) for all covered injuries or diseases, with or without a permanent impairment. Items 1-5, 6 B-C, 7 (if applicable), and 8-11 must be complete. If completed by a PA or NP, the ATP must countersign the form.

DoWC Z0752 Closing Report

$51.00

If the injured worker has sustained a permanent impairment, the following additional information must be attached to the bill when MMI is determined:

(i) All necessary permanent impairment rating reports, medical reports, and narrative relied upon by the ATP, when the ATP managing the workers' compensation claim is Level II Accredited; or

(ii) The name of the Level II Accredited Physician requested to perform the permanent impairment rating when a rating is necessary and the ATP managing the workers' compensation claim is not determining the permanent impairment rating.

(c) Initial and Closing Report WC 164 completed on the same form for the same date of service:

DoWC Z0753

$51.00

(d) Progress Report WC 164:

Any request from the Payer or the employer for the information provided on this form is deemed authorization for payment. The Provider shall document the name of the person who made the request and the date of the request on the WC 164; complete items 1, 2, 4-7, and 11; and send it to all parties within five days of the request. If completed by a PA or NP, the ATP must countersign the form.

DoWC Z0751

Progress Report

$51.00

(3) Form Completion:

The requesting party shall pay for its request for a physician to complete additional forms requiring 15 minutes or less, including forms sent by a Payer or an employer. This code also may be billed when completing the requirements outlined in § 8-43-404(10)(a) or Desk Aid 15 for a non-medical discharge.

DoWC Z0754

Form Completion

$51.00

(4) Special Reports:

The term special report includes any form, questionnaire, letter, or report with variable content not otherwise addressed in Rule. Examples include:

(a) treating or non-treating medical reviewers or evaluators producing written reports not otherwise addressed in this Rule, or

(b) meeting with and reviewing another Provider's written record, and amending or signing that record.

The content and total payment shall be agreed upon by the Provider and the report's requester before the Provider begins the report.

Advance Payment: If requested, the Provider is entitled to a two hour deposit in advance in order to schedule a patient exam associated with a special report.

DoWC Z0755 Written Report, $95.37 billable in 15 minute increments

DoWC Z0757 Lengthy Form, $95.37 billable in 15 minute increments

DoWC Z0758 Meeting and Report with Non-treating Physician, $95.37 billable in 15 minute increments

In cases of cancellation for special reports not requiring a scheduled patient exam, the Provider shall be paid for the time reasonably spent in preparation up to the date of cancellation.

DoWC Z0761 Report Preparation with Cancelled Patient Exam, $95.37 billable in 15 minute increments

(5) Independent Medical Examinations (IMEs):

An IME is an objective medical examination of an injured worker performed by a Physician who has not previously treated the injured worker, in order to evaluate prior, current, or proposed treatment, or current condition. The Physician may refer a psychological component of the IME to a Psychologist and incorporate that evaluation into the IME report. In some circumstances, the IME Physician must be Level I or Level II accredited.

RIME: Respondent-requested Independent Medical Examination

DoWC Z0756 RIME Report with patient exam, $95.37 billable in 15 minute increments

Section 8-43-404 requires RIMEs to be recorded in audio in their entirety and retained by the examining Physician for 12 months and made available by request to any party to the case.

DoWC Z0766 RIME Audio Recording, $35.70 per exam

DoWC Z0767 RIME Audio Copying Fee, $24.48 per copy

CIME: Claimant-requested Independent Medical Examination, $95.37 billable in 15 minute increments to the injured worker, DoWC Code Z0770

DIME: Division Independent Medical Examination - see Rule 11

All IME reports must be served concurrently to all parties no later than 20 days after the examination. All IME reports must include an attestation that the billed charges comply with § 8-42-101(3)(a)(I) and Rule 16-8, as well as document the total time spent.

Cancellations:

In cases of a cancelled or rescheduled RIME or CIME, the Provider shall be paid the following fees:

If the Provider is notified of the cancellation of the RIME or CIME at least fourteen days prior to the scheduled examination, the Provider shall be paid the number of hours reasonably spent in preparation, less any deposit paid by the requesting party. DoWC Z0762, $95.37 billable in 15 minute increments.

If the Provider is notified less than fourteen days in advance of a cancelled or rescheduled RIME or CIME, the Provider shall be paid the number of hours reasonably spent in preparation and scheduled for the examination. DoWC Z0763, $95.37 billable in 15 minute increments.

(H) USE OF AN INTERPRETER

(1) Payers shall reimburse for the services of an interpreter when interpretation is reasonable and necessary to provide access to medical benefits. Interpreter services provided in a hospital or ambulatory surgery center are included in the facility reimbursement and are not separately payable.

An interpreter may be provided on-site or via video or audio remote interpreting service, based on availability and the preference of the treating Provider.

(2) Providers are prohibited from relying on minor children and should refrain from using adult family members and friends as interpreters, except in an emergency.

(3) Payment requirements:

(a) Interpreters for certifiable languages must be listed as certified on the Certification Commission for Healthcare Interpreters or National Board of Certification for Medical Interpreters website directory. Certifiable languages are:

* Spanish

* Cantonese

* Mandarin

* Russian

* Korean

* Vietnamese

* Arabic

(b) For all other languages, or in the event a certified interpreter is unavailable, the interpreter shall be qualified. Qualified means the interpreter has documentation showing completion of at least 40 hours of healthcare interpreter training.

(c) When a qualified interpreter is used in lieu of a certified interpreter, Payers must document a good faith effort was made to obtain a certified interpreter and submit this documentation to the Division upon request. By way of example, the payer may document a good faith effort by contacting at least two certified interpreters who are unavailable for the requested date and time.

(d) Prior authorization is required for on-site interpreters except for initial and emergency treatment.

(4) Interpreters shall submit claims using the Interpreter Invoice Form or electronic data interchange (EDI). The codes and maximum allowances are:

(a) DoWC Z0710, Certified Spanish Interpreter, on-site, $15.00, billable in 15 minute increments with a minimum of one hour;

(b) DoWC Z0711, Qualified Spanish Interpreter, on-site, $11.25, billable in 15 minute increments with a minimum of one hour;

(c) DoWC Z0712, Interpreter for languages other than Spanish, on-site, rates shall be negotiated;

(d) HCPCS T1013, Sign Language, rates shall be negotiated;

(e) DoWC Z0713, On-Demand Video or Audio Remote Interpreting, all languages, $1.35 per minute, with no minimum.

(f) DoWC Z0773, Travel time for distances 50 miles or greater one-way is separately payable to on-site interpreters and shall not exceed $35.37 per hour.

(g) DoWC Z0772, Mileage is separately payable to on-site interpreters, and shall not exceed 59 cents per mile. The reimbursement shall be calculated based on the actual number of miles driven portal to portal or the most direct route available on the date of service, whichever is less.

(h) If a prior authorized interpreter receives a cancellation notice less than 24 hours prior to the scheduled service, the Payer shall pay one-half of the usual fee for the scheduled service, or $187.27, whichever is less. DoWC Z0720, plus full reimbursement for incurred mileage and eligible travel time.

(I) GUARDIAN AD LITEM AND CONSERVATOR SERVICES

When reasonably necessary for employees who are legally incapacitated as a result of a work-related injury or occupational disease, the following services are allowed reasonable fees and costs as agreed upon by the parties:

Guardian ad litem

Conservator

Attorney/Paralegal

The parties may submit an invoice or other agreed upon form for these services. If the parties are unable to agree on a reasonable fee, the parties may bring the matter before the Director for resolution.

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 1101-3-18-7 - DIVISION-ESTABLISHED CODES AND VALUES

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 1101-3-18-7 - DIVISION-ESTABLISHED CODES AND VALUES