The Colorado Division of Workers’ Compensation (DOWC) sets the fee schedule and provides direction regarding which codes are to be billed for home health services in workers’ compensation. The DOWC does not recognize HCPCS (S or G prefix) codes for occupational and physical therapy services provided in the home. Instead, based on the therapy provided, these services must be billed using the prior year’s Current Procedural Terminology® (CPT) codes. However, nursing services provided in the home are to be billed using S prefix HCPCS codes based on the type of nurse.
Nursing Services
Nursing services are limited to two hours without prior authorization unless otherwise indicated in the DOWC’s Medical Treatment Guidelines:
Physical Medicine
Pinnacol can only process CPT codes for physical, occupational or any other rehabilitation therapy services in accordance with Rule 18-4(H). Modifiers are required to identify the type of therapy provided (GP = physical therapy, GO = occupational therapy). The DOWC defines procedures and modalities as follows:
- Procedure is any treatment listed in the Medicine/Physical Medicine and Rehabilitation section of CPT® under the subheading “Therapeutic Procedures.” For purposes of this rule, the term “procedure” includes acupuncture.
- Modality is any treatment listed in the Medicine/Physical Medicine and Rehabilitation section of CPT® under the subheading “Modalities.”
Below are most of the CPT physical medicine therapy codes, including Rule 18 limits and an indication if services can be performed by a certified therapy assistant.
If you have questions about billing or coding, please contact Pinnacol’s provider medical billing auditors at 303.361.4940 or billingsuccess@pinnacol.com.
