The Colorado Division of Workers’ Compensation (DOWC) recently finalized rule changes that affect workers’ compensation billing, effective January 1, 2023. For more information, we have included the citation references for Rules 16 and 18.
Rule 16 Changes
Payers may limit approval of initial treatment without a medical review. The payer may limit approval of initial treatment to the number or duration specified in the relevant DOWC Medical Treatment Guideline without a medical review. - Rule 16-6(C)(1), p. 8
When resubmitting a paper claim, providers must append the appropriate resubmission code on the bill form. – Rule 16-8-1 (A)(1-2), pp. 11-12
For providers billing for professional services, a CMS1500 shall be used. The appropriate resubmission code must be listed in field 22 along with the original claim number to the right of field 22.
1 - Original claim (duplicate of a previously submitted claim that was never processed)
7 - Replacement/corrected claim (previously adjudicated claim with new or amended information)
8 - Void/cancel prior claim (previously paid claim that was submitted in error)
For hospital or facility services, a UB04 shall be used. The appropriate resubmission code must be listed in box 4, and the original claim number in field 64.
XX7 - Correction/replacement of prior claim
XX8 - Void/cancel of prior claim
Rule 18 Changes
Conversion factors (CFs) for 2023 have been updated. – Rule 18-4(A)(1), p. 5
- Anesthesia: $44.00
- Surgery/Radiology/Pathology/Medicine: $68.00
- Physical Medicine and Rehabilitation: $48.00
(includes Medical Nutrition Therapy and Acupuncture)
- Evaluation & Management (E&M): $54.10
Professional status codes E, I, N, R and X will no longer be payable (with some exceptions). In addition, some procedure codes will only be payable if prior authorization is obtained. For the full list of codes payable by exception, and those that require prior authorization, reference Rule 18-4(A)(1)(c), pp. 6-7.
Services provided in whole or in part by a physical therapist assistant shall be billed with a CQ modifier. Services provided in whole or in part by an occupational therapist assistant shall be billed with a CO modifier. “In part” is defined as exceeding the CPT mid-point. The CQ and CO modifiers shall be billed in addition to the GP or GO modifiers. – Rule 18-4(H)(1)(a)(ii), p. 25
There are specific exclusions from the global package, including but not limited to
- Services by a provider who is not in the same specialty
- Visits unrelated to the accurate modifier
- Diagnostic tests and procedures
For the full list of exclusions, reference Rule 18-4(D)(2), pp. 15-16.
The maximum allowance for services performed by a physical therapist assistant or occupational therapist assistant shall be 85% of the fee schedule. - Rule 18-4(H)(4)(b)(iii), p. 26
The maximum allowance for services billed by a massage therapist shall be 72% of the fee schedule. - Rule 18-4(H)(4)(b)(ii), p. 26
Exercise equipment with a total invoice cost of $50 or less may be billed using A9300 at no more than 120% of the actual cost without an invoice. Reimbursement shall be based on billed charges. - Rule 18-6(A)(1)(b), p. 38
Prior authorization is required on dispensed medication when a therapeutic equivalent is available at a significantly lower cost. Prior authorization applies to any non-steroidal anti-inflammatory drug (NSAID), muscle relaxant, or topical agent for which a significantly lower-cost therapeutic equivalent is available. This includes commercial or over-the-counter (OTC) medication, even in a different strength or dosage. Significantly lower cost means the therapeutic equivalent costs at least $100 less than the same number of days’ supply of medication. - Rule 18-6(C)(1)(b), p.43
If electronic records are readily producible, and appropriate security measures are in place, including but not limited to compatible encryption, the provider shall supply the requestor with an electronic copy (e.g., email). - Rule 18-7(C), p. 49
Download 2023 Division rule changes guide (preview below)