The Colorado Division of Workers’ Compensation (DOWC) recently finalized rule changes that affect workers’ compensation billing, effective Jan. 1, 2020. Pinnacol will ensure its systems and processes accommodate the rule changes, and we expect no payment disruptions. For more information, we have included the citation references for Rules 16 and 18.
Definition and requirements for certified interpreters — Rule 16-2(E) and Rule 18-7(H)
- Required national certification for reimbursement — IMPLEMENTATION DELAYED TO APRIL 30, 2020
Reimbursement changes — Rule 18
- WC164 form reimbursement increased to $50 from $47 — Rule 18-7(G).
- WC196 form increased to $15.30 — Rule 18-4(H)(6).
- QPOP — Z0815 increased to $81.60; Z0816 increases to $40.80 — Rule 18-9(C).
- Opioid management billing codes increased to $85 — Rule 18-9(A).
- Impairment ratings are paid at $586 for Level II primary care physician or $790 if the worker has not been previously treated by the physician — Rule 18-7(F).
- Conversion factors were revised — Rule 18-4(A)(1).
- Set rate removed for professional components of MRI, CT, nuclear medicine scans — Rule 18-4(E)(2)(b).
- Copying fees set — Rule 18-7(C).
- Deposition, testimony, report preparation, cancellation and IME rates set — Rule 18-7.
Timely filing of bills for service is within 120 days of service — Rule 16-9(E)
- Electronic submission of bill requires a confirmation of acceptance from payer.
- Faxes require a confirmation of receipt.
Payer requirements for processing bill appeals — Rule 16-11(D)(2)(a)
- Corrected claims are to be submitted as appeals or they may be rejected as duplicates.
- Appeals for medical reasons require a physician review with reasoning and relevant documentation.
Physician availability to physician assistants and nurse practitioners — Rule 16-3(A)(5)
- Removed requirement for physician to be immediately available.
Required use of the Medical Treatment Guidelines (MTG) — Rule 16-4
- Added “initial recommendation for a treatment or modality should not exceed the time to produce function parameters in the applicable MTG."
Manual therapies — Rule 18-4(G)(4)
- Osteopathic and chiropractic manipulative treatment codes include manual therapies unless the therapy is in a separate region and it meets Modifier 59 requirements.
- RVUs were modified for chiropractic spinal manipulation treatment.
Modifiers required for physical and occupational therapy — Rule 18-4(H)(1)(a)
- GP modifier must be appended to all physical therapy codes.
- GO modifier must be appended to all occupational therapy codes.
Non-medical facility fees — Rule 18-4(H)(10)
- Gyms, pools, etc. and training or supervision by non-medical providers requires prior authorization.
- A written negotiated fee is required for every three month period.
Opioids and scheduled controlled substances in house dispensing — Rule 18-6(C)
- If prescribed for longer than three days, they must be provided through a pharmacy in compliance with the law.
Psychiatric/psychological services are detailed — Rule 18-4(G)(1-12)
Durable medical equipment purchases and rentals — Rule 18-6(A)(1-5)
- Caps rental/purchase equipment and identifies modifiers for billing.
- Lists examples of take-home exercise equipment.
- Passive motion and intermittent pneumatic devices are bundled in facility charges.
- For exceptions and guidelines, see Rule 18-6(A)(1)(d-e).
Urgent care facility accreditation added for Joint Commission — Rule 18-5(C)(1)
Licensure is required for acupuncture — Rule 18-4(H)(13)
Pinnacol will continue to communicate key changes and recommendations. For questions about the rule changes, please contact the DOWC at 303.318.8700 or https://cdle.colorado.gov/dwc. For Pinnacol billing-related questions, contact billingsuccess@pinnacol.com.
