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DOWC 2021 rule changes

The Colorado Division of Workers' Compensation finalized rules that impact medical providers

December 10, 2020
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The Colorado Division of Workers’ Compensation (DOWC) recently finalized rule changes that affect workers’ compensation provider billing, effective Jan. 1, 2021. Pinnacol Assurance 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.

Responses to prior authorization requests have changed to 10 calendar days from seven business days. - Rule 16-7(B), p 7-8

  • Requesting party has 10 calendar days from the denial to appeal.
  • Payer has 10 calendar days to issue a final decision on the appeal request.

Medical records shall be provided within 30 days from the date the request is received. - Rule 18-7(C), p 54

Cancellation fees are payable when an injured worker fails to keep a payer-made appointment and the payer has not canceled five days prior to the appointment. The cancellation period for IMEs or DIMEs is 14 days instead of 10. - Rule 18-7(B), p 54

Central nervous system assessments/tests are limited to 16 hours, from six, unless prior authorization is obtained. - Rule 18-4(G)(4)(c), p 23-24

Hearing and vision items are purchased at a maximum allowance of 120% to the provider as indicated by invoice. - Rule 18-6(A)(1)(f), p 44

App-based interventions for patient education and training are covered. - Rule 18-9(D), p 64

  • Aid in curing and/or relieving the injured worker from the effects of the work injury.
  • Payable by invoice, and ordering providers may not receive any remuneration from the service provider for the referral.

Requirement for interpreters to be certified by Jan. 1, 2022 - Rule 18-7(H), p 60-61

Dry needling codes (without injection) were added to the 2021 fee schedule.

  • CPT 20560 for one or two muscles
  • CPT 20561 for three or more muscles


Inpatient per diem rates were established for skilled nursing facilities and rehabilitation hospitals. - Rule 18-5(A)(2)(b), p 32

Inpatient facility charges, except for associated professional fees, are allowed a reasonable charge, as negotiated by the provider and payer, for children’s, Veterans Administration and psychiatric hospitals and will be paid at a negotiated rate. - Rule 18-5(B)(3)(a), p 34

Critical access hospitals

  • Follow the MS DRG for inpatient charges and Medicare OPPS Addendum A for outpatient charges. - Rule 18-5(B)(4), p 34-35
  • Are no longer paid a separate clinic facility fee. - Rule 18-5(B)(7), p 41

Outpatient status indicators for J1 are paid at the comprehensive ambulatory payment classifications value. -  Rule 18-5(B)(6)(a-c), p 38  

  • The maximum allowance for multiple procedures with a T status indicator is limited to four codes per episode.

Procedures with a J2 status indicator indicate services reimbursed as part of the comprehensive observation service. Requirements for payment on J2 codes include eight hours of observation, no status T procedure on the claim, and either an E&M visit on the same day or before the observation date of service or a direct admit to observation. - Rule 18-5(B)(6)(a-c), p 39  

Exhibits for Rule 18 – Separate exhibits are no longer required for data now incorporated within the Rule. - Rule 18-11

  • Exhibit 1 (previously Exhibit 7) - Evaluation and Management (no content changes).
  • Exhibit 2 - Hospital Base Rates and Cost-to-Charge Ratios.
  • Exhibit 3 (previously Exhibit 6) - Dental Fee Schedule.
  • All other exhibits were deleted.
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