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Important 2019 DOWC rule changes affecting providers

The Colorado Division of Workers’ Compensation (DOWC) recently finalized rule changes that affect

December 12, 2018
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The Colorado Division of Workers’ Compensation (DOWC) recently finalized rule changes that affect workers’ compensation billing, effective Jan. 1, 2019. Pinnacol will ensure its systems and processes accommodate the rule changes, and we expect that you won’t experience any payment disruptions. For more information, we have included page number references below for Rules 16 and 18.

Units of service based on code descriptions, Rule 18-5(I)(6) (p. 31)

  • Total time of billed unit time cannot exceed the total time spent performing the procedure.

Code 97110: Therapeutic procedure, one or more areas, each 15 minutes Code 97140: Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutesCode 97010: Application of a modality to one or more areas, each 15 minutes

Reference: Time Based Therapy Codes – Units of Service

Division Independent Medical Exam changes (Rule 11)

  • Rule 11 updates the process, billing codes, payment and forms.

Optional notification process update, Rule 16-5(D)(1-2) (p. 9)

  • Notification may be limited based on the number of treatments, the treatment duration and the functional progress made by the injured worker.

Prior authorization updates

  • Rule 18-6(N)(1) (p. 62): Prior authorization is required for medications “not recommended” in the medical treatment guidelines for a particular diagnosis or if Rules 16-6(B) and 17-4(A) apply.
  • Rule 16-6(A) (p. 10): Prior authorization may be requested using Form WC 188 or, in the alternative, shall be clearly labeled as a prior authorization request.
  • Rule 16-7(B)(1) (p. 12): Added a provision that a clinical pharmacist licensed in Colorado may review prior authorizations for medications or services already provided, without having a Level I or II accreditation.

Conversion factors revised, Rule 18-4 (pp. 3-4)

  • Rates have increased for surgery, radiology, pathology, medicine, physical medicine and rehabilitation, and evaluation and management.
  • Anesthesia conversion factor remained the same as in 2018.

Professional status codes incorporated in fee schedule from RBRVS tables, Rule 18-5(B)(3) (pp. 5-12)

  • Expanded professional/technical components.
  • Global days and pre-, intra- and post-operative percentages of the total surgical fee value.
  • Multiple procedure and bilateral modifiers.
  • Assistant surgeon, co-surgeon and team surgeon indicators.

Cancellation fees for payer-made appointments, Rule 18-6(B)(1-2) (pp. 37-38)

  • Payable for a payer-made appointment the injured worker fails to keep and that Pinnacol has not canceled three business days prior to the appointment.
  • DOWC Code Z0720 – pays one-half of the usual fee for the scheduled service, or $180, whichever is less.
  • New code: DOWC Code Z0740 – if the scheduled, payer-made appointment was to have been four hours or longer, pays one-half of the usual fee for the scheduled service, such as a functional capacity evaluation.
  • The provider must also bill the code for what the scheduled appointment was (e.g., an office visit or functional capacity) in Box 19 of the CMS-1500 billing form.

Fees increased for MMI impairment ratings, Rule 18-6(F)(4)(b) (p. 41)

  • DOWC Code Z0759 increased to $575 from $355, performed by a Level II authorized treating physician (ATP) providing primary care.
  • DOWC Code Z0760 increased to $775 from $575, by referral to a Level II ATP who has not previously treated or evaluated the injured worker for the same injury.  

New exhibit for CPT, HCPCS and Z codes, Rule 18, Exhibit 9

  • Shows the created DOWC Z codes with the fee schedule, billing increments, a description and the Rule 18 reference for each.
  • Lists existing codes where the DOWC has altered the RVU values.
  • Includes values for codes where the RBRVS does not list values.

Pinnacol will continue to communicate key changes and recommendations.

For questions about the rule changes, please contact the DOWC at 303.318.8700 or 888.390.7936 or visit colorado.gov/pacific/cdle/dwc

For Pinnacol billing-related questions, please contact billingsuccess@pinnacol.com.

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