DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 CCR 1101-3
WORKERS’ COMPENSATION RULES OF PROCEDURE
Rule 16           UTILIZATION STANDARDS
 16-1      STATEMENT OF PURPOSE
           	In an effort to comply with its legislative charge to assure appropriate and timely medical care at a reasonable cost, the Director (Director) of the Division of Workers' Compensation (Division) has promulgated these utilization standards, effective January 1, 2017.  This Rule defines the standard terminology, administrative procedures and dispute resolution procedures required to implement the Division's Medical Treatment Guidelines and Medical Fee Schedule.  With respect to any matter arising under the Colorado Workers' Compensation Act and/or the Workers' Compensation Rules of Procedure and to the extent not otherwise precluded by the laws of this state, all providers and payers shall use and comply with the provisions of the "Medical Treatment Guidelines," Rule 17, and the "Medical Fee Schedule," Rule 18, as incorporated and defined in the Workers' Compensation Rules of Procedure, 7 CCR 1101-3.
16-2      STANDARD TERMINOLOGY FOR RULES 16 AND 18
(A)	Ambulatory Surgical Center (ASC) – licensed as an ambulatory surgery center by the Colorado Department of Public Health and Environment.
(B)	Authorized Treating Provider (ATP) – may be any of the following:
(1)	The treating physician designated by the employer and selected by the injured worker;
(2)	A health care provider to whom an authorized treating physician refers the injured worker for treatment, consultation, or impairment rating;
(3)	A physician selected by the injured worker when the injured worker has the right to select a provider;
(4)	A physician authorized by the employer when the employer has the right or obligation to make such an authorization;
(5)	A health care provider determined by the Director or an administrative law judge to be an ATP;
(6)	A provider who is designated by the agreement of the injured worker and the payer.
(C)	Billed Service(s) – any billed service, procedure, equipment or supply provided to an injured worker by a provider.
(D)	Billing Party – a service provider or an injured worker who has incurred authorized medical costs.
(E)	Certificate of Mailing – a signed and dated statement containing the names and mailing addresses of all persons receiving copies of attached or referenced document(s), certifying the documents were placed in the U.S. Mail, postage pre-paid, to those persons.
(F)	Children’s Hospital – identified and Medicare-certified by the Colorado Department of Public Health and Environment.
(G)	Convalescent Center – licensed by the Colorado Department of Public Health and Environment.
(H)	Critical Access Hospital (CAH) – Medicare-certified by the Colorado Department of Public Health and Environment.
(I)	Day – defined as a calendar day unless otherwise noted. 
(J)	Free-Standing Facility – an entity that furnishes healthcare services and is not integrated with any other entity as a main provider, a department of a provider, remote location of a hospital, satellite facility, or provider –based entity.
(K)	Hospital – licensed by the Colorado Department of Public Health and Environment.
(L)	Long-Term Care Facility –licensed and Medicare-certified by the Colorado Department of Public Health and Environment.
(M)	Medical Fee Schedule – Division's Rule 18, its exhibits, and the documents incorporated by reference in that Rule.
(N)	Medical Treatment Guidelines – the medical treatment guidelines as incorporated into Rule 17, "Medical Treatment Guidelines."
(O)	Over-the-Counter Drugs – Drugs that are safe and effective for use by the general public without a prescription.
(P)	Payer – an insurer, employer, or their designated agent(s) who is responsible for payment of medical expenses.
(Q)	Prior Authorization – assurance that appropriate reimbursement for a specific treatment will be paid in accordance with Rule 18, its exhibits, and the documents incorporated by reference in that Rule.
(R)	Provider – a person or entity providing authorized health care service, whether involving treatment or not, to a worker in connection with work-related injury or occupational disease.
(S)	Psychiatric Hospital – licensed by the Colorado Department of Public Health and Environment.
(T)	Rehabilitation Hospital Facility – licensed as a rehabilitation hospital by the Colorado Department of Public Health and Environment.
(U)	Rural Health Clinic Facility – Medicare-certified by the Colorado Department of Public Health and Environment.
(V)	Skilled Nursing Facility (SNF) – licensed as a skilled nursing facility by the Colorado Department of Public Health and Environment.
(W)	“Supply et al.” – any single supply, durable medical equipment (DME), orthotic, prosthesis, biologic item, or single drug dose, for which the billed amount exceeds $500.00 and all implants.
(X)	Telehealth – a mode of delivery of health care services through telecommunications systems, including information, electronic, and communication technologies, to facilitate the assessment, diagnosis, consultation, treatment, education, care management, or self-management of an injured worker’s health care while the injured worker is located at an originating site and the provider is located at a distant site.  The term includes synchronous interactions and store-and-forward transfers.  The term does not include the delivery of health care services via telephone, facsimile machine, or electronic mail systems.  .
(Y)	Veterans’ Administration Medical Facilities – all medical facilities overseen by the United States Department of Veterans’ Affairs.
16-3      REQUIRED USE OF THE MEDICAL TREATMENT GUIDELINES AND PAYMENT FOR SERVICE
             When an injury or occupational disease falls within the purview of Rule 17, Medical Treatment Guidelines and the date of injury occurs on or after July 1, 1991, providers and payers shall use the medical treatment guidelines, in effect at the time of service, to prepare or review their treatment plan(s) for the injured worker.  A payer may not dictate the type or duration of medical treatment or rely on its’ own internal guidelines or other standards for medical determination.  When treatment exceeds or is outside of the Medical Treatment Guidelines, prior authorization is required. Requesters and reviewers are expected to consider how their decision will affect the overall treatment plan for the individual patient.  In all instances of contest appropriate processes to deny are required.  Refer to applicable sections of 16-10, 16-11 and/or 16-12.
16-4      REQUIRED USE OF THE MEDICAL FEE SCHEDULE
(A)	When services provided to an injured worker fall within the purview of the Medical Fee Schedule, all payers shall use the fee schedule to determine maximum allowable fees.
	(B)	Providers must accurately report their services using codes and modifiers listed in the National Relative Value File, as published by Medicare in January 2016 Resource Based Relative Value Scale (RBRVS).  Providers also must use codes, modifiers, instructions, and parenthetical notes listed in the American Medical Association’s Current Procedural Terminology (CPT®) 2016 edition.  Finally, providers must use codes, modifiers, and billing instructions listed in Rule 18, Medical Fee Schedule.  The Medical Fee Schedule sets the maximum allowable payment but the fee schedule does not limit the billing charges. 
	(C)	The provider may be subject to penalties under the Workers’ Compensation Act for inaccurate billing when the provider knew or should have known that the services billed were inaccurate, as determined by the Director or an administrative law judge.

16-5      RECOGNIZED HEALTH CARE PROVIDERS
(A)        Physician and Non-Physician Providers
(1)        For the purpose of this Rule, recognized health care providers are divided into the major categories of "physician" and "non-physician".  Recognized providers are defined as follows:
(a)        "Physician providers" are those individuals who are licensed by the State of Colorado through one of the following state boards:
1)        Colorado Medical Board;
2)        Colorado Board of Chiropractic Examiners;
3)        Colorado Podiatry Board; or 
4)        Colorado Dental Board.
	Only physicians licensed by the Colorado Medical Board may be included as individual physicians on the employer’s or insurer’s designated provider list required under § 8-43-404(5)(a)(I), C.R.S.
(b)        "Non-physician providers" are those individuals who are registered, certified, or licensed by the Colorado Department of Regulatory Agencies (DORA), the Colorado Secretary of State, or a national entity recognized by the State of Colorado as follows:
1)	Acupuncturist (LAc) – licensed by the Office of Acupuncture Licensure, Colorado Department of Regulatory Agencies;
2)	Advanced Practice Nurse (APN) – licensed by the Colorado Board of Nursing; Advanced Practice Nurse Registry;
3)	Anesthesiologist Assistant (AA) – licensed by the Colorado Medical Board, Colorado Department of Regulatory Agencies;
4)	Athletic Trainers (ATC) –registered by the Office of Athletic Trainer Registration, Colorado Department of Regulatory Agencies;
5)	Audiologist (AU.D. CCC-A) – licensed by the Office of Audiology and Hearing Aid Provider Licensure, Colorado Department of Regulatory Agencies; 
6)	Certified Registered Nurse Anesthetist (CRNA) – licensed by the Colorado Board of Nursing;
7)	Clinical Social Worker (LCSW) – licensed by the Board of Social Work Examiners, Colorado Department of Regulatory Agencies;
8)	Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS) Supplier – licensed by the Colorado Secretary of State; 
9)	Marriage and Family Therapist (LMFT) – licensed by the Board of Marriage and Family Therapist Examiners, Colorado Department of Regulatory Agencies;
10)	Massage Therapist (MT) –licensed as a massage therapist by the Office of Massage Therapy Licensure, Colorado Department of Regulatory Agencies;
11)	Nurse Practitioner (NP) – licensed as an APN and authorized by the Colorado Board of Nursing;
12)	Occupational Therapist (OTR) – licensed by the Office of Occupational Therapy, Colorado Department of Regulatory Agencies,;
13)	Optometrist (OD) – licensed by the Board of Optometry, Colorado Department of Regulatory Agencies;
14)	Orthopedic Technologist (OTC) – certified by the National Board for Certification of Orthopedic Technologists;
15)	Pharmacist – licensed by the Board of Pharmacy, Colorado Department of Regulatory Agencies;
16)	Physical Therapist (PT) – licensed by the Physical Therapy Board, Colorado Department of Regulatory Agencies;
17)	Physical Therapist Assistant (PTA) – licensed by the Physical Therapy Board, Colorado Department of Regulatory Agencies;
18)	Physician Assistant (PA) – licensed by the Colorado Medical Board;
19)	Practical Nurse (LPN) – licensed by the Colorado Board of Nursing;
20)	Professional Counselor (LPC) – licensed by the Board of Professional Counselor Examiners, Colorado Department of Regulatory Agencies;
21)	Psychologist (PsyD, PhD, EdD) – licensed by the Board of Psychologist Examiners, Colorado Department of Regulatory Agencies;
22)	Registered Nurse (RN) – licensed by the Colorado Board of Nursing;
23)	Respiratory Therapist (RTL) – certified by the National Board of Respiratory Care and licensed by the Office of Respiratory Therapy Licensure, Colorado Department of Regulatory Agencies;
24)	Speech Language Pathologist (CCC-SLP) – certified by the Office of Speech-Language Pathology Certification, Colorado Department of Regulatory Agencies; and
25)	Surgical Technologist (CST) – registered by the Office of Surgical Assistant and Surgical Technologist Registration, Colorado Department of Regulatory Agencies.
(2)        Upon request, health care providers must provide copies of license, registration, certification or evidence of health care training for billed services.
(3)	Any provider not listed in section 16-5(A)(1)(a) or (b) must comply with section 16-10, Prior Authorization when providing all services.
(4)	Referrals:
(a)	A payer or employer shall not redirect or alter the scope of an authorized treating provider’s referral to another provider for treatment or evaluation of a compensable injury.  Any party who has concerns regarding a referral or its scope shall advise the other parties and providers involved. 
(b)	All non-physician providers must have a referral from an authorized treating physician.  An authorized treating physician making the referral to any listed or unlisted non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care.
(c)	Any listed or non-listed non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care with the referring authorized treating physician.
(5)        Rule 18, Medical Fee Schedule applies to authorized services provided in relation to a specific workers’ compensation claim.
		(6)	Use of PAs and NPs in Colorado Workers’ Compensation Claims:
		(a)	All Colorado Workers’ Compensation claims (medical only or lost time claims) 	shall have an “authorized treating physician” responsible for all services rendered to an injured worker by any PA or NP.
		(b)	The authorized treating physician provider must be immediately available in person or by telephone to furnish assistance and/or direction to the PA or NP while services are being provided to an injured worker. 
		(c)	The service is within the scope of the PA’s or NP’s practice and complies with all applicable provisions of the Colorado Medical Practice Act or the Colorado Nurse Practice Act, and all applicable rules promulgated by the Colorado Medical Board or the Colorado Board of Nursing.
		(d)	For services performed by an NP or a PA, the authorized treating physician must counter sign patient records related to the injured worker’s inability to work resulting from the claimed work injury or disease, and the injured worker’s ability to return to regular or modified employment.  The authorized treating physician also must counter sign Form WC 164.  The signature of the physician provider shall serve as a certification that all requirements of this rule have been met.         
		(e)	The authorized treating physician must evaluate the injured worker within the first three visits to the physician’s office.  
 (B)        Out-of-State Provider
(1)        Injured Worker Relocated
(a)        Upon receipt of the "Employer's First Report of Injury" or the "Worker's Claim for Compensation” form, the payer shall notify the injured worker that the procedures for change-of-provider, should s/he relocate out-of-state, can be obtained from the payer.
(b)        A change of provider must be made:
1)        Through referral by the injured worker's authorized treating physician; or
2)        In accordance with § 8-43-404 (5)(a), C.R.S.
(2)        Injured Worker Referred
In the event an injured worker has not relocated out-of-state but is referred to an out-of-state provider for treatment or services not available within Colorado, the referring provider shall obtain prior authorization from the payer as set forth in section 16-10, Prior Authorization.  The referring provider's written request for out-of-state treatment shall include the following information:
(a)        Medical justification prepared by the referring provider;
(b)        Written explanation as to why the requested treatment/services cannot be obtained within Colorado;
(c)        Name, complete mailing address and telephone number of the out-of-state provider;
(d)        Description of the treatment/services requested, including the estimated length of time and frequency of the treatment/service, and all associated medical expenses; and
(e)        Out-of-state provider’s qualifications to provide the requested treatment or services.
(3)        The Colorado fee schedule should govern reimbursement for out-of-state providers.

16-6      HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS 
(A)        Use of agents, including but not limited to Preferred Provider Organizations (PPO) networks, bill review companies, third party administrators (TPAs) and case management companies, shall not relieve the employer or insurer from their legal responsibilities for compliance with these Rules.  
(B)        Payment for billed services identified in the Medical Fee Schedule shall not exceed those scheduled rates and fees, or the provider's actual billed charges, whichever is less.
(C)        Payment for billed services not identified or identified but without established value in the Medical Fee Schedule shall require prior authorization from the payer as set forth in section 16-10, Prior Authorization, except when the billed non-established valued service or procedure is an emergency or a payment mechanism under Rule 18 is identifiable, but not explicit. Examples of the prior authorization request exception(s) include ambulance bills or supply bills that are covered under Rule18-6(H) with an identified payment mechanism. 
Similar established code values from the Medical Fee Schedule, recommended by the requesting physician, shall govern the maximum fee value payment. 
 (D)	Any payer contesting a provider’s treatment shall follow the procedures as outlined under section 16-11, Contest of a Request for Prior Authorization, or section 16-12, Payment of Medical Benefits.
(E)	International Classification of Diseases (ICD) codes shall not be used to establish the work relatedness of an injury or treatment.
16-7      REQUIRED BILLING FORMS AND ACCOMPANYING DOCUMENTATION
(A)        Providers may use electronic reproductions of any required form(s) referenced in this section; however, any such reproduction shall be an exact duplication of such form(s) in content and appearance.  With the agreement of the payer, identifying information may be placed in the margin of the form.
(B)        Required Billing Forms
All health care providers shall use only the following billing forms or electronically produced formats when billing for services:
(1)        CMS (Centers for Medicare & Medicaid Services) -1500 shall be used by all providers billing for professional services, durable medical equipment (DME) and ambulance services, with the exception of those providers billing for dental services or procedures.  Health care providers shall provide their name and credentials in the appropriate box of the CMS-1500. Non-hospital based ASCs may bill on the CMS-1500, however an SG modifier shall be appended to the billed procedures for the facility component. 
(2)        UB-04 - shall be used by all hospitals, hospital-based ambulance/air services, Children’s Hospitals, CAHs, Veterans’ Administration Medical Facilities, home health and facilities meeting the definitions found in section 16-2, when billing for hospital services or any facility fees billed by any other provider, such as hospital-based ASCs.
(a)	Some outpatient hospital therapy services (Physical, Occupational, or Speech) may also be billed on UB-04.  For these services, the UB-04 must have Form Locator Type 013x, 074x, 075x, or 085x, and one of the following revenue code(s):
•	Revenue Code 042X  Physical Therapy
•	Revenue Code 043X  Occupational Therapy
•	Revenue Code 044X  Speech/Language Therapy
(b)	CAHs designated by Medicare or Exhibit # 3 to Rule 18 may use UB-04 to bill professional services if the professional has reassigned his or her billing rights to the CAH using Medicare’s Method II.  The CAH shall list bill type 851-854, as well as one of the following revenue code(s) and Health Care Common Procedure Coding System (HCPCS) codes in the HCPCS Rates field number 44:
•	0960 - Professional Fee General
•	0961 - Psychiatric
•	0962 - Ophthalmology
•	0963 - Anesthesiologist (MD)
•	0964 - Anesthetist (CRNA)
•	0971 - Professional Fee For Laboratory 
•	0972 - Professional Fee For Radiology Diagnostic 
•	0973 – Professional Fee - Radiology - Therapeutic
•	0974 - Professional Fee - Radiology - Nuclear
•	0975 - Professional Fee - Operating Room
•	0981 - Emergency Room Physicians
•	0982 - Outpatient Services 
•	0983 - Clinic 
•	0985 - EKG Professional
•	0986 - EEG Professional
•	0987 - Hospital Visit  professional (MD/DO)
•	0988 - Consultation (Professional (MD/DO)
All professional services billed by a CAH are subject to the same coding and payment rules as professional services billed independently.  The following modifiers shall be appended to HCPCS codes to identify the type of provider rendering the professional service:
GF 	Services rendered in a CAH by a NP, clinical nurse specialist, certified registered nurse, or PA 
SB	Services rendered in a CAH by a nurse midwife 
AH	Services rendered in a CAH by a clinical psychologist 
AE	Services rendered in a CAH by a nutrition professional/registered dietitian 
AQ	Physician services in a physician-scarcity area
(c)	No provider except those listed above shall bill for the professional fees using UB-04.
(3)        American Dental Association’s Dental Claim Form, Version 2012 shall be used by all providers billing for dental services or procedures.
(4)        With the agreement of the payer, the ANSI ASC X12 (American National Standards Institute Accredited Standards Committee) or NCPDP (National Council For Prescription Drug Programs) electronic billing transaction containing the same information as in  (1), (2) or (3) in this subsection may be used.
	NCPDP Workers’ Compensation/Property and Casualty (P&C) universal claim form, version 1.1, for prescription drug billed on paper shall be used by dispensing pharmacies and pharmacy benefit managers (PBM).  Physicians may use the CMS-1500 billing form as described in section 16-7(B)(1).
	Physicians shall list the “repackaged” and the “original” NDC numbers in field 24 of the CMS-1500.  List the “repackaged” NDC number first and the “original” NDC number second, with the prefix ‘ORIG’ appended.
(C)	International Classification of Diseases (ICD) Codes
	All provider bills, including outpatient hospital bills, shall list the appropriate diagnosis codes using the current ICD-10-Clinical Modification (CM) code(s). If a seventh character is required by ICD-CM, it must be applied in accordance with ICD-10-CM Chapter Guidelines provided by the Centers for Medicare and Medicaid Services (CMS).
(D)    	Required Billing Codes
             All billed services shall be itemized on the appropriate billing form as set forth in sections 16-7(A) and (B), and shall include applicable billing codes and modifiers from the Medical Fee Schedule.  National provider identification (NPI) numbers are required for workers’ compensation bills; providers who cannot obtain NPI numbers are exempt from this requirement.  When billing on a CMS-1500, the NPI should be that of the rendering provider and should include the correct place of service codes at the line level.
(E)        Inaccurate Billing Forms or Codes
Payment for any services not billed on the forms identified in this Rule, and/or not itemized as instructed in sections 16-7(B) and (C), may be contested until the provider complies.  However, when payment is contested, the payer shall comply with the applicable provisions set forth in section 16-12, Payment of Medical Benefits.
(F)        Accompanying Documentation
(1)        Authorized treating physicians sign (or countersign) and submit to the payer, with their initial and final visit billings, a completed “Physician’s Report of Workers’ Compensation Injury” (Form WC 164) specifying:  
(a)        The report type as “initial” when the injured worker has their initial visit with the authorized treating physician managing the total workers’ compensation claim of the patient.  Generally, this will be the designated or selected authorized treating physician.  When applicable, the emergency room or urgent care authorized treating physician for this workers’ compensation injury may also create a WC 164 initial report.  Unless requested or prior authorized by the payer in a specific workers’ compensation claim, no other authorized physician should complete and bill for the initial WC 164 form.  This form shall include completion of items 1-7 and 10.  Note that certain information in item 2 (such as Insurer Claim #) may be omitted if not known by the provider.
(b)        The report type as “closing” when the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient determines the injured worker has reached maximum medical improvement (MMI) for all injuries or diseases covered under this workers’ compensation claim, with or without a permanent impairment.  The form requires the completion of items 1-5, 6.B, C, 7, 8 and 10.  If the injured worker has sustained a permanent impairment, then item 9 must also be completed and the following additional information shall be attached to the bill at the time MMI is determined:
1)        All necessary permanent impairment rating reports when the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is Level II Accredited; or
2)        Referral to a Level II Accredited physician requested to perform the permanent impairment rating when a rating is necessary and the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is not determining the permanent impairment rating.
(c)     	At no charge, the physician shall supply the injured worker with one legible copy of all completed “Physician’s Report of Workers’ Compensation Injury” (WC 164) forms at the time the form is completed.
(d)     	The provider shall submit to the payer the completed WC 164 form as specified in section 16-7(E), no later than 14 days from the date of service.
(2)      	Providers, other than hospitals, shall provide the payer with all supporting documentation at the time of submission of the bill unless other agreements have been made between the payer and provider.  This shall include copies of the examination, surgical, and/or treatment records.
(3)      	Hospital documentation shall be available to the payer upon request.  Payers shall specify what portion of a hospital record is being requested.  (For example, only the emergency room (ER) chart notes, in-patient physician orders and chart notes, x-rays, pathology reports, etc.)
(4)      	In accordance with section 16-12, the payer may contest payment for billed services until the provider completes and submits the relevant required accompanying documentation as specified by section16-7(E).
(G)	Providers shall submit their bills for services rendered within 120 days of the date of service or the bill may be denied unless extenuating circumstances exist.  Extenuating circumstances may include, but are not limited to, delays in compensability being decided or the provider has not been informed where to send the bill.
(H)	All services provided to patients are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service. Amendments, corrections and delayed entries must comply with Medicare’s widely accepted recordkeeping principles. 
16-8      REQUIRED MEDICAL RECORD DOCUMENTATION
(A)        A treating provider shall maintain medical records for each injured worker when the provider intends to bill for the provided services.
(B)        All medical records shall contain legible documentation substantiating the services billed.  The documentation shall itemize each contact with the injured worker and shall detail at least the following information per contact or, at a minimum for cases where contact occurs more than once a week, be summarized once per week:
(1)        Patient's name;
(2)        Date of contact, office visit or treatment;
(3)        Name and professional designation of person providing the billed service;
(4)        Assessment or diagnosis of current condition with appropriate objective findings;
(5)        Treatment status or patient’s functional response to current treatment;
(6)        Treatment plan including specific therapy with time limits and measurable goals and detail of referrals;
(7)        Pain diagrams, where applicable;
(8)	If being completed by an authorized treating physician, all pertinent changes to work and/or activity restrictions which reflect lifting, standing, stooping, kneeling, hot or cold environment, repetitive motion or other appropriate physical considerations; and
(9)        All prior authorization(s) for payment received from the payer (i.e., who approved the prior authorization for payment, services authorized, dollar amount, length of time, etc.).
16-9      NOTIFICATION
(A)	Notification is for treatment consistent with the Medical Treatment Guidelines. Providers may, but are not required to, utilize the Notification process to ensure payment for medical treatment that falls within the purview of the Medical Treatment Guidelines. Therefore, lack of response from the payer shall not prohibit the provider from proceeding with treatment consistent with the Medical Treatment Guidelines.
(B)	Notification may be made by phone, during regular business hours.
(1)	Providers can accept verbal confirmation; or
(2)	Providers may request written confirmation of a verbal notification, which the payer should provide within three (3) business days.
(C)	Notification may be submitted using the “Authorized Treating Provider’s Notification to Treat” (Form WC 195).
(1)	The completed form shall include: 
(a)	Provider’s certification that the proposed treatment(s)/service(s) are within the Medical Treatment Guidelines.
(b)	Documentation of the specific Medical Treatment Guideline(s) applicable to the proposed treatment/service.
(c)	Provider’s email address to which the payer can respond.
(2)	Payers should respond to written submissions of Notification within three (3) business days from receipt of the request.
(D)	Payers may respond to a notification submission with an approval or contest of the proposed treatment. If the proposed treatment is contested by the payer, it may only be done for the following reasons:
(1)	No admission of liability or final order finding the injury compensable has been issued:
(2)	Proposed treatment is not related to the admitted injury;
(3)	Provider submitting Notification is not an Authorized Treating Provider (ATP), or is proposing for treatment to be performed by a provider who is not an ATP;
(4)	Injured worker is not entitled to proposed treatment pursuant to statute or settlement;
(5)	Medical records contain conflicting opinions among the ATPs regarding proposed treatment;
(6)	Proposed treatment falls outside the Medical Treatment Guidelines.
(E)	If the payer contests Notification under sections (16-9(D)(b), (e) or (f) above, the payer shall notify the provider, allow the submission of relevant supporting medical documentation as defined in section 16-10 (F), and review the submission as a prior authorization request, allowing an additional seven (7) business days for review.
(F)	Contests for denied Notification by a provider shall be made in accordance with the prior authorization dispute process outlined in 16-11(C).
(G)	Any provider or payer who knowingly or repeatedly misuses the Medical Treatment Guidelines in the Notification/prior authorization process may be subject to penalties under the Workers’ Compensation Act.
16-10	PRIOR AUTHORIZATION
(A)        Granting of prior authorization is a guarantee of payment when in accordance with Rule 18, RBRVS and CPT® for those services/procedures requested by the provider per section16-10 (F).
(B)	Prior authorization for payment shall be requested by the provider when:
(1)        A prescribed service exceeds the recommended limitations set forth in the Medical Treatment Guidelines;
(2)        The Medical Treatment Guidelines otherwise require prior authorization for that specific service;
(3)        A prescribed service is identified within the Medical Fee Schedule as requiring prior authorization for payment; or
(4)        A prescribed service is not identified in the Medical Fee Schedule as referenced in section 16-6(C).
(C)	Prior authorization for a prescribed service or procedure may be granted immediately and without medical review.  However, the payer shall respond to all providers requesting prior authorization within seven (7) business days from receipt of the provider’s completed request, as defined in section16-10(F).  The duty to respond to a provider's written request applies without regard for who transmitted the request.
(D)	The payer, upon receipt of the "Employer's First Report of Injury" or a "Worker's Claim for Compensation,” shall give written notice to the injured worker stating that the requirements for obtaining prior authorization for payment are available from the payer.
(E)	The payer, unless they have previously notified said provider, shall give notice to the provider of these procedures for obtaining prior authorization for payment upon receipt of the initial bill from that provider.  
(F)	To complete a prior authorization request, the provider shall concurrently explain the reasonableness and the medical necessity of the services requested, and shall provide relevant supporting medical documentation.  Supporting medical documentation is defined as documents used in the provider’s decision-making process to substantiate the need for the requested service or procedure. 
(1) 		When the indications of the Medical Treatment Guidelines are met, no prior authorization is required.  When prior authorization for payment is indicated, the following documentation is recommended:
(a)  	An adequate definition or description of the nature, extent, and necessity for the procedure;
(b) 	Identification of the appropriate Medical Treatment Guideline application to the requested service, if applicable;
(c)  	Medical Treatment Guideline indications have been met; and
(d)	Final diagnosis.
(2)  	When the service/procedure does not fall within the Medical Treatment Guidelines and/or past treatment failed functional goals; or if the requested procedure is not identified in the Medical Fee Schedule or does not have an established value under the Medical Fee Schedule, such as any unlisted procedure/service with a BR value or an RNE value listed in the RBRVS, authorization requests may be made using the “Authorized Treating Provider’s Request for Prior Authorization” (Form WC 188).
(G)	To contest a request for prior authorization, the payer is required to comply with the provisions outlined in section 16-11.
(H)	The Division recommends payers confirm in writing, to providers and all parties, when a request for prior authorization is approved.
(I)	If, after the service was provided, the payer agrees the service provided was reasonable and necessary, lack of prior authorization for payment does not warrant denial of payment.  However, the provider is still required to provide, with the bill, the documentation required by section 16-10(F) for any unlisted valued service or procedure for payment.
(J)	All medical records should be signed by the rendering provider.  Electronic signatures are accepted.
16-11    CONTEST OF A REQUEST FOR PRIOR AUTHORIZATION
(A)        If the payer contests a request for prior authorization for non-medical reasons as defined under section 16-12(B)(1), the payer shall notify the provider and parties, in writing, of the basis for the contest within seven (7) business days from receipt of the provider’s completed request as defined in section 16-10(F).  A certificate of mailing of the written contest must be sent to the provider and parties. 
            If an ATP requests prior authorization and indicates in writing, including their reasoning and relevant documentation, that they believe the requested treatment is related to the admitted workers’ compensation claim, the insurer cannot deny based solely on relatedness without a medical review as required by section 16-11(B).  
(B)       If the payer is contesting a request for prior authorization for medical reasons, the payer shall, within seven (7) business days of the completed request:
(1)        Have all the submitted documentation under section 16-10(F) reviewed by a physician or other health care professional, as defined in section 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  The physicians or chiropractors performing this review shall be Level I or Level II accredited.
(2)        After reviewing all the submitted documentation and other documentation available to the carrier, the reviewing provider may call the requesting provider to expedite communication and processing of prior authorization requests.  However, the written contest or approval still needs to be completed within the specified seven (7) business days under section 16-11(B).
(3)        Furnish the provider and the parties with a written contest that sets forth the following information:
(a)        An explanation of the specific medical reasons for the contest, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;
(b)        The specific cite from the Medical Treatment Guidelines exhibits to Rule 17, when applicable;
(c)        Identification of the information deemed most likely to influence the reconsideration of the contest when applicable; and
(d)        A certificate of mailing to the provider and parties.
(C)        Prior Authorization Disputes
(1)        The requesting party or provider shall have seven (7) business days from the date of the certificate of mailing on the written contest to provide a written response to the payer, including a certificate of mailing.  The response is not considered a "special report" when prepared by the provider of the requested service.
(2)        The payer shall have seven (7) business days from the date of the certificate of mailing of the response to issue a final decision, including a certificate of mailing to the provider and parties.
(3)        In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
(D)        An urgent need for prior authorization of health care services, as recommended in writing by an authorized treating provider, shall be deemed good cause for an expedited hearing.
(E)        Failure of the payer to timely comply in full with the requirements of section 16-11(A) or (B), shall be deemed authorization for payment of the requested treatment unless:
(1)	A hearing is requested within the time prescribed for responding as set forth in section 16-11(A) or (B) and the requesting provider is notified accordingly.  A request for hearing shall not relieve the payer from conducting a medical review of the requested treatment, as set forth in section 16-11(B); or
(2)	The payer has scheduled an independent medical examination (IME) that will occur within the time prescribed for responding as set forth in section 16-11(B).
(F)        Unreasonable delay or denial of prior authorization, as determined by the Director or an administrative law judge, may subject the payer to penalties under the Workers’ Compensation Act.
16-12    PAYMENT OF MEDICAL BENEFITS
(A)        Payer Requirements for Processing Medical Service Bills
(1)	For every medical service bill submitted by a provider, the payer shall reply with a written notice or explanation of benefits.   In those instances where the payer reimburses the exact billed amount, identification of the patient’s name, the payer, the paid bill, the amount paid and the dates of service are required.  If any adjustments are made then the payer’s written notice shall include: 
	(a)        Name of the injured worker or patient;
(b)        Specific identifying information coordinating the notice with any payment instrument associated with the bill;
(c)	Date(s) of service(s), if date(s) was (were) submitted on the bill;
(d)        Payer’s claim number and/or Division’s workers’ compensation claim number, if one has been created; 
(e)        Reference to the bill and each item of the bill;
(f)         Notice that the billing party may submit corrected bill or appeal within 60 days;
(g) 	For compensable services for a work-related injury or occupational disease the payer shall notify the billing provider that the injured worker shall not be balance-billed for services related to the work-related injury or occupational disease;
(h)	Name of insurer with admitted, ordered or contested liability for the workers’ compensation claim, when known;  
(i)	Name, address, e-mail (if any), phone number and fax of a person who has responsibility and authority to discuss and resolve disputes on the bill;
(j)	Name and address of the employer, when known; and
(k)	Name and address of the Third Party Administrator (TPA) and name and address of the bill reviewer if separate company when known; and
(l)	If applicable, a statement that the payment is being held in abeyance because a relevant issue is being brought to hearing.
(2)        The payer shall send the billing party written notice that complies with sections 16-12(A)(1) and (B) or (C) if contesting payment for non-medical or medical reasons within 30 days of receipt of the bill.  Any notice that fails to include the required information set forth in sections 16-12(A)(1) and (B) or (C) if contesting payment for non-medical or medical reasons is defective and does not satisfy the payer’s 30-day notice requirements set forth in this section.   
(3)	Unless the payer provides timely and proper reasons as set forth by the provisions outlined in sections 16-12(B) - (D), all bills submitted by a provider are due and payable in accordance with the Medical Fee Schedule within 30 days after receipt of the bill by the payer.  
(4)	If the payer discounts a bill and the provider requests clarification in writing, the payer shall furnish to the requester the specifics of the discount within 30 days including a copy of any contract relied on for the discount.  If no response is forthcoming within 30 days, the payer must pay the maximum Medical Fee Schedule allowance or the billed charges, whichever is less.
(5)	Date of receipt of the bill may be established by the payer’s date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) business days after the date the bill was mailed to the payer’s correct address.   
(6)	Unreasonable delay in processing payment or denial of payment of medical service bills, as determined by the Director or an administrative law judge, may subject the payer to penalties under the Workers’ Compensation Act.
(7)	If the payer fails to make timely payment of uncontested billed services, the billing party may report the incident to the Division’s Carrier Practices Unit who may use it during an audit.
 (B)    	Process for Contesting Payment of Billed Services Based on Non-Medical Reasons
 (1)       Non-medical reasons are administrative issues.  Examples of non-medical reasons for contesting payment include the following:  no claim has been filed with the payer; compensability has not been established; the billed services are not related to the admitted injury; the provider is not authorized to treat; the insurance coverage is at issue; typographic, gender or date errors are in the bill; failure to submit medical documentation; unrecognized CPT® code.
(2)        If an ATP bills for medical services and indicates in writing, including their reasoning and relevant documentation that they believe the medical services are related to the admitted WC claim, the payer cannot deny based solely on relatedness without a medical review as required by section 16-12(C).  
(3)        In all cases where a billed service is contested for non-medical reasons, the payer shall send the billing party written notice of the contest within 30 days of receipt of the bill.  The written notice shall include all of the notice requirements set forth in section 16-12(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s) was(were) submitted on the bill;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested; and
(d)        Clear and persuasive reasons for contesting the payment of any item specific to that bill including the citing of appropriate statutes, rules and/or documents supporting the payer’s reasons for contesting payment.
Any notice that fails to include the required information set forth in this section is defective.  Such defective notice shall not satisfy the payer’s 30 day notice requirement set forth in this section.  
(4)        Prior to modifying a billed code, the payer must contact the billing provider and determine if the modified code is accurate.
(a)        If the billing provider agrees with the payer, then the payer shall process the service with the agreed upon code and shall document on their explanation of benefits (EOB) the agreement with the provider.  The EOB shall include the name of the person at the provider’s office who made the agreement.
(b)        If the provider is in disagreement, then the payer shall proceed according to section 16-12(B) or 16-12(C), as appropriate.
(5)        Lack of prior authorization for payment does not warrant denial of liability for payment.  
(6)	When no established fee is given in the Medical Fee Schedule and the payer agrees the service or procedure is reasonable and necessary, the payer shall list on their written notice of contest (see section 16-12(A)(1)) one of the following payment options: 
(a)  	A reasonable value based upon the similar established code value recommended by the requesting provider; 
(b)  	The provider’s requested payment based on an established similar code value as required by section 16-10(F); or
(c)  	The billed charges.
If the payer disagrees with the provider’s recommended code value, the payer’s notice of contest shall include an explanation of why the requested fee is not reasonable and what their recommendation is, based on the payment options.
If the payer is contesting the medical necessity of any non-valued procedure after a prior authorization was requested, the payer shall follow section 16-12(C).
(C)     Process for Contesting Payment of Billed Services Based on Medical Reasons
When contesting payment of billed services based on medical reasons, the payer shall:
(1)        Have the bill and all supporting medical documentation under section 16-7(E) reviewed by a physician or other health care professional as defined in section 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  The physicians or chiropractors performing this review shall be Level I or Level II accredited. After reviewing the supporting medical documentation, the reviewing provider may call the billing provider to expedite communication and timely processing of the contested or paid medical bill.  
(2)        In all cases where a billed service is contested for medical reasons, the payer shall send the provider and the parties written notice of the contest within 30 days of receipt of the bill.  The written notice shall include all of the notice requirements set forth in section 16-12(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s) was (were) submitted on the bill;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested;
(d)        An explanation of the clear and persuasive medical reasons for the decision, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;
(e)        The specific cite from the Medical Treatment Guidelines exhibits to Rule 17, when applicable; and 
(f)         Identification of the information deemed most likely to influence the reconsideration of the contest, when applicable.
(3)	Any notice that fails to include the required information set forth in this section is defective. Such defective notice shall not satisfy the payer’s 30-day notice requirement set forth in this section. 
(4)	If the payer is contesting the medical necessity of any non-valued procedure provided without prior authorization, the payer shall follow the procedures given in sections 16-12(C)(1)and (2).  
(D)	Process for Ongoing Contest of Billed Services 
(1)        The billing party shall have 60 days to respond to the payer’s written notice under section 16-12(A) – (C).  The billing party’s timely response must include:
(a)	A copy of the original or corrected bill;
(b)	A copy of the written notice or EOB received;
(c)	A statement of the specific item(s) contested;
(d)	Clear and persuasive supporting documentation or clear and persuasive reasons for the appeal; and 
(e)	Any available additional information requested in the payer’s written notice.
(2)	If the billing party responds timely and in compliance with section 16-12(D)(1), the payer shall:
(a) 	When contesting for medical reasons, have the bill and all supporting medical documentation and reasoning under section16-7(E) and, if applicable, section 16-12(D)(1) reviewed by a physician or other health care professional as defined in section 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  After reviewing the provider’s documentation and response, the reviewing provider may call the billing provider to expedite communication and timely processing of the contested or paid medical bill. 
(b)	When contesting for non-medical reasons, have the bill and all supporting medical documentation and reasoning under section 16-7(E) and, if applicable, section 16-12(D)(1) reviewed by a person who has knowledge of the bill.  After reviewing the provider’s documentation and response, the reviewing person may call the billing provider to expedite communication and timely processing of the contested or paid medical bill. 
(3)	If before or after conducting a review pursuant to section 16-12(D)(2), the payer agrees with the billing party’s response, the billed service is due and payable in accordance with the Medical Fee Schedule within 30 days after receipt of the billing party’s response.  Date of receipt may be established by the payer’s date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) business days after the date the response was mailed to the payer’s correct address.  
(4)        After conducting a review pursuant to section 16-12(D)(2), if there is still a dispute regarding the billed services, the payer shall send the billing party written notice of contest within 30 days of receipt of the response.  The written notice shall include all of the notice requirements set forth in section 16-12(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s) was(were) submitted by the provider;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested;
(d)        An explanation of the clear and persuasive medical or non-medical reasons for the decision, including the name and professional credentials of the person performing the medical or non-medical review and a copy of the medical reviewer's opinion when the contest is over a medical reason; and 
(e)        The explanation shall include the citing of appropriate statutes, rules and/or documents supporting the payer’s reasons for contesting payment.
(5)	Any notice that fails to include the required information set forth in this section is defective.  Such defective notice shall not satisfy the payer’s 30-day notice requirement set forth in this section.
(6)        In the event of continued disagreement, and within 12 months of the date the original bill should have been processed in compliance with section 16-12, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
 (E)	Retroactive review of Medical Bills
(1)        All medical bills paid by a payer shall be considered final at 12 months after the date of the original explanation of benefits unless the provider is notified that:
(a)	A hearing is requested within the 12 month period, or 
(b)	A request for utilization review has been filed pursuant to § 8-43-501.
(2)        If the payer conducts a retroactive review to recover overpayments from a provider based on medical reasons, the payer shall have the bill and all supporting documentation reviewed by a physician or other health care professional as defined in section 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  The payer shall send the billing party written notice that shall include all of the notice requirements set forth in section 16-12(A)(1) and shall also include:
(a)	Reference to each item of the bill where payer seeks to recover overpayments; 
(b)	Clear and persuasive medical reason(s) for seeking recovery of overpayment(s).  The explanation shall include the citing of appropriate statutes, rules, and/or other documents supporting the payer’s reason for seeking to recover overpayment; and 
(c)	Evidence that these payments were in fact made to the provider.
(3)	If the payer conducts a retroactive review to recover overpayments from a provider based on non-medical reasons, the payer shall send the billing party written notice that shall include all of the notice requirements set forth in section 16-12(A)(1) and shall also include:
(a)	Reference to each item of the bill where payer seeks to recover overpayments; 
(b)	Clear and persuasive reason(s) for seeking recovery of overpayment(s).  The explanation shall include the citing of appropriate statutes, rules, and/or other documents supporting the payer’s reason for seeking to recover overpayment; and 
(c)	Evidence that these payments were in fact made to the provider.
 (4)	In the event of continued disagreement, the parties may follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
(F)	An injured worker shall never be required to directly pay for admitted or ordered medical benefits covered under the Workers’ Compensation Act.  In the event the injured worker has directly paid for medical services that are then admitted or ordered as covered under the Workers’ Compensation Act, the payer shall reimburse the injured worker for the amounts actually paid for authorized services within 30 days after receipt of the bill.  If the actual costs exceed the maximum fee allowed by the Medical Fee Schedule, the payer may seek a refund from the medical provider for the difference between the amount charged to the injured worker and the maximum fee.  Each request for a refund shall indicate the service provided and the date of service(s) involved.
(G)	To the extent not otherwise precluded by the laws of this state, contracts between providers, payers and any agents acting on behalf of providers or payers shall comply with section 16-12. 
16-13	DISPUTE RESOLUTION PROCESS
(      When seeking dispute resolution from the Division’s Medical Policy Unit (MPU), the requesting party must complete the Division’s “Medical Billing Dispute Resolution Intake Form” (Form WC 181) found on the Division’s web page.  The items listed on the bottom of the form must be provided at the time of submission.  If necessary items are missing or if more information is required, the Division will forward a request for additional information and initiation of the process may be delayed.
When the request is properly made and the supporting documentation submitted, the Division will issue a confirmation of receipt.  If after reviewing the materials the Division believes the dispute criteria have not been met, the Division will issue an explanation of those reasons.  If the Division determines there is cause for facilitating the disputed items, the other party will be sent a request for a written response, allowing the other party ten (10) business days to respond.
The MPU will facilitate the dispute by reviewing the parties’ compliance with Rules 16 and 18 within 30 days of receipt of the complete supporting documentation; or as soon thereafter as possible.
Upon review of all submitted documentation, disputes resulting from violation of Rules 16 and/or 18, as determined by the Director, may result in a Director’s Order that cites the specific violation.
Evidence of compliance with the order shall be provided to the Director.   If the party does not agree with the findings, it shall state with particularity and in writing its reasons for all disagreements by providing a response with all relevant legal authority, and/or other relevant proof upon which it relies in support of its position(s) concerning disagreements with the order. 
Failure to respond or cure violations may result in penalties in accordance with § 8-43-304.  Daily fines up to $1000/day for each such offence will be assessed until the party complies with the Director’s Order. 
Resolution of disputes not pertaining to Rule violations will be facilitated by the MPU to the extent possible.  In the event both parties cannot reach an agreement, the parties will be provided additional information on pursuing resolution and adjudication procedures available through the Office of Administrative Courts.  Use of the dispute resolution process does not extend the 12 month application period for hearing.
16-14    ONSITE REVIEW OF HOSPITAL OR OTHER MEDICAL CHARGES
(A)        The payer may conduct a review of billed and non-billed hospital or medical facility charges related to a specific workers’ compensation claim.
(B)        The payer shall comply with the following procedures:
Within 30 days of receipt of the bill, notify the hospital or other medical facility of its intent to conduct a review. Notification shall be in writing and shall set forth the following information:
(1)        Name of the injured worker;
(2)        Claim and/or hospital or other medical facility I.D. number associated with the injured worker's bill;
(3)        An outline of the items to be reviewed; and
(4)        If applicable, the name, address and telephone number of any person who has been designated by the payer to conduct the review (reviewer).
(C)        The hospital or other medical facility shall comply with the following procedures:
(1)        Allow the review to begin within 30 days of the payer's notification;
(2)        Upon receipt of the patient's signed release of information form, allow the reviewer access to all items identified on the injured worker's signed release of information form;
(3)        Designate an individual(s) to serve as the primary liaison(s) between the hospital or other medical facility and the reviewer who will acquaint the reviewer with the documentation and charging practices of the hospital or other medical facility;
(4)        Provide a written response to each of the preliminary review findings within ten (10) business days of receipt of those findings; and
(5)        Participate in the exit conference in an effort to resolve discrepancies.
(D)        The reviewer shall comply with the following procedures:
(1)        Obtain from the injured worker a signed information release form; 
(2)        Negotiate the starting date for the review;
(3)        Assign staff members who are familiar with medical terminology, general hospital or other medical facility charging and medical records documentation procedures or have a level of knowledge equivalent at least to that of an LPN;
(4)        Establish the schedule for the review which shall include, at a minimum, the dates for the delivery of preliminary findings to the hospital or other medical facility, a ten (10) business day response period for the hospital or other medical facility, and the delivery of an itemized listing of discrepancies at an exit conference upon the completion of the review; and
(5)        Provide the payer and hospital or other medical facility with a written summary of the review within 20 business days of the exit conference.

DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 CCR 1101-3
WORKERS’ COMPENSATION RULES OF PROCEDURE
Rule 18	MEDICAL FEE SCHEDULE
18-1	STATEMENT OF PURPOSE
Pursuant to § 8-42-101(3)(a)(I), C.R.S., and § 8-47-107, C.R.S., the Director promulgates this Medical Fee Schedule to review and establish maximum allowable fees for health care services falling within the purview of the Act.  The Director adopts and hereby incorporates by reference, as modified and published by Medicare in January 2016, National Physician Fee Schedule Relative Value file (RBRVS-Resource Based Relative Value Scale); the Current Procedural Terminology CPT® 2016, Professional Edition, published by the American Medical Association (AMA); and Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 34 using MS-DRGs effective after October 1, 2016.  The incorporation is limited to the specific editions named and does not include later revisions or additions.  For information about inspecting or obtaining copies of the incorporated materials, contact the Medical Policy Unit Supervisor, 633 17th Street, Suite 400, Denver, Colorado 80202-3626.  These materials may be examined at any state publications depository library.  All guidelines and instructions are adopted as set forth in the RBRVS, CPT® and MS-DRGs, and all CPT® modifiers, unless otherwise specified in this Rule.
This Rule applies to all services rendered on or after January 1, 2017.  All other bills shall be reimbursed in accordance with the fee schedule in effect at the time service was rendered.
18-2	STANDARD TERMINOLOGY FOR THIS RULE
(A)	CPT® - Current Procedural Terminology CPT® 2016, copyrighted and distributed by the AMA and incorporated by reference in 18-1.
(B)        DoWC Zxxxx – Colorado Division of Workers’ Compensation created codes.
(C)        MS-DRGs – version 33.0 incorporated by reference in 18-1.
(D)        Medicare’s January 2016 National Physician Fee Schedule Relative Value file (RBRVS) 
(E)        For other terms, see Rule 16, Utilization Standards.
18-3      HOW TO OBTAIN COPIES
All users are responsible for the timely purchase and use of Rule 18 and its supporting documentation as referenced herein.  The Division shall make available for public review and inspection the copies of all materials incorporated by reference in Rule 18.  Copies of the RBRVS may be obtained from Medicare’s website, www.cms.gov/Medicare/Medicare-Fee-For-Service-Payment/PhysicianFeeSched/Index.html.  The Current Procedural Terminology, 2016 Edition, may be purchased from the AMA.  The MS-DRGs Definitions Manual may be purchased from 3M Health Information Systems. The Colorado Workers' Compensation Rules of Procedures with Treatment Guidelines, 7 CCR 1101-3, may be purchased from LexisNexis Matthew Bender & Co., Inc., Albany, NY.  Interpretive Bulletins and unofficial copies of all rules, including Rule 18, are available on the Colorado Department of Labor and Employment web site.  An official copy of the rules is available on the Secretary of State’s webpage.
18-4      CONVERSION FACTORS (CF)
The following CFs shall be used to determine the maximum allowed fees.  The maximum fee is determined by multiplying the following section CFs by the established facility or non-facility total relative value unit(s) (RVUs) found in the corresponding RBRVS sections:
RBRVS SECTION		CF 
Anesthesia	$55.61/RVU
Surgery	$68.01/RVU
Radiology	$71.99/RVU
Pathology	$68.31/RVU
Medicine	$67.00/RVU
Physical Medicine	$41.14/RVU
(Physical Medicine and Rehabilitation,
Medical Nutrition Therapy and Acupuncture)
Evaluation & Management (E&M)	$50.20/RVU
Table #1 lists the place of service codes used with the RBRVS facility RVUs.  All other maximum fee calculations shall use the non-facility RVUs listed in the RBRVS.  
Table #1	
 Place of Service Code 	 Place of Service Code Description	
19	 Off Campus – Outpatient Hospital	
21	 Inpatient Hospital	
22	 On Campus - Outpatient Hospital	
23	 Emergency Room-Hospital	
24	 Ambulatory Surgery Center (ASC)	
26	 Military Treatment Facility 	
31	 Skilled Nursing Facility	
34	 Hospice	
41	 Ambulance - Land	
42	 Ambulance - Air or Water	
51	 Inpatient Psychiatric Hospital	
52	 Psychiatric Facility-Partial Hospitalization	
53	 Community Mental Health Center	
56	 Psychiatric Residential Treatment Center	
61	 Comprehensive Inpatient Rehabilitation Facility	

18-5	INSTRUCTIONS AND/OR MODIFICATIONS TO THE DOCUMENTS INCORPORATED BY REFERENCE IN RULE 18-1 
(A)	Maximum allowance for all providers under Rule 16-5 is 100% of the RBRVS value or as specified in this Rule.  The maximum fee schedule value for Physician Assistants (PAs) and Nurse Practitioners (NPs) shall be 85% of the Medical Fee Schedule.  However, PAs and NPs may be allowed 100% of the Medical Fee Schedule value if the requirements of Rule 16-5(A)(6) have been met and one of the following conditions applies:
		(1)	The service is provided in a rural area.  Rural area means: 
				●	a county outside a Metropolitan Statistical Area (MSA) or 
●	a Health Professional Shortage Area, either located outside of an MSA or in a rural census tract, as determined by the Office of Rural Health Policy, Health Resources and Services Administration, United States Department of Health and Human Services.
		(2)	The “incident to” criteria found in 42 CFR §§ 410.26(a) and (b), 410.27, and 410.32(b)(3) have been met. 
(B)	Unless modified herein, the RBRVS is adopted for RVUs.  Division-created codes (Zxxxx) and values supersede the CPT® or RBRVS codes. Those codes listed with RVUs of “BR” (by report), not listed, or listed with a zero value and not included by Medicare in another procedure(s), require prior authorization pursuant to Rule 16. The CPT® 2016 is adopted for codes, descriptions, parenthetical notes and coding guidelines, unless modified in this Rule. 
	When billing timed codes, practitioners are required to document in the medical record the time spent with the patient.  The time counted is the time the patient is treated and must be appropriately documented. 
	Any billed CPT® code identified as a “separate procedure” in CPT® shall have an appropriate modifier appended to the code for the payer to allow separate payment (i.e., modifier 59). 

	One of the following descriptive modifiers shall be used in place of modifier 59 unless none apply:
•	XE - Separate Encounter: a service that is distinct because it occurred during a separate encounter.
•	XS – Separate Structure: a service that is distinct because it was performed on a separate organ/structure.
•	XP – Separate Practitioner: a service that is distinct because it was performed by a different practitioner. 
•	XU – Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap usual components of the main service.
If none of these modifiers apply, the provider shall obtain prior authorization from the payer.
	No code listed in CPT® identified as an “add-on” code is payable unless an appropriate primary code is billed with the “add-on” code in the same episode of care. 
	The National Physician Fee Schedule Relative Value file, as modified, are the only fields recognized in the Colorado Workers’ Compensation Medical Fee Schedule: 
(1)	HCPCS (Healthcare Common Procedure Coding System) –including any non-listed CPT® codes;
(2)	Level I (CPT®) and Level II (HCPCS) Modifiers (listed and unlisted); 
(3)	Description – short description as listed in the file and long description as specified in CPT®;
(4)	Total Non-Facility RVU;
(5)	Total Facility RVU;
(6)	PC/TC (Professional Component/Technical Component) Indicators: 
(a)	“0” – Physician Services Only – PC/TC distinction does not apply to these service codes;
(b)	“1” – Diagnostic Radiology Tests/Services - diagnostic test codes for radiology service may be billed with or without modifiers 26 or TC; 
(c)	“2” – Professional Component Only Codes – stand-alone professional service codes only (no modifier is appropriate because the code description dictates the service is professional only, e.g., 93010 Electrocardiogram represents “interpretation and report only”);
(d)	“3” - Technical Component Only Codes - stand-alone technical service codes only (no modifier is appropriate because the code description dictates the service is technical only, e.g., 93005 Electrocardiogram represents “tracing only”);  
(e)	“4” – Global Test Only Codes - modifiers 26 and TC cannot be used with these codes because the values equal to the sum of the total RVUs (work, practice expense and malpractice);
(f)	“5” - Incident To Codes - do not apply to workers’ compensation;
(g)	“6” - Laboratory Physician Interpretation Codes – clinical laboratory codes for which separate payments for interpretations by laboratory physicians may be made (these codes represent the professional component of a clinical laboratory service and cannot be billed with a modifier TC); 
(h)	“7” - Physical Therapy Services – these codes are not recognized by DoWC; 
(i)	“8” - Physician Interpretation Codes –clinical laboratory codes for which separate payments may be made only when a physician interprets an abnormal smear for a hospital in-patient.  This indicator applies to CPT® codes 88411, 85060, and HCPCS code P3001-26.  No TC component is recognized;
(j)	“9” - Not Applicable – PC/TC component does not apply to this indicator;
(7)	Global Days;
(8)	Conversion factors as specified in Rule 18-4.
(C)	CPT® Category III codes listed in the RBRVS may be used for billing with agreement of the payer as to reimbursement.  Payment shall be in compliance with Rule 16-6(C).
(D)	Anesthesia
		(1)	All anesthesia base values shall be established by the use of the codes as set forth in Medicare’s 2016 Anesthesia Base Values.  Anesthesia services are only reimbursable if the anesthesia is administered by a physician, a Certified Registered Nurse Anesthetist (CRNA), or an anesthesiologist assistant (AA) who remains in constant attendance during the procedure for the sole purpose of rendering anesthesia.
			When anesthesia is administered by a CRNA or AA:
			(a)	CRNAs not under the medical direction of an anesthesiologist, reimbursement shall be 90% of the maximum anesthesia value;
			(b)	If billed separately, CRNAs and AAs, under the medical direction of an anesthesiologist, shall be reimbursed 50% of the maximum anesthesia value.  The other 50% is payable to the anesthesiologist providing the medical direction to the CRNA or AA;
			(c)	Medical direction for administering the anesthesia includes performing the following activities:
				(i)	Performs a pre-anesthesia examination and evaluation,
				(ii)	Prescribes the anesthesia plan,
				(iii)	Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence,
				(iv)	Ensures that any procedure in the anesthesia plan that s/he does not perform is performed by a qualified anesthetist,
				(v)	Monitors the course of anesthesia administration at frequent intervals,
				(vi)	Remains physically present and available for immediate diagnosis and treatment of emergencies, and
				(vii)	Provides indicated post-anesthesia care.
 		(2)	The following modifiers are to be used when billing for anesthesia services:
AA – anesthesia services performed personally and billed by the anesthesiologist.  Maximum allowance is 100% of maximum anesthesia calculated fees. 
AD – greater than four (4) concurrent (occurring at the same time) anesthesia service cases being supervised by an anesthesiologist.  Maximum allowance for supervising multiple cases is calculated using three (3) base anesthesia units to each case, regardless of the number of base anesthesia units assigned to each specific anesthesia episode of care.  
QK – anesthesiologist providing direction to qualified individuals of two (2) to four (4) concurrent anesthesia cases.  Maximum allowance is 50% of maximum anesthesia calculated fees for the billing anesthesiologist providing direction.
QX – CRNA or AA service; with medical direction by a physician.  Maximum allowance is 50% of the maximum anesthesia calculated fees for the CRNA or AA administering the anesthesia.
QZ – CRNA service; without medical direction by a physician.  Maximum allowance is 90% of maximum anesthesia calculated fees for the CRNA.
QY – Medical direction of one CRNA or AA by an anesthesiologist.  Maximum allowance is 50% of maximum anesthesia calculated fees for the anesthesiologist providing direction.
QS – Monitored anesthesia care service (MAC).
G8 – Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedure.
G9 – Monitored anesthesia care (MAC) of a patient who has a history of severe cardiopulmonary disease.
	(3)	The supervision of AAs shall be limited in accordance with the Medical Practice Act.	
		(4)	Physical status modifiers are reimbursed as follows, using the anesthesia conversion factor:
	P-1	Healthy patient					0 RVUs
	P-2	Patient with mild systemic disease		0 RVUs
	P-3	Patient with severe systemic disease		1 RVU

	P-4	Patient with severe systemic disease that is a 
		constant threat to life				2 RVUs
	P-5	A moribund patient who is not expected to
		survive without the operation			3 RVUs
	P-6	A declared brain-dead patient			0 RVUs
		(5)	Qualifying circumstance codes are reimbursed using the anesthesia conversion factor: 
	Anesthesia complicated by extreme age; 
	under 1 year old or > 70 years old			1 RVU
	Anesthesia complicated by utilization of 	
	total body hypothermia					5 RVUs
	Anesthesia complicated by utilization of
	controlled hypotension					5 RVUs
	Anesthesia complicated by emergency
	conditions (specify) 					2 RVUs

		(6)	When more than one surgical procedure is performed during a single episode, only the highest valued base anesthesia procedure value is billed with the total anesthesia time for all procedures.  

		(7) 	Anesthesia time begins when the anesthesiologist prepares the patient for the induction of anesthesia and ends when the anesthesiologist is no longer in personal attendance and the patient is placed under postoperative supervision.  Total minutes are reported for reimbursement.  Each 15-minutes of anesthesia time equals 1 additional RVU.  Five minutes or more is considered significant time and adds 1 RVU to the payment calculation. 
		(8)	Calculation of Maximum Fees for Anesthesia
Base Anesthesia value from the Medicare’s 2016 Anesthesia Base Values 

			+1 Unit/15 minutes of anesthesia time
					+Any physical status modifier units
			Total Relative Value Anesthesia Units
			Multiplied by the Anesthesia CF in section 18-4
			Total Maximum Anesthesia Fees

“Qualifying circumstance” codes are reimbursed under section 18-5(D)(1)(f) of this Rule.
		(9)	Non-time based Anesthesia Procedures 
			Modifier -47 shall be used by surgeons performing non-time based anesthesia.
 	(E)	Surgery: 
		(1)	The use of assistant surgeons shall be limited according to the American College Of Surgeons'  Physicians as Assistants at Surgery:  2016 Update (April 2016), available from the American College of Surgeons, Chicago, IL, or from their web page.  The incorporation is limited to the edition named and does not include later revisions or additions.  Copies of the material incorporated by reference may be inspected at any State publications depository library.  For information about inspecting or obtaining copies of the incorporated material, contact the Medical Policy Unit Supervisor, 633 17th Street, Suite 400, Denver, Colorado, 80202-3626.
Where the publication restricts use of such assistants to "almost never" or a procedure is not referenced in the publication, prior authorization for payment (see Rule 16-10) is required.
		(2)	Incidental procedures are commonly performed as an integral part of a total service and do not warrant a separate benefit.  
		(3)	No payment shall be made for more than one (1) assistant surgeon or minimum assistant surgeon without prior authorization for payment (see Rule 16-10).
		(4)	The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate modifier should be used on the bill.  To modify a billed code refer to Rule 16-12(B)(4).
		(5)	When an operation requires two primary surgeons performing two distinct portions of the operation, modifier -62 is used with the procedure in question and reimbursement is increased to 125% of the value, apportioned in relation to the responsibilities and work of each surgeon or 50% of the total increased maximum fee to each surgeon.
	Surgical team reimbursement requires prior authorization and the use of modifier - 66 on the surgical codes.
	Assistant Surgeon, indicated by modifier -80 has a maximum allowance of 20 % of the surgeon’s fees.
Assistant Surgeon (when qualified resident surgeon is not available), indicated by modifier -82, is also reimbursed at 20% of the surgeon’s fees.
Minimum Assistant Surgeon Modifiers and Maximum Fees:
●	Modifier –AS should be appended to services performed by NPs or PAs;
●	Modifier –81 should be appended to services performed by clinical nurse specialists, surgical technicians, or any other non-physician providers;
●	Minimum Assistant Surgeon’s maximum fees are 10% of the surgeon’s fees.
		(6)	Global Period   
(a)	All surgical procedures include the following:
				(i)	Local infiltration, metacarpal/metatarsal/digital block or typical anesthesia;
				(ii)	One related E&M encounter on the date immediately prior to or on the date of the procedure (including history and physical);
				(iii)	Intraoperative services that are normally a usual and necessary part of a surgical procedure; 
				(iv)	Immediate postoperative care, including dictating operative notes, talking with the family and other physicians;
				(v)	Evaluating the patient in the post-anesthesia recovery room;
				(vi)	Post-surgical pain management by the surgeon;
				(vii)	Typical postoperative follow-up care during the global period of the surgery that is related to recovery from the surgery as identified in RBRVS as global:
•	000 –are endoscopies or some minor surgical procedures, typically a 0 day postoperative period. Visits on the same day of procedures are generally included in the allowance for the procedure, unless a separately identifiable service is performed and billed with the appropriate modifier. 
•	010 - are other minor procedures, 10 day postoperative period. 
•	090 - are major surgeries, 90 day postoperative period.
•	XXX – does not apply
•	ZZZ – are covered under another procedure’s global days 
•	MMM – global service day’s concept does not apply.  (See Medicare’s Global Maternity Care reporting rule.)
•	Global period, defined RBRVS, begins the day after surgery and continues for the defined period.
				(viii)	Supplies – Except for those identified as exclusions;
				(ix)	Miscellaneous Services – Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and removal of urinary catheters, routine peripheral IV lines, nasograstric and rectal tubes; changes and removal of tracheostomy tubes;
				(x)	Applicable Surgical Modifiers:
•	24 - Unrelated E&M service by the same physician during a postoperative period.
•	25 - Significant and separately identifiable E&M service on the same day of the procedure within the global period of minor surgical procedures (0 or 10 days). 
•	54 - Surgical Care only.  Fee is 60% of the billed surgery code Maximum Fee Schedule value.
•	55 - Postoperative management only.  Fee is 30% of the billed surgery code Maximum Fee Schedule value.
•	56 - Preoperative management only. Fee is 10% of the billed surgery code Maximum Fee Schedule value.
•	57 - Decision for surgery.
•	58 - Staged or related procedure or service by the same physician during the postoperative period.
•	76 - Repeat procedure or service by the same physician.
•	78 - Unplanned Return to the Operating/Procedure Room by the same physician following initial procedure for a related procedure during the postoperative period.
•	79 - Un-related procedure or service by the same physician during the postoperative period.
(b)	The following services performed during a global period would warrant separate billing if documentation demonstrates significant identifiable services were involved, such as:
				(i)	E&M services unrelated to the primary surgical procedure.
				(ii)	Services necessary to stabilize the patient for the primary surgical procedure.
				(iii)	Services not considered part of the surgical procedure, including an E&M visit by an authorized treating physician for disability management.  The E&M service shall have an appropriate modifier appended to the E&M level of the service code when the surgeon is performing services during the global period.  If at all possible, an appropriate identifying diagnosis code shall identify the E&M service as unrelated to the surgical global period.  In addition, the reasonableness and necessity for an E&M service that is separate and identifiable from the surgical global period shall be clearly documented in the medical record.  
				(iv)	Disability management of an injured worker for the same diagnosis requires the managing physician to clearly identify in the medical record the specific disability management detail that was performed during that visit.  The definitions of what is considered disability counseling can be located under 18-5(I)(1) and in Exhibit #7 of this Rule. 
				(v)	Unusual circumstances, complications, exacerbations, or recurrences.
				(vi)	Unrelated diseases or injuries.
				(vii)	If a patient is seen for the first time or an established patient is seen for a new problem and the “decision for surgery” is made the day of the procedure or the day before the procedure is performed, then the surgeon can bill both the procedure code and an E&M code, using a -57 modifier or -25 modifier on the E&M code.
			(c)	Separate identifiable services shall use an appropriate CPT®/ modifier in conjunction with the billed service.
		(7)	Multiple Procedures (modifier -51) and Bilateral Procedures (modifier -50)
Multiple procedure guidelines (modifier -51) do not apply to codes specifically identified in CPT® as add-on procedures “+” or to those specifically identified as exempt from modifier -51 Ø.
Bilateral procedures not identified by CPT® as bilateral shall be billed on one line with one (1) unit and modifier -50 shall be appended to the CPT® code.  The maximum fee is calculated at 150% of the Maximum Fee Schedule value. 
When multiple procedures are performed by the same surgeon during the same surgical setting, modifier -51 shall be appended to the lower valued procedure(s). When multiple surgical procedures are performed in a single surgical setting, the highest valued or primary procedure is allowed 100% of the maximum fee and all other valued procedures, appended with a modifier -51, are allowed at 50% of the maximum fee.  
 		(8)	If a surgical arthroscopic procedure is converted to the same surgical open procedure on the same joint, only the open procedure is payable.  If an arthroscopic procedure and open procedure are performed on different joints, the two (2) procedures may be separately payable with anatomic modifiers or modifier -50.
		(9)	Use code G0289 to report any combination of surgical knee arthroscopies for removal of loose body, foreign body, and/or debridement/shaving of articular cartilage.  
G0289 shall not be paid when reported in conjunction with other knee arthroscopy codes in the same compartment of the same knee.
G0289 shall be paid when reported in conjunction with other knee arthroscopy codes in a different compartment of the knee.  
		(10)	Venipuncture maximum fee allowance is covered under Exhibit #8 of this Rule. 
		(11)	Platelet Rich Plasma (PRP) Injections
The Medical Treatment Guidelines promulgated by the Director of the Division of Workers’ Compensation (Rule 17) govern when PRP injections are appropriate.  Any PRP injections outside of the Medical Treatment Guidelines require prior authorization.  
The provider shall bill DoWC Z0813, maximum total all-inclusive allowance of $735.00, for PRP injections to any body part.  This includes imaging guidance, harvesting and preparation (if performed), the injection itself, as well as kits and supplies.  
	(F)	Radiology:
(1)	General Policies
(a)	The professional component (PC) represents the supervision and interpretation of a procedure provided by the physician or other healthcare professional. It is identified by appending modifier 26 to the procedure code.
(b)	The technical component (TC) represents the cost of equipment, supplies and personnel to perform the procedure. It is identified by appending modifier TC to the procedure code.
(c)	A global service includes both professional and technical components. The global service is identified by reporting the eligible code without modifier 26 or TC.
	A stand-alone procedure code describes the selected diagnostic tests for which there are associated codes that describe (a) the professional component of a test only, (b) the technical component of a test only and (c) the global test only. Modifiers 26 and TC cannot be billed with these codes.
(2)	Payments
(a)	The American College of Radiology (ACR) Accreditation is recognized as the “gold standard” for quality and safe radiological imaging. The medical fee schedule shall apply to all radiology offices/facilities that have attained any of the ACR Accreditation(s) (MRI, CT, Mammography, Breast MRI, Breast Ultrasound, Nuclear Medicine & PET, Radiation Oncology Practice, or Stereotactic Breast Biopsy).  The professional component of MRIs shall be reimbursed 130% of the medical fee schedule if the technical component is performed in an ACR-accredited office/facility.  All offices/facilities that perform x-rays or ultrasounds, either as a stand-alone procedure or for image guidance, are allowed the maximum fee without ACR Accreditation.  Reimbursement for any facility that is not ACR Accredited and performing one of the eight types of ACR Accredited imaging procedures shall be 85% of the maximum allowed fee.  
(b)	The cost of dyes and contrast shall be reimbursed in accordance with 18-6(H)).
(c)	Copying charges for x-rays and MRIs shall be $15.00/film regardless of the size of the film.
(d)	The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate CPT®/RBRVS modifier should have been used on the bill.  To modify a billed code, refer to Rule 16-12(B)(4).
(e)	In billing radiology services, the applicable radiology procedure code shall be billed using the appropriate modifier to bill either the professional component (26) or the technical component (TC).  If a physician bills the total or professional component, a separate written interpretive report is required.  
If a physician interprets the same radiological image more than once, or if multiple physicians interpret the same radiological image, only one (1) interpretation shall be reimbursed.  If an X-ray consultation is requested, the consultant’s report shall include the name of the requesting provider, the reason for the request, and documentation that the report was sent to the requesting provider.  The maximum fee for an X-ray consultation shall be no greater than the maximum fee for the professional component of the original X-ray.
The time a physician spends reviewing and/or interpreting an existing radiological image is considered a part of the physician’s evaluation and management service code.
(3)	Thermography
(a)	The provider supervising and interpreting the thermographic evaluation shall be board certified by the examining board of one (1) of the following national organizations and follow their recognized protocols:
American Academy of Thermology;
American Chiropractic College of Infrared Imaging. 
(b)	Indications for diagnostic thermographic evaluation must be one (1) of the following:
Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy (CRPS/RSD);
Sympathetically Maintained Pain (SMP);
Autonomic neuropathy;
(c)	General Protocols for Stress Testing
	Cold Water Autonomic Functional Stress Testing – Baseline infrared images are obtained in a 68º F +/- 1 degree steady state environment following equilibration for 15 minutes.  After the quantitative and qualitative baseline images are captured, cold water autonomic functional stress testing is performed by submersing the asymptomatic extremity in 68º F +/- 1 degree cold water bath for 5 minutes while imaging and evaluating the autonomic response.
	Whole Body Autonomic Stress Testing – Refer to the thermogram discussion section found in the Complex Regional Pain Syndrome Medical Treatment Guidelines.
(d)	Thermography Billing Codes:
DoWC Z0200  Upper body w/ Autonomic Stress Testing     $865.37
DoWC Z0201  Lower body w/Autonomic Stress Testing      $865.37
(e)	Prior authorization for payment (see Rule 16-10) is required for thermography services only if the requested study does not meet the indicators for thermography as outlined in this radiology section.  The billing shall include a report supplying the thermographic evaluation and reflecting compliance with 18-5(E)(2).
		(4)	Urea breath test C-14 (Isotopic); acquisition for analysis and the analysis maximum fees are listed under Exhibit #8 of this Rule. 
 (G)	Pathology:
(1)	General Policies
(a)	The professional component (PC) represents the supervision and interpretation of a procedure provided by the physician or other healthcare professional. It is identified by appending modifier 26 to the procedure code.
(b)	The technical component (TC) represents the cost of equipment, supplies and personnel to perform the procedure. It is identified by appending modifier TC to the procedure code.
(c)	A global service includes both professional and technical components. The global service is identified by reporting the eligible code without modifier 26 or TC.
	A standalone procedure code describes the selected diagnostic tests for which there are associated codes that describe (a) the professional component of a test only, (b) the technical component of a test only and (c) the global test only. Modifiers 26 and TC cannot be billed with these codes.
(2) 	Clinical Laboratory Improvement Amendments (CLIA)
Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver, or other providers billing for services performed by these laboratories, shall bill using the QW modifier. 
Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation, or other providers billing for services performed by these laboratories, do not append the QW modifier to claim lines.  (3)	Payments
	All clinical pathology laboratory tests, except as allowed by this rule, are reimbursed at the total component dollar value listed under Exhibit #8 of this Rule or billed charges, whichever is less.  No separate technical or professional component maximum dollar split is separately payable by the payer.  However the technical and professional component billing parties may agree upon a dollar value split of the total maximum fees listed in Exhibit #8 of this Rule.
	When a physician clinical pathologist is required for consultation and interpretation, and a separate written report is created, the maximum fee is determined by using the RBRVS values and the pathology conversion factors.  Maximum Fee Schedule value is determined by the Pathology Conversion Factor when the Pathology CPT® code description includes “interpretation” and “report” or the following Pathology CPT® code description is from: 
•	physician blood bank services, 
•	cytopathology and cell marker study interpretations, 
•	cytogenics or molecular cytogenics interpretation and report, 
•	surgical pathology gross and microscopic and special stain groups 1 and 2 and histochemical stain, blood or bone marrow interpretations, and
•	Skin tests for “unlisted antigen each, coccidoidomycosis, histoplasmosis, TB intradermal.
When ordering automated laboratory tests, the ordering physician may seek verbal consultation with the pathologist in charge of the laboratory’s policy, procedures and staff qualifications.  The consultation with the ordering physician is not payable unless the ordering physician requested additional medical interpretation and judgment and requested a separate written report.  Upon such a request, the pathologist may bill using the proper CPT® code and values from the RBRVS, not DoWC Z0755.
(4)	Clinical Drug Screening/Testing Codes and Values
(a)	Clinical drug screening/testing evaluates whether:
				(i)	Prescribed medications are at or below therapeutic or toxic levels (Therapeutic Drug Monitoring); or
				(ii)	The patient is taking prescribed controlled substance medication(s); or 
	(iii)	The patient is taking any illicit or non-prescribed drugs. 
	(b)	Billing requirements for Clinical Drug Testing:
				(i)	The ordering physician shall document the medical necessity of the clinical drug test.  
				(ii)	The ordering physician shall specify which drugs require quantitative tests to meet the patient’s medical needs.   
				(iii)	Quantification of illicit or non-prescribed drugs or drug classes requires a physician order.
				(iv)	Medicare codes and CPT® codes used in the 2016 Medicare Fee Schedule shall be billed for qualitative or quantitative presumptive and definitive urine drug tests. 
				(v)	All recognized codes and maximum fee values are listed in Exhibit #8 to this rule.
		(c)	Presumptive Tests 
Presumptive drug class assays identify possible use or non-use of drug(s) or drug class(es), but may not identify the specific drug or metabolite. All drug class immunoassays or enzymatic methods are considered to be presumptive. .  Providers may ONLY bill for one (1) of the three types of presumptive codes per patient encounter:
				(i)	Drug test(s), presumptive, any number of drug classes; any number of devices or procedures (e.g. immunoassay) capable of being read by a direct optical observation only (e.g. dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service (G0477).
				(ii)	 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g, immunoassay) read by instrument-assisted direct optical observation (e.g. dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service (G0478).  
				(iii)	Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers (e.g, immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service (G0479).
Presumptive drug class screening shall be billed using either G0477 or G0479 CPT® drug class list A or  B, replacing CPT® codes  80300-80304.  

Drug Class A from CPT® for Presumptive Testing	Drug Class A from CPT® for Presumptive Testing	
Alcohol (Ethanol)	Acetaminophen	
Amphetamine or methamphetamine	Carisoprodol/Meprobamate	
Barbiturates	Ethyl Glucuronide	
Benzodiazepines	Fentanyl	
Buprenorphine	Ketamine	
Cocaine metabolite	Meperidine	
Heroin metabolite	Methylphenidate	
Methadone	Nicotine/Cotinine	
Methadone metabolite (EDDP)	Salicylate	
Methamphetamine	Synthetic Cannabinoids	
Methaqualone	Tapentadol	
Methylenedioxymethamphetamine (MDMA)	Tramadol	
Opiates	Zolpidem	
Oxycodone	Not otherwise specified	
Phencyclidine		
Propoxyphene		
Tetrahydrocannabinol (THC) metabolites		
Tricyclic Antidepressants		
(d) 	Definitive Tests – Gas Chromatography/Mass Spectrometry (GC/MS) or Liquid Chromatography/Mass Spectrometry (LC/MS) – no Immunoassays
				(i)	Definitive qualitative or quantitative tests identify specific drug(s) and any associated metabolites, providing sensitive and specific results expressed as a concentration in ng/mL or as the identity of a specific drug.  Definitive quantitative tests must be ordered by a physician.  The reasons for ordering a definitive quantification drug test may include:
					a)	Unexpected positive presumptive or qualitative test results inadequately explained by the injured worker; 
					b)	Unexpected negative presumptive or qualitative test results and suspected medication diversion;
					c)	Differentiate drug compliance:
•	Buprenorphine vs. norbuprenorphine
•	Oxycodone vs. oxymorphone, noroxycodone and oxycodone
					d)	Need for quantitative levels to compare with established benchmarks for clinical decision-making, such as tetrahydrocannabinol (THC) quantitation to document discontinuation of a drug.
					e)	Chronic Opioid Management
						i)	Drug testing shall be done prior to the implementation of the initial long-term drug prescription and randomly repeated at least annually.
						ii)	While the injured worker is receiving chronic opioid management, additional drug screens with documented justification may be conducted.  Examples of documented justification include the following:
●	Concern regarding the functional status of the patient
●	Abnormal results on previous testing
●	Change in management of dosage or pain
●	Chronic daily opioid dosage above 150 mg of morphine or equivalent
		f)	Billing fees for definitive quantitative testing are listed in Exhibit #8. The following three codes and descriptions replace CPT® codes 80320-80377:
			G0481- Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g. IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g. alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity Page 4 of 21 testing, per day, 8-14 drug class(es), including metabolite(s) if performed.
			G0482- Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g. IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed.)
			G0483- Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed.Definitive Drug Classes from CPT®	
Alcohol(s)	Benzodiazepines	Opiates	
Alcohol Biomarkers	Buprenorphine	Opioids and opiate analogs	
Alkaloids, not otherwise Specified	Cannabinoids, natural	Oxycodone	
Amphetamines	Cannabinoids, synthetic	Phencyclidine	
Anabolic steroids	Cocaine	Pregabalin	
Analgesics, non-opioid	Fentanyls	Propoxyphene	
Antidepressants, serotonergic class	Gabapentin, non-blood	Sedative Hypnotics (nonbenzodiazepines)	
Antidepressants, Tricyclic and other cyclicals	Heroin metabolite	Skeletal muscle relaxants	
Antidepressants, not otherwise specified	Ketamine and Norketamine	Stereoisomer (enantiomer) analysis	
Antiepileptics, not otherwise specified 	Methadone	Stimulants, synthetic	
Antipsychotics, not otherwise specified	Methylenedioxyamphetamines	Tapentadol	
Barbiturates	Methylphenidate	Tramadol	
Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified	

(H)	Medicine: 
(1)	Medicine home therapy services in the RBRVS are not adopted.  For appropriate codes see section 18-6(M), Home Care Services.
(2)	Anesthesia qualifying circumstance values are reimbursed in accordance with the section 18-5(D)(1).
(3)	Biofeedback
Licensed medical and mental health professionals who provide biofeedback must practice within the scope of their training.  Non-licensed biofeedback providers must hold Clinical Certification from the BCIA, practice within the scope of their training, and receive a prior approval of their biofeedback treatment plan from the patient’s authorized treating physician, psychologist, or psychiatrist.  Professionals integrating biofeedback with any form of psychotherapy must be licensed as a psychologist, a social worker, a marriage or a family therapist, or a licensed professional counselor.  For purposes of this rule, “licensed” means holding a license issued by the Colorado Medical Board, the Colorado Board of Chiropractic Examiners, the Colorado Podiatry Board, the Colorado Dental Board, or a board of the Colorado Department of Regulatory Agencies (DORA).
Biofeedback treatment must be provided in conjunction with other psychosocial or medical interventions.  
All biofeedback providers shall document biofeedback instruments used during each visit (including, but not limited to, surface EMG, HRV, EEG, or temperature training), placement of instruments, and patient response, if sufficient time has passed. 
Maximum Fee Schedule values for biofeedback services shall be as follows: 
			CPT® Code 90901, Biofeedback training by any modality:	
			Non-facility RVU is 2.14, Facility RVU is 1.14
			CPT® Code 90911, Biofeedback peri/uro/rectal:			
			Non-facility RVU is 4.76, Facility RVU is 2.48
(4)	Appendix J of the 2016 CPT® identifies mixed, motor and sensory nerve conduction studies and their appropriate billing.  
(5)	Manipulation -- Chiropractic (DC), Medical (MD) and Osteopathic (DO):
(a)	Prior authorization for payment (see Rule 16-10) shall be obtained before billing for more than four body regions in one (1) visit.  Manipulative therapy is limited to the maximum allowed in Rule 17, Medical Treatment Guidelines.  The provider's medical records shall reflect medical necessity and prior authorization for payment (see Rule 16-10) if treatment exceeds these limitations.
(b)	An office visit may be billed on the same day as manipulation codes when the documentation meets the E&M requirement and an appropriate modifier is used.
(c)	Facility RVU is 0.79 and non-facility RVU is 1.00 for CPT® code 98940.
(6)	Psychiatric/Psychological Services:  
(a)	A licensed psychologist (PsyD, PhD, EdD) is reimbursed a maximum of 100% of the medical fee listed in the RBRVS.  Other non-physician providers performing psychological/psychiatric services shall be paid at 85% of the fee allowed for physicians.  
(b)	Prior authorization for payment (see Rule 16-10) is required any time the limitations discussed in this rule are exceeded on a single day.
The relative value weights for psychiatric diagnostic evaluations, with or without medical services, including time for internal records review, are as follows (per claim):
(i)	Without Evaluation & Management Service:
	Non-facility is 9.91 RVUs
	Facility is 9.6 RVUs
(ii)	With Evaluation and Management Service
	Non-facility is 11.12 RVUs
	Facility is 10.8 RVUs
			(c)	Central Nervous System (CNS) Assessments/Tests, (neuro-cognitive, mental status, speech) requiring more than six (6) hours require prior authorization. 
Brief psychological screens (including, but not limited to, the Distress Risk and Assessment Method (DRAM), Primary Care Evaluation of Mental Disorders (PRIME-MD), Zung Self-Rating Depression Scale, Beck Depression Inventory, and CES-D (Center for Epidemiologic Studies Depression Scale) are not equivalent to psychological testing, CPT® codes 96101-96127.
The RVUs for the following psychological and neuropsychological tests and for health and behavior assessments/interventions shall be modified to:

CPT® code	Non-facility Relative Value Units	Facility Relative Value Units	
96101	3.00	2.91	
96102	1.79	0.65	
96103	1.36	1.33	
96116	3.40	3.16	
96118	4.11	3.31	
96119	2.51	0.74	
96120	2.30	1.24	
96150	0.80	0.79	
96151	0.78	0.77	
96152	0.74	0.73	
96153	0.18	0.17	
96154	0.74	0.73	
96155	0.73	0.73	
Most initial evaluations for delayed recovery, exclusive of testing, can be completed in two (2) hours.  
(d)	The limit for psychotherapy services is 60 min. per visit.
Prior authorization for payment (see Rule 16-10) is required any time the 60 minutes per visit limitation is exceeded. The time for internal record review/documentation is included in this limit.  
Psychotherapy for work-related conditions requiring more than 20 visits or continuing for more than three (3) months after the initiation of therapy, whichever comes first, requires prior authorization for payment (see Rule 16-10) except where specifically addressed in Rule 17, Medical Treatment Guidelines.
(e)	When billing an evaluation and management (E&M) code in addition to psychotherapy:
(1)	Both services must be separately identifiable;
(2)	The level of E&M is based on history, exam and medical decision making;
(3)	Time may not be used as the basis for the E&M code selection; and 
(4)	Add-on psychotherapy codes are to be used by psychiatrists to indicate both services were provided.
Non-medical disciplines cannot bill most E&M codes.
(f) 	Upon request of a party to a workers’ compensation claim and pursuant to HIPAA Privacy regulations, a psychiatrist, psychologist or other qualified health care professional may generate a separate report and bill for that service using CPT® code 90889. A party to a claim may bill for any separate documentation under CPT® code 90889.  The relative value for this code is 1.4 RVUs for both facility and non-facility billings.

(7)	Qualified Non-Physician Provider Telephone or On-Line Services
Reimbursement to qualified non-physician providers for coordination of care with professionals shall be based upon the telephone codes for qualified non-physician providers found in the RBRVS Medicine Section.  Coordination of care reimbursement is limited to telephone calls made to professionals outside of the non-physician provider’s employment facility(ies) and/or to the injured worker or their family.
(8)	Quantitative Autonomic Testing Battery (ATB) and Autonomic Nervous System Testing.
(a)	Quantitative Sudomotor Axon Reflex Test (QSART) is a diagnostic test used to diagnose Complex Regional Pain Syndrome.  This test is performed on a minimum of two (2) extremities, and encompasses the following components:
(i)	Resting Sweat Test
(ii)	Stimulated Sweat Test
(iii)	Resting Skin Temperature Test
(iv)	Interpretation of clinical laboratory scores.  Physician must evaluate the patient specific clinical information generated from the test and quantify it into a numerical scale.  The data from the test and a separate report interpreting the results of the test must be documented.
(b)	Maximum fee when all of the services outlined in 18-5(G)(9)(a) are completed and documented.
QSART Billing Code 
DoWC Z0401	QSART		$1,007.00
Z0401 may only be billed once per workers’ compensation claim, regardless of the number of limbs tested.
(9)	Intra-Operative Monitoring (IOM)
IOM is used to identify compromise to the nervous system during certain surgical procedures.  Evoked responses are constantly monitored for changes that could imply damage to the nervous system. 
(a)	Clinical Services for IOM: Technical and Professional
(i)	Technical staff:  A qualified specifically trained technician shall setup the monitoring equipment in the operating room and is expected to be in constant attendance in the operating room with the physical or electronic capacity for real-time communication with the supervising neurologist or other physician trained in neurophysiology.  The technician shall be specifically trained/registered with:
The American Society of Neurophysiologic Monitoring; or
The American Society of Electrodiagnostic Technologists
(ii)	Professional/Supervisory /Interpretive
A specifically neurophysiology trained Colorado licensed physician shall monitor the patient’s nervous system throughout the surgical procedure.  The monitoring physician’s time is billed based upon the actual time the physician devotes to the individual patient, even if the monitoring physician is monitoring more than one (1) patient.  The monitoring physician’s time does not have to be continuous for each patient and may be cumulative.  The monitoring physician shall not monitor more than three (3) surgical patients at one time.  The monitoring physician shall provide constant neuromonitoring at critical points during the surgical procedure as indicated by the surgeon or any unanticipated testing responses.  There must be a neurophysiology trained Colorado licensed physician backup available to continue monitoring the other two patients if one of the patients being monitored has complications and/or requires the monitoring physician’s undivided attention for any reason.  There is no additional payment for the back-up neuromonitoring physician, unless he/she is utilized in a specific case.
(iii)	Technical Electronic Capacity for Real-time Communication requirements
The electronic communication equipment shall use a 16-channel monitoring and minimum real-time auditory system, with the possible addition of video connectivity between monitoring staff, operating surgeon and anesthesia.  The equipment must also provide for all of the monitoring modalities that may be applied with the IOM procedure code.
(b)	Procedures and Time Reporting
Physicians shall include an interpretive written report for all primary billed procedures.
			(c)	Billing Restrictions:
The technical component (equipment, technical certified staff) is only payable to the person who owns the equipment.
The monitoring physician is the only billing party allowed to report the intraoperative neuro-monitoring codes (95940 or 95941).
 (10)	Speech Therapy/Evaluation and Treatment
Speech-language therapist/pathology or any care rendered under a speech-language therapist/pathology plan of care shall be billed with a “GN” modifier appended to all billing codes.
Reimbursement shall be according to the unit values as listed in the RBRVS, multiplied by their section’s respective CF.
(11)	Vaccine and Toxoids
Shall be billed using the appropriate J code or CPT® code listed in the Medicare Part B Drug Average Sale Price (ASP), or at cost to the billing provider if no dollar value is listed in ASP.
(12)	IV Infusions Performed in Physicians’ Offices or Sent Home with Patient
IV infusion therapy performed in a physician’s office shall be billed under the “Therapeutic, Prophylactic, and Diagnostic Injections and Infusions” and the “Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration” in the Medicine Section of CPT®.  The appropriate CPT®/RBRVS code units multiplied by the Medicine conversion factor is the Maximum Fee Schedule value for the infusion service. The infused therapeutic drugs are payable at cost to the provider’s office.
		Maximum fees for supplies and medications provided by a physician's office for self-administered home care infusion therapy is covered under section 18-6(M)(1).
	(13)	Special Services, Procedures and Reports in the Medicine Section of CPT®
		(a)	Handling and conveyance of specimens in connection with a transfer from an office to a laboratory is a flat rate of $25.00 (CPT codes 99000 and/or 99001).  Any other handling and conveyance in connection with implementation of an order involving devices (such as orthotics) is a flat rate of $13.00 (CPT code 99002).
		(b)	Postoperative follow-up visit, CPT code 99024, is included in the global package and is not separately payable.
		(c)	Educational supplies are considered “at cost” to the provider and may be billed based upon an agreement between the payer and provider (CPT codes 99070, 99071 or 99078).
		(d)	Any stored clinical or physiological data analysis is not recognized unless the provider shows the reasonableness and necessity of these services and obtains prior authorization from the payer (CPT codes 99090 and 99091).   
		(e)	The charges for services performed after regular business hours, during holidays, or during scheduled disruptions of regular office services are not separately payable unless the provider shows the reasonableness and necessity of these services and obtains prior authorization (CPT codes 99026, 99027, 99050, 99051, 99053, 99056, 99058, and 99060). 
 		(f)	Unusual travel expenses require prior authorization by the payer.  The payer and billing provider shall agree upon maximum fees (CPT code 99082). 
(g)	Medical testimony is covered under Rule 18-6(D) and special reports are covered under Rule 18-6(G)(3)&(4) (CPT codes 99075 and 99080). 
 (I)	Physical Medicine and Rehabilitation (PM&R): 
Restorative services are an integral part of the healing process for a variety of injured workers.
 (1)	Billing and documentation requirements:
Physical therapy or any care provided under a physical therapist’s plan of care shall be billed with a “GP” modifier appended to all billed codes.
Occupational therapy or any care provided under an occupational therapist’s plan of care shall be billed with a “GO” modifier appended to all billed codes.
Each PM&R billed service must be clearly identifiable.  The provider must clearly document the time spent performing each billed service and the beginning and ending time for each session.
	Functional objectives shall be included in the PM&R plan of care for all injured workers, in compliance with Rule 16-8.  Any request for additional treatment must be supported by evidence of positive objective functional gains or PM&R treatment plan changes.  The ordering PM&R ATP must also agree with the PM&R continuation or changes to the treatment plan.
(2)	Prior authorization for payment (see Rule 16-10) is required for medical nutrition therapy.  
(3)	For recommendations on the use of the physical medicine and rehabilitation procedures, modalities, and testing, see Rule 17, Medical Treatment Guidelines.
(4)	Special Note to All Physical Medicine and Rehabilitation Providers:
	The authorized treating provider shall obtain prior authorization for payment (see Rule 16-10) from the payer for any physical medicine or rehabilitation treatment not listed in or exceeding the frequency or duration recommendations in Rule 17, Medical Treatment Guidelines.
	The injured worker shall be re-evaluated by the prescribing physician within 30 calendar days from the initiation of the prescribed treatment and at least once every month while that treatment continues to establish achievement of functional goals.  Prior authorization for payment (see Rule 16-10) shall be required for treatment of a condition not covered under Rule 17, Medical Treatment Guidelines and exceeding 60 calendar days from the initiation of treatment.  
(5)	Interdisciplinary Rehabilitation Programs – Requires Prior Authorization for Payment (see Rule 16-10).
	An interdisciplinary rehabilitation program is one that provides focused, coordinated, and goal-oriented services using a team of professionals from varying disciplines to deliver care.  These programs can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning.  As defined in Rule 17, Medical Treatment Guidelines, interdisciplinary rehabilitation programs may include, but are not limited to:  chronic pain, spinal cord, or brain injury programs.
		Billing Restrictions: All billing providers shall detail to the payer the services, frequency of services, duration of the program and their proposed fees for the entire program and all professionals.  The billing provider and payer shall attempt to mutually agree upon billing code(s) and fee(s) for each interdisciplinary rehabilitation program.
	If there is a single billing provider for the entire interdisciplinary rehabilitation program and a daily per diem rate is mutually agreed upon, use billing code Z0500.
	If the individual interdisciplinary rehabilitation professionals bill separately for their participation in an interdisciplinary rehabilitation program, the applicable CPT® codes shall be used to bill for their services.  Demonstrated participation in an interdisciplinary rehabilitation program allows the use of the frequencies and durations listed in the relevant Medical Treatment Guideline’s recommendations.
(6)	Procedures (therapeutic exercises, neuromuscular re-education, aquatic therapy, gait training, massage, acupuncture, dry needling of trigger points, manual therapy techniques, therapeutic activities, cognitive development, sensory integrative techniques and any unlisted physical medicine procedures.)
	The provider’s medical records shall reflect the medical necessity and the provider shall obtain prior authorization for payment (see Rule 16-10) if the procedures are not recommended or the frequency and duration exceeds the recommendations of the Rule 17, Medical Treatment Guidelines.  The maximum amount of time allowed is one (1) hour of procedures per day, per discipline; unless medical necessity is documented and prior authorization is obtained from the payer.
Unlisted procedure CPT code 97139 value is equal to the value for therapeutic exercises.  
Dry Needling of Trigger Points, Single or multiple needles, 
DoWC Z0501 -	initial 15 minutes of dry needling		1.3 non-facility RVUs 
						.77 facility RVUs 
DoWC Z0502 - each add’l 15 minutes of dry needling 	.77 non-facility RVUs
						.72 facility RVUs
(7)	Modalities
RBRVS Timed and Non-timed Modalities 
Billing Restrictions:  There is a total limit of two (2) modalities (whether timed or non-timed) per visit, per discipline, per day.
NOTE:  Instruction and application of a transcutaneous electric nerve stimulation (TENS) unit for the patient's independent use at home shall be billed only once using CPT® code 64550.  Rental or purchase of a TENS unit requires prior authorization for payment (see Rule 16-10).  For Maximum Fee Schedule value, see 18-6(H).
The maximum value for any unlisted modality, CPT® code 97039, is equal to the value of ultrasound CPT® code 97035.
(8)	Evaluation Services for Therapists:  Physical Therapy (PT), Occupational Therapy (OT) and Athletic Trainers (ATC).
(a)	All evaluation services must be supported by the appropriate history, physical examination documentation, treatment goals and treatment plan or re-evaluation of the treatment plan.  The provider shall clearly state the reason for the evaluation, the nature and results of the physical examination of the patient, and the reasoning for recommending the continuation or adjustment of the treatment protocol.  Without appropriate supporting documentation, the payer may deny payment.  The re-evaluation codes shall not be billed for routine pre-treatment patient assessment.
If a new problem or abnormality is encountered that requires a new evaluation and treatment plan, the professional may perform and bill for another initial evaluation.  A new problem or abnormality may be caused by a surgical procedure being performed after the initial evaluation has been completed.
A reexamination, reevaluation, or reassessment (CPT® codes 97002, 97004, or 97006) are different from a progress note.  Therapists should not bill these codes for a progress note.  Therapists may bill CPT® codes 97002, 97004, or 97006 for a reevaluation only in the following cases:
●	Professional assessment indicates a significant improvement or decline or change in the patient’s condition or a functional status that was not anticipated in the Plan of Care (POC) for that time interval.
●	New clinical findings come to light.
●	The patient fails to respond to the treatment outlined in the current POC.
PT and OT and Athletic Trainer Evaluation and Re-Evaluation RVU changes are as follows:
				●	CPT® code 97001 PT and 97003 OT Initial Evaluation = 2.48 RVUs, facility and non-facility;
				●	CPT® code 97005 Athletic Trainer Initial Evaluation is 85% of the PT/OT initial evaluation service value; 
				●	CPT® code 97002 PT and 97004 OT Re-Evaluation = 1.68 RVUs, facility and non-facility;  
				●	CPT® code 97006 Athletic Trainer re-evaluation is 85% of the PT/OT reevaluation value. 
(b)	A PT or OT may utilize a Rehabilitation Communication Form (WC 196) in addition to a progress note every 2 weeks.  The WC 196 form should not be used for an evaluation, reevaluation or reassessment.  The WC 196 form must be completed and sent to the referring physician before the patient's follow up appointment with the physician.

Billing code DoWC Z0817 - $15.00
(c)	Payers are only required to pay for evaluation services directly performed by a PT, OT, or ATC.  All evaluation notes or reports must be written and signed by the PT, OT or ATC.  Physicians shall bill the appropriate E&M code from the E&M section of the RBRVS.
(d)	A patient may be seen by more than one (1) health care professional on the same day.  An evaluation service with appropriate documentation may be charged by each professional per patient, per day.
(e)	Reimbursement to PTs and OTs for coordination of care with professionals shall be based upon the telephone codes for qualified non-physician providers found in the RBRVS Medicine Section.  Coordination of care reimbursement is limited to telephone calls made to outside professionals and/or to the injured worker or their family.
(f)	All interdisciplinary team conferences shall be billed in compliance with section18-5(I)(5).
(9)	Special Tests 
(a)	The following respective tests are considered special tests: 
•	Job Site Evaluation 
•	Functional Capacity Evaluation
•	Assistive Technology Assessment
•	Speech
•	Computer Enhanced Evaluation (DoWC Z0503)
•	Work Tolerance Screening (DoWC Z0504)  
The facility and non-facility RVUs for DoWC Z0503 and DoWC Z0504 shall be 0.93.
(b)	Billing Restrictions:
(i)	Job Site Evaluations require prior authorization for payment (see Rule 16-10) if exceeding two (2) hours. Computer-Enhanced Evaluations and Work Tolerance Screenings require prior authorization for payment for more than four (4) hours per test or more than three (3) tests per claim.  Functional Capacity Evaluations require prior authorization for payment for more than four (4) hours per test or two (2) tests per claim.
(ii)	The provider shall specify the time required to perform the test in 15-minute increments.
(iii)	The value for the analysis and the written report is included in the code’s value.
(iv)	No E&M services or PT, OT, or acupuncture evaluations shall be charged separately for these tests.
(v)	Data from computerized equipment shall always include the supporting analysis developed by the physical medicine professional before it is payable as a special test.
(c)	Provider Restrictions: all special tests must be fully supervised by a physician, PT, OT, speech language pathologist/therapist or audiologist.  Final reports must be written and signed by the physician, PT, OT, speech language pathologist/therapist or audiologist.
(10)	Supplies 
Physical medicine supplies are reimbursed in accordance with section18-6(H).
(11)	Unattended Treatment
When a patient uses a facility or its equipment for unattended procedures, in an individual or a group setting, bill:
DoWC Z0505     fixed fee per day                        0.232 RVU
(12)	Non-Medical Facility
Fees, such as gyms, pools, etc., and training or supervision by non-medical providers require prior authorization for payment (see Rule 16-10) and a written negotiated fee.
(13)	Unlisted Service Physical Medicine
All unlisted services or procedures require a report.
(14)	Work Conditioning, Work Hardening, Work Simulation
(a)	Work conditioning is a non-interdisciplinary program that is focused on the individual needs of the patient to return to work.  Usually one (1) discipline oversees the patient in meeting goals to return to work.  Refer to Rule 17, Medical Treatment Guidelines.
Restriction:  Maximum daily time is two (2) hours per day without additional prior authorization for payment (see Rule 16-10).
(b)	Work Hardening is an interdisciplinary program that uses a team of disciplines to meet the goal of employability and return to work.  This type of program entails a progressive increase in the number of hours a day that an individual completes work tasks until they can tolerate a full workday.  In order to do this, the program must address the medical, psychological, behavioral, physical, functional and vocational components of employability and return to work.  Refer to Rule 17, Medical Treatment Guidelines.
Restriction:  Maximum daily time is six (6) hours per day without additional prior authorization for payment (see Rule 16-10).  
(c)	Work Simulation is a program where an individual completes specific work-related tasks for a particular job and return to work.  Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision.  The need for work simulation should be based upon the results of a functional capacity evaluation and/or job analysis.  Refer to Rule 17, Medical Treatment Guidelines.
(d)	For Work Conditioning, Work Hardening, or Work Simulation, the following apply:
(i)	The provider shall submit a treatment plan including expected frequency and duration of treatment.  If requested by the provider, the payer will prior authorize payment for the treatment plan services or shall identify any concerns including those based on the reasonableness or necessity of care.
(ii)	If the frequency and duration is expected to exceed the Medical Treatment Guidelines’ recommendation, prior authorization for payment is required (see Rule 16-10).
(iii)	Provider Restrictions:  All procedures must be performed by or under the onsite supervision of a physician, psychologist, PT, OT, speech language pathologist or audiologist.
(e)	Work Hardening/Conditioning/Simulation Billing codes and RVUs:
				●	CPT® code 97545 Initial 2 hours, 3.4 RVUs 
				●	CPT® code 97546 Each additional hour, 1.7 RVUs
		(15)	Wound Care
Wound care is separately payable only when devitalized tissue is debrided using a recognized method (chemical, water, vacuums).  CPT® code 97602 is not recognized for payment.
(J)	Evaluation and Management Section (E&M)
(1)	Evaluation and management codes may be billed by medical providers as defined in Rule 16-5(A)(1)(a) as well as nurse practitioners (NP) and physician assistants (PA).  Medical record documentation shall encompass the “E&M Documentation Guidelines” criteria as adopted in Exhibit #7 of this Rule or Medicare’s 1997 Evaluation and Management Documentation Guidelines, to justify the billed level of E&M service.  If greater than 50% of the time spent for an E&M visit is shared decision making, disability counseling or coordination of care, then time can determine the level of E&M service.  Documented telephonic or on-line communication time with the patient or other healthcare providers one (1) day prior or seven (7) days following the scheduled E&M visit, may be included in the calculation of total time.
Disability counseling should be an integral part of managing workers’ compensation injuries.  The counseling shall be completely documented in the medical records, including, but not limited to, the amount of time spent with the injured worker and the specifics of the discussion as it relates to the individual patient.  Disability counseling shall include, but not be limited to, return to work, temporary and permanent work restrictions, self-management of symptoms while working, correct posture/mechanics to perform work functions, job task exercises for muscle strengthening and stretching, and appropriate tool and equipment use to prevent re-injury and/or worsening of the existing injury.
(2)	New or Established Patients
An E&M visit shall be billed as a “new” patient service for each “new injury” even though the provider has seen the patient within the last three (3) years.  Any subsequent E&M visits are to be billed as an “established patient” and reflect the level of service indicated by the documentation when addressing all of the current injuries. 
Transfer of care from one physician to another with the same tax ID and the same specialty shall be billed as an “established patient” regardless of the location.         
(3)	Number of Office Visits
All providers are limited to one (1) office visit per patient, per day, per workers’ compensation claim, unless prior authorization for payment is obtained (see Rule 16-10).  The E&M Guideline criteria as specified in the RBRVS E&M Section shall be used in all office visits to determine the appropriate level.
(4)	Treating Physician Telephone or On-line Services
Telephone or on-line services may be billed if: 
(a)	The service is performed more than one (1) day prior to a related E&M office visit, or
(b)	The service is performed more than seven (7) days following a related E&M office visit, and 
(c)	The medical records/documentation specifies all the following:
(i)	The amount of time and date;
(ii)	The patient, family member, or healthcare provider talked to; and
(iii)	The specifics of the discussion and/or decision made during the communication. 
(5)	Face-to-Face or Telephonic Treating Physician or Qualified Non-physician Medical Team Conferences
A medical team conference can only be billed if all of the criteria are met under CPT®.   A medical team conference shall consist of medical professionals caring for the injured worker. 
The billing statement shall be prepared in accordance with Rule 16, Utilization Standards.
(6)	Face -to-face or telephonic meeting by a non-treating physician with the employer, claim representatives or any attorney in order to provide a medical opinion on a specific workers’ compensation case, which is not accompanied by a specific report or written record. 
Billing Code DoWC Z0601:	$65.00 per 15 minutes billed to the requesting party.
(7)	Face-to-face or telephonic meeting by a non-treating physician with the employer, claim representatives or any attorney in order to provide a medical opinion on a specific workers’ compensation case, which is accompanied by a report or written record, shall be billed as a special report (see section 18-6(G)(4)).
(8)	Consultation/Referrals/Transfers of Care/Independent Medical Examinations 
	A consultation occurs when a treating physician seeks an opinion from another physician regarding a patient’s diagnosis or treatment.  
	A transfer of care occurs when one physician turns over the responsibility for the comprehensive care of a patient to another physician.
	An independent medical exam (IME) occurs when a physician is requested to evaluate a patient by any party or party’s representative and is billed in accordance with section 18-6(G).
	In order to bill for any of the inpatient or outpatient consultation codes (99241-99255) the following criteria must be documented in the billing providers report:
•	Identification of the requesting physician for the opinion.
•	Documentation in the report supports the need for a consultant’s opinion.
•	Identification the report was submitted to the requesting provider (either carbon copied or written directly to the requesting provider).
	Outpatient Consultation RVUs:
	CPT® 99241 non-facility = 2.57; facility = 2.15
	CPT® 99242 non-facility = 3.77; facility = 3.18
	CPT® 99243 non-facility = 4.71; facility = 3.96
	CPT® 99244 non-facility = 6.39; facility = 5.57
	CPT® 99245 non-facility = 8.15; facility = 7.23
	Inpatient Consultation facility RVUs:
	CPT® 99251 = 2.79
	CPT® 99252 = 3.83
	CPT® 99253 = 4.95
	CPT® 99254 = 6.39
	CPT® 99255 = 8.47
	Subsequent Inpatient Hospital RVU changes are as follows:
	CPT® 99231 = 2.21 RVUs
	CPT® 99232 = 3.15 RVUs
	CPT® 99233 = 4.22 RVUs
(9)	When billing for prolonged services, either face-to-face or non-face-to-face, the provider shall provide a report that documents time distinguishable from the E&M visit.
(K)	Telehealth 
(1)        “Telehealth” is defined in Rule 16­2(X). All healthcare services provided through telehealth shall comply with the applicable requirements found in the Colorado Medical Practice Act and Colorado Mental Health Practice Act, as well as the rules and policies adopted by the Colorado Medical Board and the Colorado State Board of Psychologist Examiners.
	
(2)	Telehealth facilities can bill for the originating fee as follows:
	Q3014 		 $35.00 /per 15 minutes
A private residence at which an injured worker is located when he or she is receiving healthcare services through telehealth may not bill for the originating fee.
(3)	HIPAA privacy and electronic security standards are required for both the originating site and the rendering providers. 
(a)	Protecting patient health information, and patient / client decision making and consent are vital.
(b)	Policies and procedures need to be in place to protect the electronic security of data, and the physical security of telehealth equipment so that patient health information is protected. 
(c)	Compliance with accreditation requirements, regulations, and relevant legislation is necessary. 
(d)	Health professionals providing telehealth services shall be fully licensed, registered, and credentialed by the appropriate governing agency.
(4)	All telehealth procedures are required to be at an originating site that is deemed appropriate with the appropriate HIPAA privacy and electronic security standards in place.  The originating site is responsible for establishing and verifying injured worker and provider identity.  Authorized originating sites include:
(a)	The office of a physician or practitioner
(b)	A hospital (inpatient or outpatient)
(c)	A critical access hospital (CAH)
(d)	A rural health clinic (RHC)
(e)	A federally qualified health center (FQHC)
(f)	A hospital based or critical access hospital based renal dialysis center (including satellites)
(g)	A skilled nursing facility (SNF)
(h)	A community mental health center (CMHC)

 (5)	The physician-patient / psychologist-patient relationship needs to be established.
(a)	This relationship is established through assessment, diagnosis and treatment of the patient.  Two way live audio / video services are among acceptable methods to ‘establish' a patient relationship.
(b)	Physicians / psychologists need to meet standard of care.

(c)         The patient is required to provide the appropriate consent for treatment.
 (6)	Payment for telehealth services from distant site practitioners
(a)	The medical providers shall bill codes G0425-G0427 for telehealth consultations, emergency department or initial inpatient.  The maximum fee values are determined by multiplying the RBRVS RVUs and the E&M conversion factor listed in Rule 18-4.
 (b)	The medical providers shall bill codes G0406-G0408 for follow up inpatient telehealth consultations.  The maximum fee values are determined by multiplying the RBRVS RVUs and the E&M conversion factor listed in Rule 18-4. 
	
(c)        For all telehealth services, the provider shall bill the appropriate RBRVS CPT® code with the GT modifier.  Reimbursement is the RVU value for the CPT® code times the appropriate CF + $5.00 when modifier GT is appended to the appropriate CPT® code(s).
GT –     Attached to the distance (rendering) provider billed CPT® or HCPCS indicates the service was performed via telehealth.  Using the modifier certifies that the patient was present at an eligible originating site when the telehealth service was furnished. 

18-6	DIVISION ESTABLISHED CODES AND VALUES 
(A)	Face-to-face or telephonic meeting by a treating physician with the employer, claim representatives, or any attorney, and with or without the injured worker.  Claim representatives may include physicians or qualified medical personnel performing payer-initiated medical treatment reviews, but this code does not apply to requests initiated by a provider for prior authorization for payment (see Rule 16-10).
Before the meeting is separately payable, the following requirements must be met:
(1)	Each meeting shall be at a minimum 15 minutes.  
(2)	A report or written record signed by the physician is required and shall include the following:
(a)	Who was present at the meeting and their role at the meeting;
(b)	Purpose of the meeting;
(c)	A brief statement of recommendations and actions at the conclusion of the meeting;
(d)	Documented time (both start and end times); and
(e)	Billing code DoWC Z0701. 
$75.00 per 15 minutes for time attending the meeting and preparing the report (no travel time or mileage is separately payable).  The fee includes the cost of the report for all parties, including the injured worker.
(B)	Cancellation Fees for Payer Made Appointments
(1)	A cancellation fee is payable only when a payer schedules an appointment the injured worker fails to keep, and the payer has not canceled three (3) business days prior to the appointment.  The payer shall pay:
One-half of the usual fee for the scheduled services, or $150.00, whichever is less.
Cancellation Fee Billing Code:     DoWC Z0720 
(2)	Missed Appointments:
When claimants fail to keep scheduled appointments, the provider should contact the payer within two (2) business days.  Upon reporting the missed appointment, the provider may request whether the payer wishes to reschedule the appointment for the claimant.  If the claimant fails to keep the payer’s rescheduled appointment, the provider may bill for a cancellation fee according to section 18-6(B).
(C)	Copying Fees
The payer, payer's representative, injured worker and injured worker's representative shall pay a reasonable fee for the reproduction of the injured worker's medical record.  If the requester and provider agree, the copy may be provided on a disc.  If the requester and provider agree and appropriate security is in place, including, but not limited to, compatible encryption, the copies may be submitted electronically.  Requester and provider should attempt to agree on a reasonable fee.  Absent an agreement to the contrary, the fee shall be $0.10 per page.
Copying charges do not apply for the initial submission of records that are part of the required documentation for billing.
Copying Fee Billing Codes and Maximum Fees:           
DoWC Z0721 - $18.53 for first 10 or fewer paper page(s)
DoWC Z0725 - $0.85 per paper page for the next 11-40 paper page(s)
DoWC Z0726 - $0.57 per paper page for remaining paper page(s)
DoWC Z0727 - $1.50 per microfilm page
		DoWC Z0728 - $14.00 per computer disc or as agreed
		DoWC Z0729 - $0.10 per electronic page or as agreed
		DoWC Z0802 – actual postage paid
(D)	Deposition and Testimony Fees
(1)	When requesting deposition or testimony from physicians or any other type of provider, guidance should be obtained from the Interprofessional Code, as prepared by the Colorado Bar Association, the Denver Bar Association, the Colorado Medical Society and the Denver Medical Society.  If the parties cannot agree upon lesser fees for the deposition or testimony services, or cancellation time frames and/or fees, the following deposition and testimony rules and fees shall be used.
If, in an individual case, a party can show good cause to an Administrative Law Judge (ALJ) for exceeding the Maximum Fee Schedule value, that ALJ may allow a greater fee than listed in section 18-6(D) for that case.
(2)	By prior agreement, the provider may charge for preparation time for a deposition, for reviewing and signing the deposition or for preparation time for testimony.
Preparation Time: 
Treating or Non-treating Provider: DoWC Z0730		$325.00 per hour
(3)	Deposition:
Payment for a treating or non-treating provider’s testimony at a deposition shall not exceed $325.00 per hour, billed in half-hour increments.  Calculation of the provider’s time shall be "portal to portal."
If requested, the provider is entitled to a full hour deposit in advance in order to schedule the deposition.
If the provider is notified of the cancellation of the deposition at least seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours s/he has reasonably spent in preparation and shall refund to the deposing party any portion of an advance payment in excess of time actually spent preparing and/or testifying. Bill using code DoWC Z0731.
If the provider is notified of the cancellation of the deposition at least five (5) business days but less than seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours s/he has reasonably spent in preparation and one-half the time scheduled for the deposition. Bill using code DoWC Z0732.
If the provider is notified less than five (5) business days in advance of a cancellation, or the deposition is shorter than the time scheduled, the provider shall be paid the number of hours s/he has reasonably spent in preparation and has scheduled for the deposition. Bill using code DoWC Z0733.
Deposition: 
Treating or Non-treating provider:  DoWC Z0734		$325.00 per hr.
Billed in half-hour increments
(4)	Testimony:
Calculation of the provider’s time shall be "portal to portal” (includes travel time and mileage in both directions).
For testifying at a hearing, if requested,	 the provider is entitled to a four (4) hour deposit in advance in order to schedule the testimony.
If the provider is notified of the cancellation of the testimony at least seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours s/he has reasonably spent in preparation and shall refund any portion of an advance payment in excess of time actually spent preparing and/or testifying. Bill using code DoWC Z0735.
If the provider is notified of the cancellation of the testimony at least  five (5) business days but less than seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours s/he has reasonably spent in preparation and one-half the time scheduled for the testimony. Bill using code DoWC Z0736.
If the provider is notified of a cancellation less than five (5) business days prior to the date of the testimony or the testimony is shorter than the time scheduled, the provider shall be paid the number of hours s/he has reasonably spent in preparation and has scheduled for the testimony. Bill using code DoWC Z0737.
Testimony:                    
Treating or Non-treating provider:    DoWC Z0738  	$450.00 per hour
(E)	Injured Worker Travel Expenses
The payer shall pay an injured worker for reasonable and necessary expenses for travel to and from medical appointments and reasonable mileage to obtain prescribed medications.  The rate for mileage shall be 53 cents per mile.  The injured worker shall submit a request to the payer showing the date(s) of travel and mileage, with an explanation for any other reasonable and necessary travel expenses incurred or anticipated.
Mileage Expense Billing Code:    DoWC Z0723
Other Travel Expenses Billing Code:  DoWC Z0724
(F)	Permanent Impairment Rating
(1)	The payer is only required to pay for one (1) combined whole-person permanent impairment rating per claim, except as otherwise provided in the Workers' Compensation Rules of Procedures.  Exceptions that may require payment for an additional impairment rating include, but are not limited to, reopened cases, as ordered by the Director or an Administrative Law Judge, or a subsequent request to review apportionment.  The authorized treating provider is required to submit in writing all permanent restrictions and future maintenance care related to the injury or occupational disease.
(2)	Provider Restrictions
The permanent impairment rating shall be determined by the Level II Accredited Authorized Treating Physician (see Rule 5-5(D)).
(3)	Maximum Medical Improvement (MMI) Determined Without any Permanent Impairment
When physicians determine the injured worker is at MMI and has no permanent impairment, the physicians should be reimbursed an appropriate level of E&M service. The authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient should complete the Physician’s Report of Workers’ Compensation Injury (Closing Report), WC164 (see section 18-6(G)(2)).  Reimbursement for the appropriate level of E&M service is only applicable if the physician examines the injured worker and meets the criteria as defined in the RBRVS
(4)	MMI Determined with a Calculated Permanent Impairment Rating
(a)	Calculated Impairment:  The total fee includes the office visit, a complete physical examination, complete history, review of all medical records except when the amount of medical records is extensive (see below), determining MMI, completing all required measurements, referencing all tables used to determine the rating, using all report forms from the AMA's Guide to the Evaluation of Permanent Impairment, Third Edition (Revised), (AMA Guides), and completing the Division form, titled Physician's Report of Workers’ Compensation Injury (Closing Report) WC164.
Extensive medical records take longer than one (1) hour to review and a separate report is created.  The separate report must document each record reviewed, specific details of the record reviewed and the dates represented by the record(s) reviewed.  The separate record review can be billed under special reports for written reports only and requires prior authorization and agreement from the payer for the separate record review fees.
(b)	Use the appropriate DoWC code:
1)	Fee for the Level II Accredited Authorized Treating Physician Providing Primary Care:
Bill DoWC Z0759 $355.00.
2)	Fee for the Referral, Level II Accredited Authorized Physician:
Bill DoWC Z0760 $575.00.
(3)	A return visit for a range of motion (ROM) validation shall be reimbursed using the appropriate separate procedure CPT® code in the medicine section of the RBRVS.
4)	Fee for a Multiple Impairment Evaluation Requiring More Than One (1) Level II Accredited Physician:
All physicians providing consulting services for the completion of a whole person impairment rating shall bill using the appropriate E&M consultation code and shall forward their portion of the rating to the authorized physician determining the combined whole person rating.
(G)	Report Preparation
(1)	Routine Reports
Providers shall submit routine reports free of charge as directed in Rule 16-7(E) and by statute.  Requests for additional copies of routine reports and for reports not in Rule 16-7(E) or in statute are reimbursable under the copying fee section of this Rule. Routine reports include:

•	Diagnostic testing 
•	Procedure reports
•	Progress notes
•	Office notes 
•	Operative reports
•	Supply invoices, if requested by the payer
 (2)	Completion of the Physician’s Report of Workers’ Compensation Injury (WC164)
(a)	Initial Report
The authorized treating physician (generally the designated or selected physician)  managing the total workers’ compensation claim of the patient completes the initial WC164 and submits it to the payer and to the injured worker after the first visit with the injured worker.  When applicable, the emergency department or urgent care authorized treating physician for this workers’ compensation injury may also create a WC164 initial report.  Unless requested or prior authorized by the payer in a specific workers’ compensation claim, no other authorized physician should complete and bill for the initial WC164 form. This form shall include completion of items 1-7 and 10.  Note that certain information in Item 2 (such as Insurer Claim #) may be omitted if not known by the provider.
(b)	Closing Report
The WC164 closing report is required from the authorized treating physician (generally the designated or selected physician)  managing the total workers’ compensation claim of the patient when the injured worker is at maximum medical improvement for all injuries or diseases covered under this workers’ compensation claim, with or without a permanent impairment.  The form requires the completion of items 1-5, 6 b-c, 7, 8 and 10.  If the injured worker has sustained a permanent impairment, then item 9 must be completed and the following additional information shall be attached to the bill at the time MMI is determined:
(i)	All necessary permanent impairment rating reports, medical reports and narrative relied upon bythe authorized treating physician(ATP), when the ATP (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is Level II Accredited, or
(ii)	The name of the Level II Accredited Physician requested to perform the permanent impairment rating when a rating is necessary and the ATP (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is not determining the permanent impairment rating.
(c)	Payer Requested WC164 Report 
If the payer requests a provider complete the WC164 report, the payer shall pay the provider for the completion and submission of the completed WC164 report.
(d)	Provider Initiated WC164 Report 
If a provider wants to use the WC164 report as a progress report or for any purpose other than those designated in section18-6(G)(2)(a), (b) or (c), and seeks reimbursement for completion of the form, the provider shall get prior approval from the payer.
(e)	Billing Codes and Maximum Allowance for completion and submission of WC164 report 
Maximum allowance for the completion and submission of the WC164 report is:
DoWC Z0750  	$47.00	Initial Report
DoWC Z0751	$47.00	Progress Report (Payer Requested or Provider Initiated)
DoWC Z0752	$47.00	Closing Report
DoWC Z0753	$47.00	Initial and Closing Reports are completed on the
		same form for the same date of service
(3)	Request for physicians to complete additional forms sent to them by a payer or employer shall be paid by the requesting party.  A form requiring 15 minutes or less of a physician’s time shall be billed pursuant to (a) and (b) below.  Forms requiring more than 15 minutes shall be paid as a special report.
(a)	Billing Code Z0754 
(b)	Maximum fee is $47.00 per form completion
(4)	Special Reports
Description:  The term special reports includes reports not otherwise addressed under Rule 16, Utilization Standards, Rule 17, Medical Treatment Guidelines and Rule 18, including any form, questionnaire or letter with variable content.  This includes, but is not limited to, independent medical evaluations (Z0756, Z0770 and Z0771) or reviews when the physician is requested to review files and examine the patient to provide an opinion for the requesting party, performed outside C.R.S. §8-42-107.2 (the Division IME process) and treating or non-treating medical reviewers or evaluators producing written reports pertaining to injured workers not otherwise addressed.  Special reports also include payment for meeting, reviewing another’s written record, and amending or signing that record (see section 18-5(I)(7)).  Reimbursement for preparation of special reports or records shall require prior agreement with the requesting party.  
Billable Hours:  Because narrative reports may have variable content, the content and total payment shall be agreed upon by the provider and the report's requester before the provider begins the report.
Advance Payment:  If requested, the provider is entitled to a two (2) hour deposit in advance in order to schedule any patient exam associated with a special report.    
Cancellation:
Written Reports Only:  In cases of cancellation for those special reports not requiring a scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation up to the date of cancellation.  Bill the cancellation using DoWC code Z0761.
IME/report with patient exam:  In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation at least seven (7) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and shall refund to the party requesting the special report any portion of an advance payment in excess of time actually spent preparing.  Bill the cancellation using DoWC code Z0762.
In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation at least five (5) business days but less than seven (7) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and one-half the time scheduled for the patient exam.  Any portion of a deposit in excess of this amount shall be refunded.  Bill the cancellation using DoWC code Z0763.
In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation less than five (5) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and has scheduled for the patient exam. Bill the cancellation using DoWC code Z0764.
	Billing Codes:
Written Report Only 		DoWC Code:	Z0755
Respondent requested Independent Medical Examination (RIME)/Report with patient exam	 	DoWC Code:	Z0756
CRS 8-43-404 requires RIMEs to be recorded in audio in their entirety and retained by the examining physician until requested by any party.
IME Audio Recording		DoWC Code:	Z0766 $30.00 per exam
IME Audio copying fee		DoWC Code:	Z0767 $20.00 per copy
Claimant requested Independent Medical Examination (CIME)/Report with patient exam		DoWC Code:	Z0770
Division Independent Medical Examination (DIME)/Report with patient exam				DoWC Code:	Z0771
IME Fees are established in Rule 11.
Lengthy Form Completion	DoWC Code:	Z0757
18-5(I)(7) meeting and report
with Non-treating Physician	DoWC Code:	Z0758
Special Report Maximum Fees: 	$325.00 per hour billed in 15- minute increments.
 (5)	Chronic Opioid Management Report 
(a)	When the authorized treating physician prescribes long-term opioid treatment, s/he shall use the Division of Workers’ Compensation Chronic Pain Disorder Medical Treatment Guidelines and review the Colorado Medical Board Policy #40-26, “Policy for Prescribing and Dispensing Opioids.”  Urine drug tests for chronic opioid management shall employ testing methodologies that meet or exceed industry standards for sensitivity, specificity and accuracy.  The test methodology must be capable of identifying and quantifying the parent compound and relevant metabolites of the opioid prescribed.  In-office screening tests designed to screen for drugs of abuse are not appropriate for chronic opioid compliance monitoring.
(i)	Drug testing shall be done prior to the initial long-term drug prescription being implemented and randomly repeated at least annually.
(ii)	When drug screen tests are ordered, the authorized treating physician shall utilize the Colorado Prescription Drug Monitoring Program (PDMP).
(iii)	While the injured worker is receiving chronic opioid management, additional drug screens with documented justification may be conducted.  Examples of documented justification include the following:
a)	Concern regarding the functional status of the patient
b)	Abnormal results on previous testing
c)	Change in management of dosage or pain
d)	Chronic daily opioid dosage above 100 mg of morphine or equivalent
(iv)	The opioids classified as Schedule II or Schedule III controlled substances that are prescribed for treatment longer than 30 days shall be provided through a pharmacy.
(v)	The authorized treating physician may consider whether the injured worker experienced an opiate-related drug overdose event that resulted in an opiate antagonist being prescribed or dispensed pursuant to §§ 12-36-117.7, 12-38-125.5, 12-42.5-120, or 13-21-108.7, C.R.S. (2015).  For reimbursement for an opiate antagonist, please see Rule 18-6(N)(3)(c).    
(vi)	The prescribing authorized treating physician shall review and integrate the screening results, PDMP, and the injured worker’s past and current functional status on the prescribed levels of medications.  A written report will document the treating physician’s assessment of the patient’s past and current functional status of work, leisure activities and activities of daily living competencies.
(b)	Codes and maximum fees for the authorized treating physician for a written report with all the following review services completed and documented:
(i)	Ordering and reviewing drug tests
(ii)	Ordering and reviewing PDMP results
(iii)	Reviewing the medical records
(iv)	Reviewing the injured workers’ current functional status
(v)	Determining what actions, if any, need to be taken
(vi)	Appropriate chronic pain diagnostic code (International Classification of Diseases (ICD))
Bill using code DoWC Z0765	$75.00 per 15 minutes – maximum of 30 minutes per report
NOTE:  This code is not to be used for acute or sub-acute pain management.
		(6) 	Functional Assessments: 
(a)	Pre-and post-injection assessments by a trained physician, nurse, physician’s assistant, occupational therapist, physical therapist, chiropractor or a medical assistant may be billed with spinal or sacroiliac (SI) joint injection codes. The following 3 elements are required:
	(i) 	A brief commentary on the procedures, including the anesthesia used in the injection and verification of the needle placement by fluoroscopy, CT or MRI. 
	(ii)	Pre-and post-injection procedure shall have at least 3 objective, diagnostically appropriate, functional measures identified, measured and documented.  These may include spinal range of motion; tolerance and time limits for sitting, walking and lifting; straight leg raises for herniated discs; a variety of provocative SI joint maneuvers such as Patrick’s sign, Gaeslen, distraction or gapping and compression tests.  Objective descriptions, preferably with measurements, shall be provided initially and post procedure at the appropriate time for medication effect, usually 30 minutes post procedure.  
	(iii)	There shall be a trained physician or trained non-physician health care professional detailed report with a pre- and post-procedure pain diagram, normally using a 0-10 point scale.   The patient(s) should be instructed to keep a post injection pain diary that details the patient’s pain level for all pertinent body parts, including any affected limbs.  The patient pain diary should be kept for at least 8 hours post injection and preferably up to seven (7) days.  The patient should be encouraged to also report any changes in activity level post injection.
(b)	If all three elements are documented, the billing codes and maximum fees are as follows:
DOWC Z0811		$60.00 per episode for the initial functional assessment of pre-injection care, billed along with the appropriate E&M code, related to spinal or SI joint injections.
DOWC Z0812		$31.44 for a subsequent visit of therapeutic post-injection care (preferably done by a non-injectionist and at least seven (7) days after the injection), billed along with the appropriate E&M code, related to follow-up care of spinal or SI joint injections.  The injured worker should provide post injection pain data, including a pain diary.  
DOWC Z0813		$31.44 for post-diagnostic injection care (repeat functional assessment within the time period for the effective agent given).
		(7) 	Quality Performance and Outcomes Payments (QPOP)
(a)	Medical providers who are Level I or II accredited, or who have completed the Division-sponsored Level I or II accreditation program and have successfully completed the QPOP training may bill separately for documenting functional progress made by the injured worker.  The medical providers must utilize both a validated psychological screen and the validated functional data provided by the injured worker or another health care provider.  The medical provider also must document whether the injured worker’s perception of function correlates with clinical findings.  The documentation of functional progress should assist the provider in preparing a successful plan of care, including specific goals and expected time frames for completion, or for modifying a prior plan of care.  The documentation must include:
(i)	Specific testing that occurred, interpretation of testing results, and the weight given to these results in forming a reasonable and necessary plan of care;
(ii)	Explanation of how the testing goes beyond the evaluation and management (E&M) services typically provided by the provider;
(iii)	Meaningful discussion of actual or expected functional improvement between the provider and the injured worker.
If these elements have been met, the billing code and maximum fee are as follows:
DOWC Z0803	$ 80.00 for the initial assessment during which the injured worker provides functional data and completes the validated psychological screen, which the provider considers in preparing a plan of care.  This code also may be used for the final assessment that includes review of the functional gains achieved during the course of treatment and documentation of MMI.
DOWC Z0804 	$ 40.00 for subsequent visits during which the injured worker provides follow-up functional data which could alter the treatment plan.  The provider may use this code if the analysis of the data causes him or her to modify the treatment plan.  The provider should not bill this code more than once every 2 to 4 weeks.
 
(b)	QPOP for post-MMI patients requires prior authorization based on clearly documented functional goals. 
(H)	Supplies, Durable Medical Equipment (DME), Orthotics and Prostheses
(1)	Supplies necessary to perform a service or procedure are considered inclusive and not separately reimbursable.  Only supplies that are not an integral part of a service or procedure are considered to be over and above those usually included in the service or procedure.
(2)	Unless other limitations exist in this Rule, medical professionals shall bill supplies, including “Supply et al.,” orthotics, prostheses, DME or drugs, including injectables, using Medicare’s HCPCS Level II codes, when one exists, as established in the January 2016 Durable Medical Equipment, Prosthetics,  Orthotics and Supplies (DMEPOS) schedule for rural (R) or non-rural (NR). Rural is identified in Medicare’s DME Rural Zip and Formats file on their website or the January 2016 Medicare’s Part B Drug Average Sale Price (ASP). Otherwise, the billing provider shall identify their cost by submitting a copy of their invoice with their bill. The DMEPOS schedule can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.The Medicare Part B Drug Average Sale Price (ASP) fees can be found at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html?redirect=/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp
	Maximum fees for any orthotic created using casting materials shall be billed using Medicare’s Q codes and values listed under Medicare’s DMEPOS fee schedule for Colorado.  The therapist time necessary to create the orthotic shall be billed using CPT® code 97760.
(3)	Payers shall pay medical professionals using Medicare’s January 2016 DMEPOS Colorado HCPCS Level II maximum fee values or Medicare’s Part B Drug ASP values listed for the codes billed. If no code exists, the payer shall pay 120% of the cost for the item as indicated on the provider’s invoice. Payers shall not recognize the KE modifier.
(4)	Unless other limitations exist in this Rule, DMEPOS suppliers shall be reimbursed using Medicare’s HCPCS Level II codes, when one exists, as established in the January 2016 DMEPOS schedule. Otherwise, the supplier shall be reimbursed at 100% of Colorado Medicaid’s January 2016 fee schedule. The Colorado Medicaid Fee Schedule can be found at: https://www.colorado.gov/hcpf/provider-rates-fee-schedule. If no Medicare or Medicaid fee schedule value exists, payers shall reimburse Suppliers the published Manufactures Suggested Retail Price (MSRP), the item will be reimbursed at MSRP less 20%. If there is no established fee schedule value or MSRP, reimbursement shall be based on 120% of the cost of the item as indicated on the supplier’s invoice.  Shipping and handling charges are not separately payable.
(5) 	The payer shall not pay for rental fees once the purchase price of the rented item has been reached. When the item is purchased, all rental fees shall be deducted from the purchase price.
(6)	Reimbursement of supplies to facilities shall be in compliance with sections 18-6 (I) – (O).
(7)      	Payment for professional services associated with the fabrication and/or modification of orthotics, custom splints, adaptive equipment, and/or adaptation and programming of communication systems and devices shall be paid in accordance with the Colorado Medicare HCPCS Level II values.
(8)	Take home exercise supplies with a total cost of $50 or less may be billed without an invoice at a maximum fee of actual billed charges; however, payers reserve the right to request an invoice, at any time, to validate the provider’s cost. Home exercise supplies can include, but are not limited to the following items: therabands, theratubes, band/tube straps, theraputty, bow-tie tubing, fitness cables/trainers, overhead pulleys, exercise balls, cuff weights, dumbbells, ankle weight bands, wrist weight bands, hand squeeze balls, flexbars, digiflex hand exercisers, power webs, plyoballs, spring hand grippers, hand helper rubber band units, ankle stretchers, rocker boards, balance paws, and aqua weights.
(9)	Complex Rehabilitation Technology dispensed and billed by Non-Physician DMEPOS Suppliers
(a)  	Complex rehabilitation technology (CRT) items, including products such as complex rehabilitation power wheelchairs, highly configurable manual wheelchairs, adaptive seating and positioning systems, and other specialized equipment, such as standing frames and gait trainers, enable individuals to maximize their function and minimize the extent and costs of their medical care.
(b)  	Complex Rehabilitation Technology products must be provided by suppliers who are specifically accredited by a Center for Medicare and Medicaid Services (CMS) deemed accreditation organization as a supplier of CRT and licensed as a DMEPOS Supplier with the Colorado Secretary of State.
(c)   	CRT shall be reimbursed as set out in section 18-6(H)(4). 
(I)	Inpatient Hospital Facility Fees
(1)	Provider Restrictions
All non-emergency, inpatient admissions require prior authorization for payment (see Rule 16-10).
(2)	Bills for Services
(a)	Inpatient hospital facility fees shall be billed on the UB-04 and require summary level billing by revenue code.  The provider must submit itemized bills along with the UB-04.
(b)	The maximum inpatient facility fee is determined by applying the Center for Medicare and Medicaid Services (CMS) “Medicare Severity Diagnosis Related Groups” (MS-DRGs) classification system in effect at the time of discharge.  Exhibit #1 of this Rule shows the relative weights per MS-DRGs that are used in calculating the maximum allowance.
The hospital shall indicate the MS-DRG code number FL 71 of the UB-04 billing form and maintain documentation on file showing how the MS-DRG was determined. The hospital shall determine the MS-DRG using the MS-DRGs Definitions Manual in effect at the time of discharge.  The attending physician shall not be required to certify this documentation unless a dispute arises between the hospital and the payer regarding MS-DRG assignment.  The payer may deny payment for services until the appropriate MS-DRG code is supplied.
(c)	Exhibit #1 of this Rule establishes the maximum length of stay (LOS) using the “arithmetic mean LOS”.  However, no additional allowance for exceeding this LOS, other than through the cost outlier criteria under section18-6(I)(3)(d) is allowed.
(d)	Any inpatient admission requiring the use of both an acute care hospital (admission/discharge) and its Medicare certified rehabilitation facility (admission/discharge) is considered as one (1) admission and MS-DRG.  This does not apply to long term care and licensed rehabilitation facilities.
(3)	Inpatient Facility Reimbursement:
(a)	The following types of inpatient facilities are reimbursed at 100% of billed inpatient charges:
(i)	Children’s hospitals
(ii)	Veterans’ Administration hospitals
(iii)	State psychiatric hospitals
(b)	The following types of inpatient facilities are reimbursed at 80% of billed inpatient charges:
(i)	Medicare certified Critical Access Hospitals (CAH) (listed in Exhibit #3 of this Rule) 
 (ii)	Colorado Department of Public Health and Environment (CDPHE) licensed rehabilitation facilities, 
(iii)	CDPHE licensed psychiatric facilities that are privately owned.
(iv)	CDPHE licensed skilled nursing facilities (SNF).
(c)	Medicare Long Term Care Hospitals (MLTCH)
	MLTCHs are reimbursed at $3,500 per day, not to exceed 75% of billed charges.  If total billed charges exceed $150,000, reimbursement shall be at 75% of billed charges.
(d)	All other inpatient facilities are reimbursed as follows:
Retrieve the relative weights for the assigned MS-DRG from the MS-DRG table in effect at the time of discharge in Exhibit #1 of this Rule and locate the hospital’s base rate in Exhibit #2 of this Rule.
The “Maximum Fee Allowance” is determined by calculating:
(i)	(MS-DRG Relative Wt x Specific hospital base rate x 185%) + (trauma center activation allowance) + (organ acquisition, when appropriate).
(ii)	For trauma center activation allowance, (revenue codes 680-685) see section18-6(J)(6)(b)5).
(iii)	For organ acquisition allowance, (revenue codes 810-819) see section 18-6(I)(3)(h).
(e)	Outliers are admissions with extraordinary cost warranting additional reimbursement beyond the maximum allowance under section 18-6(I)(3)(c).  To calculate the additional reimbursement, if any:
(i)	Determine the “Hospital’s Cost”: 
Total billed charges (excluding any trauma center activation or organ acquisition billed charges) multiplied by the hospital’s cost-to-charge ratio.
(ii)	Each hospital’s cost-to-charge ratio is given in Exhibit #2 of this Rule.
(iii)	The “Difference” = “Hospital’s Cost” – “Maximum Fee Allowance” excluding any trauma center activation or organ acquisition allowance (see (c) above).
(iv)	If the “Difference” is greater than $23,681.00, additional reimbursement is warranted.  The additional reimbursement is determined by the following equation: 
“Difference” x .80 = additional fee allowance
(f)	Inpatient combined with Emergency Department (ED), Trauma Center or organ acquisition reimbursement
(i)	If an injured worker is admitted to the hospital, the ED reimbursement is included in the inpatient reimbursement under section 18-6 (I)(3),
(ii)	Trauma Center activation fees (see section 18-6(J)(6)(b)5)) and organ acquisition allowance (see section 18-6(I)(3)(h)) are paid in addition to inpatient fees (see sections 18-6(I)(3)(c-d)).
(g)	If an injured worker is admitted to one hospital and is subsequently transferred to another hospital, the payment to the transferring hospital will be based upon a per diem value of the MS-DRG maximum value.  The per diem value is calculated based upon the transferring hospital’s MS-DRG relative weight multiplied by the hospital’s specific base rate (Exhibit #2 of this Rule) divided by the MS-DRG geometric mean length of stay (Exhibit #1 of this Rule).  This per diem amount is multiplied by the actual LOS.  If the patient is admitted and transferred on the same day, the actual LOS equals one (1).  The receiving hospital shall receive the appropriate MS-DRG maximum value.
(h)	To comply with Rule 16-6(B), the payer shall compare each billed charge type:
•	The MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier allowance);
•	The trauma center activation billed charge to the trauma center activation allowance; and  
•	The organ acquisition charges to the organ acquisition maximum fees under section 18-6(I)(3)(h).
The MS-DRG adjusted billed charges are determined by subtracting the trauma center activation billed charges and the organ acquisition billed charges from the total billed charges.  The final payment is the sum of the lesser of each of these comparisons.
(i)	The organ acquisition allowance will be calculated using the most recent filed computation of organ acquisition costs and charges for hospitals which are certified transplant centers (CMS Worksheet D-4 or subsequent form) plus 20%.
(J)	Outpatient Hospital Facility Fees
(1)	Provider Restrictions
(a)	All non-emergency outpatient surgeries require prior authorization for payment (see Rule 16-10).
(b)	A separate facility fee is only payable if the facility is licensed as a hospital by the Colorado Department of Public Health and Environment (CDPHE) or applicable out of state governing agency and statute.
(2)	Types of Bills for Service
(a)	Outpatient facility fees shall be billed on the UB-04 and require summary level billing by revenue code.  The provider must submit itemized bills along with the UB-04.
(b)	All professional charges (professional services include, but are not limited to, PT/OT, anesthesia, speech therapy, etc.) are subject to the RBRVS and Dental Fee Schedules as incorporated by this Rule and applicable to all facilities regardless of whether the facility fees are based upon Exhibit #4 of this Rule or a percentage of billed charges.
(c)	Outpatient hospital facility bills include all outpatient surgery, ED, Clinics, Urgent Care (UC) and diagnostic testing in the Radiology, Pathology or Medicine section of CPT®/RBRVS.
(3)	Outpatient Facility Reimbursement:
(a)	The following types of outpatient facilities are reimbursed at 100% of billed outpatient charges, except for any associated professional fees (see (J)(2)(b) above):
(i)	Children’s hospitals
(ii)	Veterans’ Administration hospitals
(iii)	State psychiatric hospitals
(b)	The CAHs listed in Exhibit #3 to this Rule are reimbursed at 80% of billed outpatient facility charges, except for any associated professional fees.
(c)	Exhibit #4 to this Rule:
Hospital reimbursement is based upon Medicare’s 2016 Outpatient Prospective Payment System (OPPS) as modified in Exhibit #4 of this Rule. Exhibit #4 lists Medicare’s Outpatient Hospital Ambulatory Prospective Payment (APC) Codes and the Division’s established rates for hospitals and other types of providers as follows:
•	Column 1 lists the APC code number.
•	Column 2 lists APC code description.
•	
•	Column 3 is used to determine maximum fees for all hospital facilities not listed under sections18-6(J)(3)(a) and (b).
•	Column 4 is used to determine maximum fees for all Ambulatory Surgery Centers (ASC) when outpatient surgery is performed in an ASC.
To identify which APC grouper is aligned with an Exhibit #4 APC code # and dollar value, use Medicare’s 2016 Addendum B. Spinal fusion CPT® codes listed with a “C” status indicator in Medicare’s Addendum B, shall have an equivalent value no greater than APC 5123. 
(4)	The APC Exhibit #4 values include the following packaged revenue codes inclusive of the following services and may not be billed separately:      
	(a)	nursing, technician, and related services;
	(b)	use of the facility where the surgical procedure(s) was performed;
	(c)	drugs and biologicals for which separate payment is not allowed;
	(d)	medical and surgical supplies, durable medical equipment and orthotics not listed as a “pass through”;
	(e)	surgical dressings;
	(f)	equipment;
	(g)	splints, casts and related devices;
	(h)	radiology services when not allowed under Exhibit #4;
	(i)	administrative, record keeping and housekeeping items and services;
	(j)	materials, including supplies and equipment for the administration and monitoring of anesthesia;
	(k)	supervision of the services of an anesthetist by the operating surgeon; and
	(l)	post-operative pain blocks.
	(m)	all implanted items.

Packaged Services	
Revenue Code	Description	
0250	Pharmacy; General Classification	
0251	Pharmacy; Generic Drugs	
0252	Pharmacy; Non-Generic Drugs	
0254	Pharmacy; Drugs Incident to Other Diagnostic Services	
0255	Pharmacy; Drugs Incident to Radiology	
0257	Pharmacy; Non-Prescription	
0258	Pharmacy; IV Solutions	
0259	Pharmacy; Other Pharmacy	
0260	IV Therapy; General Classification	
0261	IV Therapy; Infusion Pump	
0262	IV Therapy; IV Therapy/Pharmacy Services	
0263	IV Therapy; IV Therapy/Drug/Supply Delivery	
0264	IV Therapy; IV Therapy/Supplies	
0269	IV Therapy;  Other IV Therapy	
0270	Medical/Surgical Supplies and Devices; General Classification	
0271	Medical/Surgical Supplies and Devices; Non-sterile Supply	
0272	Medical/Surgical Supplies and Devices; Sterile Supply	
0275	Medical/Surgical Supplies and Devices; Pacemaker	
0276	Medical/Surgical Supplies and Devices; Intraocular Lens	
0278	Medical/Surgical Supplies and Devices 	
0279	Medical/Surgical Supplies and Devices 	
0280	Oncology; General Classification	
0289	Oncology; Other Oncology	
0343	Nuclear Medicine; Diagnostic Radiopharmaceuticals	
0344	Nuclear Medicine; Therapeutic Radiopharmaceuticals	
0370	Anesthesia; General Classification	
0371	Anesthesia; Anesthesia Incident to Radiology	
0372	Anesthesia; Anesthesia Incident to Other DX Services	
0379	Anesthesia; Other Anesthesia	
0390	Administration, Processing and Storage for Blood and Blood Components; General Classification	
0392	Administration, Processing and Storage for Blood and Blood Components; Processing and Storage	
0399	Administration, Processing and Storage for Blood and Blood Components; Other Blood Handling	
0621	Medical Surgical Supplies - Extension of 027X; Supplies Incident to Radiology	
0622	Medical Surgical Supplies - Extension of 027X; Supplies Incident to Other DX Services	
0623	Medical Supplies - Extension of 027X, Surgical Dressings	
0624	Medical Surgical Supplies - Extension of 027X; FDA Investigational Devices	
0630	Pharmacy - Extension of 025X; Reserved	
0631	Pharmacy - Extension of 025X; Single Source Drug	
0632	Pharmacy - Extension of 025X; Multiple Source Drug	
0633	Pharmacy - Extension of 025X; Restrictive Prescription	
0700	Cast Room; General Classification	
0710	Recovery Room; General Classification	
0720	Labor Room/Delivery; General Classification	
0721	Labor Room/Delivery; Labor	
0732	EKG/ECG (Electrocardiogram); Telemetry	
0821	Hemodialysis-Outpatient or Home; Hemodialysis Composite or Other Rate	
0824	Hemodialysis-Outpatient or Home; Maintenance - 100%	
0825	Hemodialysis-Outpatient or Home; Support Services	
0829	Hemodialysis-Outpatient or Home; Other OP Hemodialysis	
0942	Other Therapeutic Services (also see 095X, an extension of 094x); Education/Training	
0943	Other Therapeutic Services (also see 095X, an extension of 094X), Cardiac Rehabilitation	
0948	Other Therapeutic Services (also see 095X, an extension of 094X), Pulmonary Rehabilitation	
(5)	Recognized Status Indicators from Medicare’s Addendum B are applied as follows:
(a)	“A” means use another fee schedule instead of Exhibit #4, i.e., 18-4 Conversion Factors and RBRVS RVUs,18-6(R) Ambulance Fee Schedule or Exhibit #8. 
(b)	“B” means it is not recognized by Medicare for Outpatient Hospital services Part B bill type (12x and 130x) and therefore is not separately payable unless separate fees are applicable under another section of this Rule, such as home health.
(c)	“C” means recognized by Medicare as inpatient only procedures; however, the Division does recognize these procedures can be done outpatient if prior authorization is obtained per Rule 16-10.
(d)	“D” means discontinued code and not paid under OPPS by Medicare.  Therefore, this code is not separately payable in OPPS by DoWC.
(e)	“E” means not paid by Medicare when submitted on any outpatient bill type.  However, services could still be reasonable and necessary, thus requiring hospital or ASC level of care.  The billing party shall submit documentation to substantiate the billed service codes and any similar established codes with fees in Exhibit #4.
(f)	“F” means corneal tissue acquisition and certain CRNA services and Hepatitis A vaccines are allowed at a reasonable cost to the facility.  The facility must provide a separate invoice identifying their cost.
(g)	“G” means “Pass-Through Drugs and Biologicals” that are separately payable under Exhibit #4 as an APC value.
(h)	“H” means a “Pass-Through Device” that is separately payable based upon cost to the facility.  
(i)	“J1” or “J2” means the services are paid through a “comprehensive APC” for Medicare.  However, the DoWC has not adopted the “comprehensive APC.”  Therefore, an agreement between the payer and the provider is necessary to implement “comprehensive APCs.”
(j)	“K” means a separately payable “Pass-Through Drug or Biological or Device,” for therapeutic radiopharmaceuticals, brachytherapy sources, blood and blood products as listed under Exhibit #4’s APC value.
(k)	“L” represents Influenza Vaccine and therefore, is generally not considered workers’ compensation related. 
(l)	Any “Packaged Codes” with Q1, Q2, Q3, Q4 or STVX combinations are not recognized unless the payer and provider make a prior agreement.
(m)	“M” means not separately payable.
(n)	“N” means the service is bundled and is not separately payable.
(o)	“P” means partial hospitalization and is paid based upon observation fees as outlined in section 18-6(J).
(p)	“R” means separate payment for blood and blood products under Exhibit #4 APC value.
(q)	“S” and “T” mean there are multiple procedures, the highest valued code allowed at 100% of the Exhibit #4 value and up to three (3) additional codes allowed at 50% of the Exhibit #4 value, per episode of care. 
(r)	“U” means brachytherapy source and is separately payable under Exhibit #4 APC value.
 (s)	“V” represents a clinic or Emergency Department visit and is separately payable for hospitals as specified in section18-6(J). 
 (t)	“Y” represents non-implantable Durable Medical Equipment and is paid according to Medicare’s Durable Medical Equipment Regional Carrier (DMERC) fee schedule for Colorado.
(6)	Total maximum facility value for an outpatient hospital episode of care includes:
(a)	The highest valued CPT® code aligned to APC code per Exhibit #4 plus 50% of any lesser-valued CPT® code aligned APC code values.
Facility fee reimbursement is limited to a maximum of four (4) CPT® procedure codes per episode, with a maximum of only one (1) procedure reimbursed at 100% of the allowed  Exhibit #4 value for the type of facility:
•	
•	Hospitals are reimbursed based upon Column 3.
•	ASCs are reimbursed based upon Column 4.
(b)	 Hospitals billing type “A” or “B” Emergency Department (ED) visits shall meet one of the following hospital licensure criteria and hospital ED visit level criteria: (i)	The  EDs must be physically located within a hospital licensed by the CDPHE as a general hospital or meet the out-of-state facility’s state’s licensure requirements; or 
(ii)	A free-standing type “B” ED, must have equivalent operations and staffing as a licensed ED, including meeting Emergency Medical Treatment and Active Labor Act (EMTALA) regulations and being open 24/7; or 
.
(iii)	The ED “Level of Care” is identified based upon one (1) of five (5) levels of care for either a type “A” (99281-99285, 99291 or 99292) or type “B” (G0380-G0384) ED visit.  The level of care is defined by CPT® E&M definitions and internal level of care guidelines developed by the hospital in compliance with Medicare regulations.  The hospital’s guidelines should establish an appropriate graduation of hospital resources (ED staff and other resources) as the level of service increases.  Upon request the provider shall supply a copy of their level of care guidelines to the payer. (Only the higher one (1) of any ED levels or critical care codes shall be paid).
(iv)	APC 5045, Trauma Response with Critical Care, is not recognized for separate payment.  Trauma Center fees are not paid for alerts.  Trauma activation fees are as follows: 
•	Revenue Code 681		$3,000.00
•	Revenue Code 682		$2,500.00
•	Revenue Code 683		$1,000.00
•	Revenue Code 684		            $0
•	These fees are in addition to ED and inpatient fees.
•	Activation fees mean a trauma team has been activated, not just alerted. 
•	The level of trauma activation shall be determined by CDPHE’s assigned hospital trauma level designation.
  (v)	If an injured worker is admitted to the hospital through that hospital’s ED, the ED reimbursement is included in the inpatient reimbursement under section 18-6(I)(3).
(c)	Multiple APCs identified by multiple CPT® codes are to be indicated by the use of modifier –51.  Bilateral procedures require each procedure to be billed on separate lines using RT and LT for the procedure to be correctly paid. The 50% reduction applies to all lower valued procedures, even if they are identified in the CPT® as modifier -51 exempt.  The reduction also applies to the second "primary" procedure of bilateral procedures.
(i)	All surgical procedures performed in one (1) operating room, regardless of the number of surgeons, are considered one (1) outpatient surgical episode of care for purposes of facility fee reimbursement.
(ii)	If an arthroscopic procedure is converted to an open procedure on the same joint, only the open procedure is payable.  If an arthroscopic procedure and open procedure are performed on different joints, the two (2) procedures may be separately payable with anatomic modifiers.  
(iii)	When reported in conjunction with other knee arthroscopy codes, any combination of surgical knee arthroscopies for removal of loose body, foreign body, and/or debridement/shaving of articular cartilage shall be paid only if performed in a different compartment of the knee using G0289.
(iv)	Discontinued surgeries require the use of modifier -73 (discontinued prior to administration of anesthesia) or modifier -74 (discontinued after administration of anesthesia).  Modifier -73 results in a reimbursement of 50% of the APC value for the primary procedure only.  Modifier -74 allows reimbursement of 100% of the primary procedure value only.
(v)	In compliance with Rule 16-6(B), the sum of section 18-6(J)(3)(c) Columns 1-5 is compared to the total facility fee billed charges.  The lesser of the two amounts shall be the maximum facility allowance for the surgical episode of care.  A line by line comparison of billed charges to the calculated maximum fee schedule allowance of section 18-6(J)(3)(c) is not appropriate.
(d)	Any diagnostic testing clinical labs or therapies with a status indicator (SI) of “A” may be reimbursed using Exhibit #8 of this Rule or the appropriate CF to the unit values for the specific CPT® code as listed in the RBRVS.  Hospital bill types 13x are allowed payment for any clinical laboratory services (even if the SI is “N” for the specific clinical laboratory CPT® code) when these laboratory services are unrelated to any other outpatient services performed that day.  Modifier L1 should be appended to the billed laboratory services.  The maximum fees are based upon Exhibit #8.  
(e)	Observation room Maximum Fee Schedule value is limited to six (6) hours without prior authorization for payment (see Rule 16-10). Documentation should support the medical necessity for observation or convalescent care.  Observation time begins when the patient is placed in a bed for the purpose of initiating observation care in accordance with the physician’s order.  Observation or daily outpatient convalescence time ends when the patient is actually discharged from the hospital or ASC or admitted into a licensed facility for an inpatient stay.  Observation time would not include the time patients remain in the observation area after treatment is finished for reasons such as waiting for transportation home.  Hospital or convalescence licensure is required for billing observation or convalescence time beyond 23 hours.
Billing Codes:
G0378 Observation/Convalescence rate:  $45.00 per hour,
				  round to the nearest hour.
(f)	Professional fees are reimbursed according to the fee schedule times the appropriate conversion factor regardless of the facility type.  Additional reimbursement is payable for the following services not included in the values found in Exhibit #4 of this Rule:
•	ambulance services (Revenue Code 540), see section18-6(R)
•	blood, blood plasma, platelets (Revenue Codes 380X)
•	Physician or physician assistant services
•	Nurse practitioner services 
•	Licensed clinical psychologist
•	Licensed social workers
•	Rehabilitation services (PT, OT, Respiratory or Speech/Language, Revenue Codes 420, 430,440) are paid based upon the RBRVS unit value multiplied by the applicable conversion factor.  Modifiers are required to indicate the type of care plan or therapist being billed.  See Rule 18-5(I) Physical Medicine & Rehabilitation for appropriate modifiers.
(g)	Any prescription for a drug supply to be used longer than a 24 hour period, filled at any clinic, shall fall under the requirements of and be reimbursed as a pharmacy fee, see section 18-6(N).
(h)	Clinics (part of a hospital or a freestanding clinic) (Form Locator (FL) 4 are 07xx and revenue codes 51x-53x):  
(i)	Provider Restrictions - types of facilities that are recognized for separate clinic facility fees:
•	Rural Health Clinics as identified under Rule 18, Exhibit #5  and/or as certified by the Colorado Department of Public Health and Environment;
•	Critical Access Hospitals as identified under Rule 18, Exhibit #3 and/or as certified by the Colorado Department of Public Health and Environment;
•	Any specialty care clinic (wound/infections) that requires expensive drugs/supplies that are not typically provided in a physician’s office.
(ii)	Billing and Maximum Fees
•	Clinics designated as rural health facilities and listed in Exhibit #5 to this Rule may be reimbursed a single separate clinic fee at 80% of billed charges per date of service, regardless of whether the clinic has been designated by the employer, the urgency of the episode of care, or the time of day.

•	CAHs listed in Exhibit #5 of this Rule may be reimbursed a single separate clinic fee at 80% of billed charges per date of service. 

•	Any specialty care clinic (wound/infections) that requires drugs/supplies that are typically not provided in a physician’s office may be allowed a separate clinic fee with prior approval from the payer, as outlined in Exhibit #4

•	No other clinic facility fees are payable except those listed in sections 18-6(I), (J), (K) or (L).

•	Maximum fees for hospital urgent care facilities or services are covered under section 18-6(L).  These are identified by either place of service code 20, as billed on a CMS-1500 or by revenue code(s) 456, 516 or 526 on a UB-04. 
(iii)	Clinic fees are paid based upon Exhibit #4 and as outlined in this Rule.
(i)	IV Infusions Performed in Outpatient Hospital Facilities
IV infusion therapy performed in an outpatient hospital facility is reimbursed per section18-6(J). 
(j)	Off campus (place of service code 19) freestanding imaging center facilities shall be reimbursed using the RBRVS TC value(s), instead of the APC value.
(K)	Ambulatory Surgery Centers: 
		(1)	Provider Restrictions

(a)	A separate facility fee is only payable if the facility is licensed as an Ambulatory Surgery Center (ASC) by the Colorado Department of Public Health and Environment (CDPHE) or applicable out of state governing agency and statute.

(b)	All outpatient surgical procedures performed in an ASC shall be reasonable and necessary and warrant the performance of the procedure at an ASC level.  

(2)	Billing Codes and Maximum Fees 
ASCs are reimbursed in accordance with section18-6(J) for any surgical episodes of care. Column 4 from Exhibit #4 of this Rule lists the dollar value used to determine the maximum fees.
(L)	Urgent Care Facilities (hospital - revenue codes 456, 516, 526) or non-hospital):
(1)	Provider Restrictions
Facility fees are only payable if the facility qualifies as an Urgent Care facility. All Urgent Care facilities shall be certified by the Urgent Care Association of America (UCAOA) to be recognized for a separate facility payment for the initial visit. 
(2)	Billing and Maximum Fees:
(a)	Prior authorization is recommended for all facilities billing a separate Urgent Care fee. Facilities must provide documentation of the required Urgent Care facility certification if requested by the payer.
(b) 	Urgent Care Facility fee is HCPCS code S9088, $75.00.
(i)	No separate facility fees are allowed for follow-up care.  To receive a separate facility fee, a subsequent diagnosis shall be based on a new acute care situation and not the initial diagnosis.
(ii)	No facility fee is appropriate when the injured worker is sent to the employer's designated provider for a non-urgent episode of care during regular business hours of 8 am to 5 pm, Monday through Friday.
(iii)	Hospitals and affiliated free-standing clinics may bill on the UB-04 using revenue codes 456, 516, or 526 and the facility HCPCS code S9088 with 1 unit.  All maximum fees for other services billed on the UB-04 shall be based on Rule 18-6(J) and Exhibit #4.
(iv)	Non-hospital based urgent care facilities may bill for the facility fee, HCPCS code S9088, on the CMS-1500 with professional services.  All other services and procedures provided in an urgent care facility, including a freestanding facility, are reimbursed according to the appropriate CPT® code relative weight from RBRVS multiplied by the appropriate Rule 18-4 conversion factor.
(c)	All professional physician or non-physician fees shall be billed on a CMS-1500 with a Place of Service Code #20.  The maximum fees shall be in accordance with the appropriate CPT® code relative weight from RBRVS multiplied by the appropriate Rule 18-4 conversion factor.
(d)	The Observation Room allowance shall not exceed $45.00 per hour and is limited to a maximum of three (3) hours without prior authorization for payment (see Rule 16-10).
G0378 Observation rate: $45.00 per hour
(e)	All supplies are included in the facility fee for urgent care facilities.
(f)	Any prescription for a drug supply to be used for longer than 24 hours, filled at any clinic, shall fall under the requirements of and be reimbursed as a pharmacy fee.  See Rule 18-6(N).
 (M)	Home Care Services
Prior authorization for payment (see Rule 16-10) is required for all home care services. All skilled home care service providers shall be licensed by the Colorado Department of Public Health and Environment (CDPHE) as Type A or B providers. The payer and the home health entity should agree in writing on the type of care, the type and skill level of provider, frequency of care and duration of care at each visit, and any financial arrangements to prevent disputes.
(1)        Home Infusion Therapy
The per day or refill rates for home infusion therapy shall include all reasonable and necessary products, equipment, IV administration sets, supplies, supply management, and delivery services necessary to perform the infusion therapy.  Per diem rates are only payable when licensed professionals (RNs) are providing “reasonable and necessary” skilled assessment and evaluation services in the patient’s home.
Skilled Nursing fees are separately payable when the nurse travels to the injured workers home to perform initial and subsequent patient evaluation(s), education, and coordination of care.  Skilled nursing fees are billed and payable as indicated under section 18-6(L)(2).
 (a)	Parenteral Nutrition:
S9364  <1 Liter			$160.00/ day
S9365  1 liter			$174.00/ day
S9366  1.1 - 2.0 liter		$200.00/ day
S9367  2.1 - 3.0 liter		$227.00/ day
S9368  > 3.0 liter		$254.00/ day
The per day rates include the standard total parenteral nutrition (TPN) formula.  Lipids, specialty amino acid formulas, and drugs other than in standard formula are separately payable under section 18-6(N).
(b)	Antibiotic Therapy per day rate by professional + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
S9494 hourly				$158.00/ day
S9497 once every 3 hours		$152.00/ day
S9500 every 24 hours			  $97.00/ day
S9501 once every 12 hours		$110.00/ day
S9502 once every 8 hours		$122.00/ day
S9503 once every 6 hours		$134.00/ day
S9504 once every 4 hours		$146.00/ day
(c)	Chemotherapy per day rate + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
S9329	Administrative Services				$  0.00/ day
S9330	Continuous (24 hrs. or more) chemotherapy	$91.00/ day
S9331	Intermittent (less than 24 hrs.)		           $103.00/ day
(d)	Enteral nutrition (enteral formula and nursing services separately billable):
S9341	Via Gravity			$44.09/ day
S9342	Via Pump			$24.23/ day
S9343	Via Bolus			$24.23/ day
(e)	Pain Management per day or refill + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
S9326	Continuous (24 hrs. or more)			$  79.00/ day
S9327	Intermittent (less than 24 hrs.)			$103.00/ day
S9328	Implanted pump				            $116.00/ refill (No separate daily rate is applicable when the patient has an implanted pain pump.)
(f)	Fluid Replacement per day rate + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
S9373  < 1 liter per day			$61.00/ day
S9374   1 liter per day			$85.00/ day
S9375  >1 but <2 liters per day		$85.00/ day
S9376  >2 liters but <3 liters		$85.00/ day
S9377  >3 liters per day 		$85.00/ day
(g)	Multiple Therapies:
Highest cost per day or refill only + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
Medication/Drug Restrictions - the payment for drugs may be based upon Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
AWP (see section 18-6(N)) of the drug is determined through the use of industry publications such as the monthly Price Alert, First Databank, Inc.
(2)	Nursing Services
(a)	Skilled Nursing (LPN & RN)
S9123 RN 		$111.00/hr.
S9124 LPN		$   89.00/hr.
There is a limit of two (2) hours without prior authorization for payment (see Rule 16-10).
(b)	Certified Nurse Assistant (CNA):
S9122 CNA 		$ 45.00/hr. 
The amount of time spent with the injured worker must be specified in the medical records and on the bill.
(3)	Physical Medicine
Physical medicine procedures are payable at the same rate as provided in section 185(H), Physical Medicine and Rehabilitation.
(4)	Mileage
Travel allowances should be agreed upon with the payer and the mileage rate should not exceed $0.53 per mile, portal to portal.
DoWC code:	Z0772
(5)	Travel Time
Travel is typically included in the fees listed.  Travel time greater than one (1) hour one-way shall be reimbursed.  The fee shall be agreed upon at the time of prior authorization for payment (see Rule 16-10) and shall not exceed $30.00 per hour.
DoWC code:	Z0773 
		(6)	Drugs/Supplies/DME/Orthotics/Prosthetics Used For At-Home Care
As defined in Rule 18-6(H), any drugs/supplies/DME/Orthotics/Prosthetics considered integral to any at-home professional’s service are not separately payable.
The maximum fees for non-integral drugs/supplies/DME/Orthotics/Prosthetics used during a professional’s home care visits are listed in Rule 18-6(H).  All IV infusion supplies are included in the per diem or refill rates listed in this rule.
 (N)	Drugs and Medications	
(1)	Drugs (brand name or generic) shall be reported on bills using the applicable identifier from the National Drug Code (NDC) Directory as published by the Food and Drug Administration (FDA) 
(2)	Average Wholesale Price (AWP)
(a)	AWP for brand name and generic pharmaceuticals may be determined through the use of such monthly publications as Price Alert, Red Book, or Medispan.  In case of a dispute on AWP values, the parties should take the lower of their referenced published values.
(b)	If published AWP data becomes unavailable, substitute Wholesale Acquisition Cost (WAC) + 20% for AWP everywhere it is found in this Rule.
(3)	Reimbursement for Drugs & Medications 
	
(a)	For prescriptions, except compounded topical prescriptions, reimbursement shall be AWP + $4.00.  If drugs have been repackaged, use the original AWP and NDC that was assigned by the source of the repackaged drugs to determine reimbursement. 
(b)	Two or more drugs (or drug in combination with a supply) with separate formulations and specific labeling for simultaneous use (co-packaged) shall be reimbursed based upon AWP for underlying drug products, as identified by their NDCs, from original labeler. Supplies are considered integral to the package are not separately reimbursable.   
		(c)	Reimbursement for an opiate antagonist prescribed or dispensed under §§ 12-36-117.7, 12-38-125.5, 12-42.5-120, 13-21-108.7, C.R.S. (2015), to injured worker at risk of experiencing an opiate-related drug overdose event, or to a family member, friend, an employee or volunteer of a harm reduction organization, or other person in a position to assist the injured worker shall be AWP plus $4.00.
(d)	Drugs administered in the course of the provider’s direct care (injectables) shall be reimbursed at the provider’s actual cost incurred or Medicare’s Part B Drug Average Sale Price (ASP). 
 
(4)	Prescription Strength Compounded Drugs
All prescription strength compounds shall be billed using the DoWC Z code corresponding with the applicable category for compounded topical products, including prepackaged compounded medications, as follows:
Category I	Z0790	Fee $ 75.00	per 30 day supply
Any anti-inflammatory medication or any local anesthetic single agent.
Category II	Z0791	Fee $150.00	per 30 day supply
Any anti-inflammatory agent or agents in combination with any local anesthetic agent or agents.
Category III	Z0792	Fee $250.00	per 30 day supply
Any single agent other than anti-inflammatory agent or local anesthetic, either alone, or in combination with anti-inflammatory or local anesthetic agents.
Category IV	Z0793	Fee $350.00	per 30 day supply
Two (2) or more agents that are not anti-inflammatory or local anesthetic agents, either alone or in combination with other anti-inflammatory or local anesthetic agents.
All ingredient materials must be listed by quantity used per prescription.  To determine the applicable category for a compounded topical medication, the parties shall review separately each active ingredient in the Medical Treatment Guidelines.  If the Guidelines approve some but not all active ingredients for a particular diagnosis, the parties shall count only the approved ingredient(s) to determine the applicable category for the requested compound.
Category fees include materials, shipping and handling, and time.  Regardless of how many ingredients or what type, compounded drugs cannot be reimbursed higher than the Category IV fee.  The 30 day Maximum Fee Schedule value shall be fractioned down to the prescribed and dispensed amount given to the injured worker. Automatic refilling is not allowed.
(5)	Over-the-Counter Medications
(a) 	Over-the-counter medications, drugs that are safe and effective for use by the general public without a prescription, are reimbursed at NDC/AWP and are not eligible for dispensing fees.
(b)	The maximum reimbursement for any topical muscle relaxant, analgesic, anti-inflammatory and/or anti-neuritic medications containing only over-the-counter (OTC) active ingredients shall be the lesser of (1) the cost to the billing provider or (2) $30.00 per 30 day supply for any application except a patch and $70.00 for a patch.  To determine whether each active ingredient is considered an OTC, the parties shall refer to the FDA OTC Active Ingredient List as published by the FDA on the date these rules were adopted.
	Applications (except patch)	Z0794	$30.00 per 30 day supply 
	Patch				Z0795   $70.00 per 30 day supply
 (6)	Injured Worker Reimbursement
In the event the injured worker has directly paid for authorized prescriptions, the payer shall reimburse the injured worker for the amounts actually paid for authorized prescriptions or authorized over-the-counter drugs within 30 days after submission of the injured worker’s receipt.  See Rule 16-12(G).
(7)	Dietary Supplements, Vitamins and Herbal Medicines
Reimbursement for outpatient dietary supplements, vitamins and herbal medicines dispensed in conjunction with acupuncture and complementary alternative medicine are authorized only by prior agreement of the payer, except if specifically provided for in Rule 17, Medical Treatment Guidelines.
(8)	Prescription Writing
(a)	Physicians shall indicate on the prescription form that the medication is related to a workers’ compensation claim.
(b)	All prescriptions shall be filled with bio-equivalent generic drugs unless the physician indicates "Dispense As Written" (DAW) on the prescription.  In addition to the requirements outlined in Rule 16-5(B)(2), providers using pharmacies and prescribing a brand name compounded topical drug with a DAW indication shall provide a written medical justification explaining the reasonableness and necessity of the brand name over the generic equivalent.  This rule applies to all pharmacies, whether located in-state or out-of-state.
(c)	The provider shall prescribe no more than a 60-day supply per prescription.
(9)	Required Billing Forms
(a)	All parties shall use one (1) of the following forms:
(i)	CMS-1500 – the dispensing provider shall bill by using the metric quantity and NDC number of the drug being dispensed; or, if one does not exist, the RBRVS supply code; or
	
(ii)	With the agreement of the payer, the National Council for Prescription Drug Programs (NCPDP) or ANSI ASC 837 (American National Standards Institute Accredited Standards Committee) electronic billing transaction containing the same information as in (1) or (2) in this sub-section may be used for billing.
	NCPDP Workers’ Compensation/Property and Casualty (P&C) Universal Claim Form, version 1.1, for prescription drugs billed on paper shall be used by dispensing pharmacies and pharmacy benefit managers (PBMs).  Physicians may use the CMS-1500 billing form as described in Rule 16-7(B)(1).  
	Physicians shall list the “repackaged” and the “original” NDC numbers in field 24 of the CMS-1500.  List the “repackaged” NDC number first and the “original” NDC number second, with the prefix ‘ORIG’ appended.
(b)	Items prescribed for the work-related injury that do not have an NDC code shall be billed as a supply, using the RBRVS supply code (see section18-6(H)).
(c)	The payer may return any prescription billing form if the information is incomplete.
(d)	A signature shall be kept on file indicating that the injured worker or his/her authorized representative has received the prescription.
(10)	A line-by-line itemization of each drug billed and the payment for that drug shall be made on the payment voucher by the payer.
(O)	Complementary Alternative Medicine (CAM)
CAM is a term used to describe a broad range of treatment modalities, some of which are generally accepted in the medical community and others that remain outside the accepted practice of conventional western medicine.  Non-physician providers of CAM may be both licensed and non-licensed health practitioners with training in one (1) or more forms of therapy and certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in acupuncture and/or Chinese herbology. CAM requires prior authorization for payment (see Rule 16-10). Refer to Rule 17, Medical Treatment Guidelines for the specific types of CAM modalities.
(P)	Acupuncture
Acupuncture is an accepted procedure for the relief of pain and tissue inflammation.  While commonly used for treatment of pain, it may also be used as an adjunct to physical rehabilitation and/or surgery to hasten return of functional recovery.  Acupuncture may be performed with or without the use of electrical current on the needles at the acupuncture site.
(1)	Provider Restrictions
All non-physician providers must be a Licensed Acupuncturist (LAc) by the Colorado Department of Regulatory Agencies as provided in Rule 16, Utilization Standards.  All physician and non-physician providers must provide evidence of training, and licensure upon request of the payer.
(2)	Billing Restrictions
(a)	For treatment frequencies exceeding the maximum allowed in Rule 17, Medical Treatment Guidelines, the provider must obtain prior authorization for payment (see Rule 16-10).
			(b)	Unless the provider’s medical records reflect medical necessity and the provider obtains prior authorization for payment (see Rule 16-10), the maximum amount of time allowed for acupuncture and procedures is one (1) hour of procedures, per day, per discipline.
(3)	Billing Codes:
(a)	Reimburse acupuncture, including or not including electrical stimulation, as listed in the RBRVS.
(b)	Non-Physician evaluation services
(i)	New or established patient services are reimbursable only if the medical record specifies the appropriate history, physical examination, treatment plan or evaluation of the treatment plan.  Payers are only required to pay for evaluation services directly performed by an LAc.  All evaluation notes or reports must be written and signed by the LAc.  Without appropriate supporting documentation, the payer may deny payment.  (See Rule 16-12)
(ii)	LAc new patient visit:		DOWC Z0800
					Maximum value $99.80
(iii)	LAc established patient visit:	DOWC Z0801    
					Maximum value $67.60
(c)	Herbs require prior authorization for payment (see Rule 16-10) and fee agreements as per section18-6(M)(6).
(d)	See the appropriate Physical Medicine and Rehabilitation section of the RBRVS for other billing codes and limitations (see also section18-5(H)). 
(e)	Acupuncture supplies are reimbursed in accordance with section 18-6(H).
(Q)	Use of an Interpreter
Rates and terms shall be negotiated.  Prior authorization for payment (see Rule 16-10) is required except for emergency treatment.  Use DoWC Z0722 to bill.
(R)	Ambulance Fee Schedule
(1)	Billing Requirements: 
Payment under the fee schedule for ambulance services is comprised of a base rate payment plus a payment for mileage. Both the transport of the injured worker to the nearest facility and all items and services associated with such transport are considered inclusive with the base rate and mileage rate.
(2)	General Claims Submission:
(a)	All hospitals billing for ground or air ambulance services shall bill on the UB-04 and all other ambulance providers shall bill on the CMS-1500.
(b)	Use the appropriate HCPCS code plus the HCPCS origin/destination modifier.
(c)	The transporting supplier’s name, complete address and provider number should be listed in Item 33 (CMS-1500).
(d)	The zip code for the origin (point of pickup) must be in Item 23 (CMS-1500). If billing on the UB-04 use FL 39-41 with an “AO” and the point of pick up zip code. If billing for multiple trips and the zip code for each origin is the same, services can be submitted on the same claim. If the zip codes are different, a separate claim must be submitted for each trip.
(3)	Ground and Air Ambulance Vehicle and Crew Requirements
As required by the Colorado Department of Public Health and Environment.
(4)	HCPCS Procedure Codes and Maximum Allowances for Ambulance Services:
(a)	Ground (both water and land) Ambulance Base Rates and Mileage
The selection of the base code is based upon the condition of the injured worker at the time of transport, not the vehicle used and includes services and supplies used during the transport.

		Urban	Rural  (R = Zip Code) First 17 miles or > if not a Super Rural	Super Rural (B =Zip code)	
Ground Ambulance 	HCPCS Code Description	Medicare Rate *250%	Medicare Rate *250%	Medicare Rate *250%	
A0425	Ground mileage, per statute mile	$  18.11	$  18.28	$  18.28	
A0426	Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1- Non-Emergency)	$ 680.67	$ 687.34	$ 842.68	
A0427	Ambulance service, advanced life support, emergency transport, level 1 (ALS1-Emergency)	$1,077.72	$1,088.29	$1,334.24	
A0428	Ambulance service, basic life support, non-emergency transport (BLS)	$  567.22	$572.28	$  702.23	
A0429	Ambulance service, basic life support, emergency transport (BLS-Emergency)	$  907.55	$  916.45	$1,123.57	
A0432	Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers.	$992.64	$1002.37	$1002.37	
A0433	Advanced life support, level 2 (ALS2)	$1,559.86	$1,575.15	$1,931.14	
A0434	Specialty care transport (SCT)	$1,843.47	$1,861.54	$2,282.25	
					
The “urban” base rate(s) and mileage rate(s) as indicated in section 18-6(R) shall be applied to all relevant/applicable ambulance services unless the zip code range area is “Rural” or “Super Rural.”  Medicare MSA zip code grouping is listed on Medicare’s webpage with an “R” indicator for “Rural” and “B” indicator for “Super Rural.”  See Medicare’s Zip Code to Carrier Locality File- Updated 08/27/2014.
(5)	Modifiers
Modifiers identify place of origin and destination of the ambulance trip.  The modifier is to be placed next to the HCPCS code billed. The following is a list of current ambulance modifiers.  Each of the modifiers may be utilized to make up the first and/or second half of a two-letter modifier.  The first letter must describe the origin of the transport, and the second letter must describe the destination (Example: if a patient is picked up at his/her home and transported to the hospital, the modifier to describe the origin and destination would be – RH).
Code 	Description
D	Diagnostic or therapeutic site other than “P” or “H”
E	Residential, domiciliary, custodial facility, nursing home other than SNF (other than 1819 facility)
G	Hospital-based dialysis facility (hospital or hospital-related) which includes:
		- Hospital administered/Hospital located
		- Non-Hospital administered/Hospital located
H	Hospital
I	Site of transfer (e.g., airport, ferry, or helicopter pad) between modes of ambulance transport
J	Non-hospital-based dialysis facility
		- Non-Hospital administered/Non-Hospital located
		- Hospital administered/Non-Hospital located
N	Skilled Nursing Facility (SNF) (1819 Facility)
P	Physician’s Office (includes HMO non-hospital facility, clinic, etc.)
R	Residence
S	Scene of Accident or Acute Event
X	Destination Code Only (Intermediate stop at physician’s office en route to the hospital, includes HMO non-hospital facility, clinic, etc.)
(6)	Mileage
Charges for mileage must be based on loaded mileage only, i.e., from the pickup of a patient to his/her arrival at the destination. Payment is allowed for all medically necessary mileage.  If mileage is billed, the miles must be in whole numbers. If a trip has a fraction of a mile, round up to the nearest whole number.  Use code “1” as the mileage for trips of less than a mile.
18-7	DENTAL FEE SCHEDULE
The dental fee schedule is adopted using the American Dental Association’s Current Dental Terminology, 2016 (CDT-2016).  However, surgical treatment for dental trauma and subsequent, related procedures may be billed using medical codes from the RBRVS.  If billed using medical codes as listed in the RBRVS, reimbursement shall be in accordance with the Surgery/ Anesthesia section of the RBRVS and its corresponding conversion factor.  All dental billing and reimbursement shall be in accordance with the Division's Rule 16, Utilization Standards, and Rule 17, Medical Treatment Guidelines.  See Exhibit #6 of this Rule for the listing and Maximum Fee Schedule value for CDT-2016 dental codes.
Regarding prosthetic appliances, the provider may bill and be reimbursed for 50% of the allowed fee at the time the master casts are prepared for removable prosthodontics or the final impressions are taken for fixed prosthodontics.  The remaining 50% may be billed on insertion of the final prosthesis. 

Exhibit #1 	
For Hospital Inpatient Discharge Dates of Service on and after 1/1/2017	
MS-DRG 	MDC	TYPE	MS-DRG Title	Weights	Geometric mean LOS	Arithmetic mean LOS	
1	PRE	SURG	HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC	26.4695	29.5	37.2	
2	PRE	SURG	HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC	16.5028	18.2	22.5	
3	PRE	SURG	ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.	17.8719	25.1	31.5	
4	PRE	SURG	TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.	11.0096	20.1	24.4	
5	PRE	SURG	LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT	9.9972	15.1	20.6	
6	PRE	SURG	LIVER TRANSPLANT W/O MCC	4.8140	7.7	8.6	
7	PRE	SURG	LUNG TRANSPLANT	9.5319	15.7	18.2	
8	PRE	SURG	SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT	5.4620	9.3	10.5	
10	PRE	SURG	PANCREAS TRANSPLANT	3.8085	8.0	9.0	
11	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W MCC	4.9908	11.5	14.3	
12	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W CC	3.4872	8.5	9.9	
13	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W/O CC/MCC	2.2657	5.9	6.8	
14	PRE	SURG	ALLOGENEIC BONE MARROW TRANSPLANT	11.5851	23.7	27.9	
16	PRE	SURG	AUTOLOGOUS BONE MARROW TRANSPLANT W CC/MCC	6.0398	17.1	18.5	
17	PRE	SURG	AUTOLOGOUS BONE MARROW TRANSPLANT W/O CC/MCC	4.0911	8.5	11.6	
20	 01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC	9.7576	13.4	16.4	
21	 01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC	7.2829	11.9	13.6	
22	 01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC	4.7079	6.3	7.8	
23	 01	SURG	CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT	5.3794	7.7	10.6	
24	 01	SURG	CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC	4.0238	4.1	5.5	
25	 01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC	4.2576	7.1	9.2	
26	 01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC	2.9763	4.4	5.8	
27	 01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC	2.3704	2.3	3.0	
28	 01	SURG	SPINAL PROCEDURES W MCC	5.5261	9.3	11.8	
29	 01	SURG	SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS	3.2035	5.0	6.5	
30	 01	SURG	SPINAL PROCEDURES W/O CC/MCC	1.8879	2.6	3.4	
31	 01	SURG	VENTRICULAR SHUNT PROCEDURES W MCC	4.1022	7.6	10.4	
32	 01	SURG	VENTRICULAR SHUNT PROCEDURES W CC	2.0584	3.2	4.7	
33	 01	SURG	VENTRICULAR SHUNT PROCEDURES W/O CC/MCC	1.6075	1.9	2.4	
34	 01	SURG	CAROTID ARTERY STENT PROCEDURE W MCC	3.8855	5.1	7.3	
35	 01	SURG	CAROTID ARTERY STENT PROCEDURE W CC	2.3441	2.2	3.3	
36	 01	SURG	CAROTID ARTERY STENT PROCEDURE W/O CC/MCC	1.7483	1.3	1.5	
37	 01	SURG	EXTRACRANIAL PROCEDURES W MCC	3.0753	5.3	7.6	
38	 01	SURG	EXTRACRANIAL PROCEDURES W CC	1.5775	2.2	3.2	
39	 01	SURG	EXTRACRANIAL PROCEDURES W/O CC/MCC	1.0829	1.3	1.5	
40	 01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC	3.7227	7.9	10.5	
41	 01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM	2.1244	4.6	5.8	
42	 01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC	1.8939	2.6	3.3	
52	 01	MED	SPINAL DISORDERS & INJURIES W CC/MCC	1.5826	4.3	5.9	
53	 01	MED	SPINAL DISORDERS & INJURIES W/O CC/MCC	0.8619	2.9	3.5	
54	 01	MED	NERVOUS SYSTEM NEOPLASMS W MCC	1.3345	3.9	5.3	
55	 01	MED	NERVOUS SYSTEM NEOPLASMS W/O MCC	1.0241	3.0	4.0	
56	 01	MED	DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC	1.8388	5.3	7.3	
57	 01	MED	DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC	1.1142	3.7	5.2	
58	 01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W MCC	1.6782	5.0	6.6	
59	 01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W CC	1.0438	3.7	4.6	
60	 01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W/O CC/MCC	0.8117	3.0	3.6	
61	 01	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W MCC	2.7417	5.4	7.0	
62	 01	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W CC	1.8860	3.8	4.4	
63	 01	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W/O CC/MCC	1.5781	2.8	3.1	
64	 01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC	1.7553	4.5	6.1	
65	 01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS	1.0449	3.3	4.0	
66	 01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC	0.7470	2.3	2.7	
67	 01	MED	NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W MCC	1.3342	3.7	4.7	
68	 01	MED	NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC	0.8590	2.3	2.9	
69	 01	MED	TRANSIENT ISCHEMIA	0.7382	2.1	2.6	
70	 01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC	1.6238	4.7	6.4	
71	 01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W CC	0.9800	3.5	4.5	
72	 01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC	0.7341	2.4	3.0	
73	 01	MED	CRANIAL & PERIPHERAL NERVE DISORDERS W MCC	1.3220	3.7	5.0	
74	 01	MED	CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC	0.9153	3.0	3.8	
75	 01	MED	VIRAL MENINGITIS W CC/MCC	1.7034	5.2	6.6	
76	 01	MED	VIRAL MENINGITIS W/O CC/MCC	0.9680	3.1	3.7	
77	 01	MED	HYPERTENSIVE ENCEPHALOPATHY W MCC	1.5558	4.4	5.8	
78	 01	MED	HYPERTENSIVE ENCEPHALOPATHY W CC	0.9483	3.0	3.7	
79	 01	MED	HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC	0.7057	2.3	2.7	
80	 01	MED	NONTRAUMATIC STUPOR & COMA W MCC	1.2529	3.9	5.3	
81	 01	MED	NONTRAUMATIC STUPOR & COMA W/O MCC	0.7670	2.8	3.5	
82	 01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC	2.0131	3.4	5.7	
83	 01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W CC	1.2885	3.3	4.3	
84	 01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC	0.9310	2.2	2.8	
85	 01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC	2.0070	4.7	6.5	
86	 01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W CC	1.1438	3.2	4.0	
87	 01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC	0.8054	2.2	2.7	
88	 01	MED	CONCUSSION W MCC	1.4828	4.0	5.2	
89	 01	MED	CONCUSSION W CC	1.0177	2.8	3.4	
90	 01	MED	CONCUSSION W/O CC/MCC	0.7652	1.9	2.4	
91	 01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W MCC	1.5694	4.2	5.8	
92	 01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W CC	0.9174	3.1	3.9	
93	 01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC	0.7031	2.3	2.8	
94	 01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W MCC	3.4887	8.2	10.7	
95	 01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC	2.3512	5.7	7.0	
96	 01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W/O CC/MCC	2.1500	4.6	5.4	
97	 01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC	3.1120	8.1	10.6	
98	 01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W CC	1.8081	5.6	7.1	
99	 01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W/O CC/MCC	1.2395	3.9	4.8	
100	 01	MED	SEIZURES W MCC	1.5909	4.2	5.6	
101	 01	MED	SEIZURES W/O MCC	0.8001	2.7	3.3	
102	 01	MED	HEADACHES W MCC	1.0680	3.1	4.1	
103	 01	MED	HEADACHES W/O MCC	0.7394	2.3	2.9	
113	 02	SURG	ORBITAL PROCEDURES W CC/MCC	2.0881	4.3	5.9	
114	 02	SURG	ORBITAL PROCEDURES W/O CC/MCC	1.2006	2.5	3.1	
115	 02	SURG	EXTRAOCULAR PROCEDURES EXCEPT ORBIT	1.3613	3.7	4.8	
116	 02	SURG	INTRAOCULAR PROCEDURES W CC/MCC	1.5584	3.6	5.3	
117	 02	SURG	INTRAOCULAR PROCEDURES W/O CC/MCC	0.8341	2.0	2.6	
121	 02	MED	ACUTE MAJOR EYE INFECTIONS W CC/MCC	1.0555	3.9	5.2	
122	 02	MED	ACUTE MAJOR EYE INFECTIONS W/O CC/MCC	0.6428	2.8	3.4	
123	 02	MED	NEUROLOGICAL EYE DISORDERS	0.7271	2.1	2.6	
124	 02	MED	OTHER DISORDERS OF THE EYE W MCC	1.2167	3.7	5.2	
125	 02	MED	OTHER DISORDERS OF THE EYE W/O MCC	0.7607	2.6	3.2	
129	 03	SURG	MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE	2.3259	3.9	5.3	
130	 03	SURG	MAJOR HEAD & NECK PROCEDURES W/O CC/MCC	1.4615	2.3	2.8	
131	 03	SURG	CRANIAL/FACIAL PROCEDURES W CC/MCC	2.5539	4.4	6.1	
132	 03	SURG	CRANIAL/FACIAL PROCEDURES W/O CC/MCC	1.4342	2.1	2.5	
133	 03	SURG	OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC	1.9202	4.0	5.7	
134	 03	SURG	OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC	1.0498	2.0	2.5	
135	 03	SURG	SINUS & MASTOID PROCEDURES W CC/MCC	2.0198	4.5	6.2	
136	 03	SURG	SINUS & MASTOID PROCEDURES W/O CC/MCC	1.1125	2.0	2.6	
137	 03	SURG	MOUTH PROCEDURES W CC/MCC	1.4193	3.8	5.0	
138	 03	SURG	MOUTH PROCEDURES W/O CC/MCC	0.8490	2.2	2.7	
139	 03	SURG	SALIVARY GLAND PROCEDURES	1.0153	1.7	2.3	
146	 03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC	2.0785	5.8	8.4	
147	 03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC	1.3062	3.9	5.5	
148	 03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W/O CC/MCC	0.9117	2.5	3.5	
149	 03	MED	DYSEQUILIBRIUM	0.6808	2.1	2.5	
150	 03	MED	EPISTAXIS W MCC	1.3332	3.7	5.0	
151	 03	MED	EPISTAXIS W/O MCC	0.7085	2.3	2.9	
152	 03	MED	OTITIS MEDIA & URI W MCC	1.0105	3.6	4.5	
153	 03	MED	OTITIS MEDIA & URI W/O MCC	0.7001	2.7	3.2	
154	 03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W MCC	1.4080	4.0	5.3	
155	 03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC	0.8907	3.1	3.8	
156	 03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC	0.6667	2.3	2.8	
157	 03	MED	DENTAL & ORAL DISEASES W MCC	1.5364	4.4	6.0	
158	 03	MED	DENTAL & ORAL DISEASES W CC	0.8471	2.9	3.7	
159	 03	MED	DENTAL & ORAL DISEASES W/O CC/MCC	0.6149	2.1	2.5	
163	 04	SURG	MAJOR CHEST PROCEDURES W MCC	5.0243	10.4	12.9	
164	 04	SURG	MAJOR CHEST PROCEDURES W CC	2.5861	5.1	6.2	
165	 04	SURG	MAJOR CHEST PROCEDURES W/O CC/MCC	1.7864	3.0	3.6	
166	 04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W MCC	3.5559	8.3	10.6	
167	 04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W CC	1.9453	4.8	6.1	
168	 04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC	1.3308	2.9	3.7	
175	 04	MED	PULMONARY EMBOLISM W MCC	1.4724	4.7	5.8	
176	 04	MED	PULMONARY EMBOLISM W/O MCC	0.9116	3.1	3.8	
177	 04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC	1.8663	5.9	7.4	
178	 04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W CC	1.3246	4.7	5.7	
179	 04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC	0.9335	3.5	4.2	
180	 04	MED	RESPIRATORY NEOPLASMS W MCC	1.6950	5.1	6.7	
181	 04	MED	RESPIRATORY NEOPLASMS W CC	1.1650	3.7	4.7	
182	 04	MED	RESPIRATORY NEOPLASMS W/O CC/MCC	0.8229	2.5	3.1	
183	 04	MED	MAJOR CHEST TRAUMA W MCC	1.4940	4.7	5.8	
184	 04	MED	MAJOR CHEST TRAUMA W CC	0.9873	3.4	4.0	
185	 04	MED	MAJOR CHEST TRAUMA W/O CC/MCC	0.7225	2.5	2.9	
186	 04	MED	PLEURAL EFFUSION W MCC	1.5519	4.7	6.0	
187	 04	MED	PLEURAL EFFUSION W CC	1.0545	3.5	4.4	
188	 04	MED	PLEURAL EFFUSION W/O CC/MCC	0.7687	2.6	3.1	
189	 04	MED	PULMONARY EDEMA & RESPIRATORY FAILURE	1.2131	3.8	4.9	
190	 04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC	1.1472	3.9	4.8	
191	 04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC	0.9176	3.3	4.0	
192	 04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC	0.7231	2.7	3.2	
193	 04	MED	SIMPLE PNEUMONIA & PLEURISY W MCC	1.3848	4.6	5.7	
194	 04	MED	SIMPLE PNEUMONIA & PLEURISY W CC	0.9457	3.6	4.3	
195	 04	MED	SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC	0.7028	2.8	3.3	
196	 04	MED	INTERSTITIAL LUNG DISEASE W MCC	1.6250	5.1	6.5	
197	 04	MED	INTERSTITIAL LUNG DISEASE W CC	1.0502	3.5	4.4	
198	 04	MED	INTERSTITIAL LUNG DISEASE W/O CC/MCC	0.8132	2.8	3.4	
199	 04	MED	PNEUMOTHORAX W MCC	1.8070	5.6	7.2	
200	 04	MED	PNEUMOTHORAX W CC	1.0468	3.5	4.3	
201	 04	MED	PNEUMOTHORAX W/O CC/MCC	0.7390	2.6	3.2	
202	 04	MED	BRONCHITIS & ASTHMA W CC/MCC	0.8900	3.1	3.8	
203	 04	MED	BRONCHITIS & ASTHMA W/O CC/MCC	0.6716	2.5	3.0	
204	 04	MED	RESPIRATORY SIGNS & SYMPTOMS	0.7415	2.2	2.8	
205	 04	MED	OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC	1.4516	4.0	5.4	
206	 04	MED	OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC	0.8273	2.6	3.2	
207	 04	MED	RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS	5.3284	12.1	14.0	
208	 04	MED	RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS	2.3105	5.0	6.8	
215	 05	SURG	OTHER HEART ASSIST SYSTEM IMPLANT	16.2293	12.9	18.8	
216	 05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC	9.6674	12.1	15.1	
217	 05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W CC	6.3522	8.1	9.4	
218	 05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W/O CC/MCC	5.7031	5.4	6.6	
219	 05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC	7.7207	9.5	11.5	
220	 05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC	5.1618	6.4	7.0	
221	 05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC	4.6264	4.7	5.2	
222	 05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W MCC	8.4504	10.0	12.2	
223	 05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W/O MCC	6.5415	5.9	7.2	
224	 05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC	7.6211	7.9	9.8	
225	 05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC	5.7683	4.1	4.8	
226	 05	SURG	CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC	6.9437	6.9	9.0	
227	 05	SURG	CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC	5.4956	3.4	4.5	
228	 05	SURG	OTHER CARDIOTHORACIC PROCEDURES W MCC	7.1085	8.7	11.4	
229	 05	SURG	OTHER CARDIOTHORACIC PROCEDURES W/O MCC	4.7371	4.4	5.6	
231	 05	SURG	CORONARY BYPASS W PTCA W MCC	8.0801	10.6	12.3	
232	 05	SURG	CORONARY BYPASS W PTCA W/O MCC	5.8946	8.1	8.9	
233	 05	SURG	CORONARY BYPASS W CARDIAC CATH W MCC	7.5247	11.7	13.2	
234	 05	SURG	CORONARY BYPASS W CARDIAC CATH W/O MCC	4.9728	8.0	8.6	
235	 05	SURG	CORONARY BYPASS W/O CARDIAC CATH W MCC	5.7836	9.0	10.3	
236	 05	SURG	CORONARY BYPASS W/O CARDIAC CATH W/O MCC	3.8586	6.0	6.5	
239	 05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC	4.8477	10.5	13.4	
240	 05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC	2.7342	7.1	8.5	
241	 05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W/O CC/MCC	1.4497	4.4	5.2	
242	 05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W MCC	3.7139	5.7	7.3	
243	 05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W CC	2.6398	3.6	4.4	
244	 05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC	2.1451	2.5	2.9	
245	 05	SURG	AICD GENERATOR PROCEDURES	4.8071	4.1	5.6	
246	 05	SURG	PERC CARDIOVASC PROC W DRUG-ELUTING STENT W MCC OR 4+ VESSELS/STENTS	3.2586	4.2	5.5	
247	 05	SURG	PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC	2.1337	2.3	2.7	
248	 05	SURG	PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W MCC OR 4+ VES/STENTS	3.0502	4.8	6.3	
249	 05	SURG	PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC	1.9399	2.5	3.1	
250	 05	SURG	PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC	2.6315	4.1	5.5	
251	 05	SURG	PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC	1.6905	2.4	2.9	
252	 05	SURG	OTHER VASCULAR PROCEDURES W MCC	3.3147	5.6	7.9	
253	 05	SURG	OTHER VASCULAR PROCEDURES W CC	2.6482	4.3	5.7	
254	 05	SURG	OTHER VASCULAR PROCEDURES W/O CC/MCC	1.7679	2.4	3.0	
255	 05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W MCC	2.7023	6.8	8.9	
256	 05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC	1.6867	5.3	6.4	
257	 05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W/O CC/MCC	1.1208	3.3	4.1	
258	 05	SURG	CARDIAC PACEMAKER DEVICE REPLACEMENT W MCC	3.0550	5.4	6.9	
259	 05	SURG	CARDIAC PACEMAKER DEVICE REPLACEMENT W/O MCC	2.0036	2.9	3.5	
260	 05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC	3.7706	7.6	10.2	
261	 05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC	1.9537	3.5	4.5	
262	 05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W/O CC/MCC	1.5958	2.4	2.9	
263	 05	SURG	VEIN LIGATION & STRIPPING	2.0559	4.0	6.1	
264	 05	SURG	OTHER CIRCULATORY SYSTEM O.R. PROCEDURES	2.9600	5.9	8.5	
265	 05	SURG	AICD LEAD PROCEDURES	3.2422	3.3	4.6	
266	 05	SURG	ENDOVASCULAR CARDIAC VALVE REPLACEMENT W MCC	8.4559	6.3	8.5	
267	 05	SURG	ENDOVASCULAR CARDIAC VALVE REPLACEMENT W/O MCC	6.5286	3.7	4.4	
268	 05	SURG	AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W MCC	6.3127	6.6	9.5	
269	 05	SURG	AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC	4.0441	1.9	2.6	
270	 05	SURG	OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC	4.7660	6.5	9.3	
271	 05	SURG	OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC	3.1293	4.4	5.8	
272	 05	SURG	OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC	2.2985	2.3	3.0	
273	 05	SURG	PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC	3.6172	6.0	8.1	
274	 05	SURG	PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC	2.5371	2.7	3.5	
280	 05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC	1.6776	4.5	5.7	
281	 05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC	0.9965	2.8	3.4	
282	 05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC	0.7469	2.0	2.3	
283	 05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC	1.6958	3.0	4.7	
284	 05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC	0.7553	1.7	2.4	
285	 05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W/O CC/MCC	0.5134	1.3	1.6	
286	 05	MED	CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC	2.1977	5.2	7.0	
287	 05	MED	CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC	1.1691	2.6	3.3	
288	 05	MED	ACUTE & SUBACUTE ENDOCARDITIS W MCC	2.7480	7.5	9.7	
289	 05	MED	ACUTE & SUBACUTE ENDOCARDITIS W CC	1.5664	5.2	6.5	
290	 05	MED	ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC	1.2360	4.4	5.3	
291	 05	MED	HEART FAILURE & SHOCK W MCC	1.4802	4.6	5.8	
292	 05	MED	HEART FAILURE & SHOCK W CC	0.9572	3.5	4.3	
293	 05	MED	HEART FAILURE & SHOCK W/O CC/MCC	0.6620	2.6	3.0	
294	 05	MED	DEEP VEIN THROMBOPHLEBITIS W CC/MCC	1.1237	3.8	4.8	
295	 05	MED	DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC	0.6687	3.3	3.7	
296	 05	MED	CARDIAC ARREST, UNEXPLAINED W MCC	1.3736	1.9	2.9	
297	 05	MED	CARDIAC ARREST, UNEXPLAINED W CC	0.5878	1.3	1.6	
298	 05	MED	CARDIAC ARREST, UNEXPLAINED W/O CC/MCC	0.4348	1.1	1.2	
299	 05	MED	PERIPHERAL VASCULAR DISORDERS W MCC	1.4116	4.1	5.4	
300	 05	MED	PERIPHERAL VASCULAR DISORDERS W CC	1.0047	3.5	4.3	
301	 05	MED	PERIPHERAL VASCULAR DISORDERS W/O CC/MCC	0.7152	2.6	3.2	
302	 05	MED	ATHEROSCLEROSIS W MCC	1.0387	2.8	3.8	
303	 05	MED	ATHEROSCLEROSIS W/O MCC	0.6401	1.9	2.4	
304	 05	MED	HYPERTENSION W MCC	1.0118	3.2	4.1	
305	 05	MED	HYPERTENSION W/O MCC	0.6744	2.2	2.6	
306	 05	MED	CARDIAC CONGENITAL & VALVULAR DISORDERS W MCC	1.4321	4.0	5.4	
307	 05	MED	CARDIAC CONGENITAL & VALVULAR DISORDERS W/O MCC	0.8049	2.6	3.3	
308	 05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC	1.2053	3.8	4.8	
309	 05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC	0.7753	2.6	3.2	
310	 05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC	0.5624	2.0	2.3	
311	 05	MED	ANGINA PECTORIS	0.6278	1.9	2.3	
312	 05	MED	SYNCOPE & COLLAPSE	0.7744	2.4	3.0	
313	 05	MED	CHEST PAIN	0.6710	1.8	2.2	
314	 05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC	1.9559	4.9	6.7	
315	 05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W CC	0.9656	3.0	3.8	
316	 05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC	0.6708	2.1	2.5	
326	 06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC	5.3579	10.9	14.1	
327	 06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W CC	2.5858	5.5	7.2	
328	 06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC	1.5328	2.4	3.1	
329	 06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC	4.9563	11.3	13.9	
330	 06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W CC	2.5375	6.8	7.9	
331	 06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC	1.6544	4.0	4.5	
332	 06	SURG	RECTAL RESECTION W MCC	4.7503	10.2	12.5	
333	 06	SURG	RECTAL RESECTION W CC	2.4924	5.8	6.9	
334	 06	SURG	RECTAL RESECTION W/O CC/MCC	1.5894	3.3	3.9	
335	 06	SURG	PERITONEAL ADHESIOLYSIS W MCC	4.1121	10.3	12.6	
336	 06	SURG	PERITONEAL ADHESIOLYSIS W CC	2.3428	6.6	8.0	
337	 06	SURG	PERITONEAL ADHESIOLYSIS W/O CC/MCC	1.6181	4.0	4.9	
338	 06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W MCC	2.8881	7.0	8.6	
339	 06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC	1.6887	4.7	5.6	
340	 06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC	1.2135	2.8	3.3	
341	 06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC	2.2452	4.6	6.2	
342	 06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC	1.3520	2.7	3.5	
343	 06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC	1.0218	1.7	2.0	
344	 06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W MCC	3.0927	8.2	10.5	
345	 06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W CC	1.6545	5.1	6.1	
346	 06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC	1.2207	3.6	4.1	
347	 06	SURG	ANAL & STOMAL PROCEDURES W MCC	2.4775	6.2	8.2	
348	 06	SURG	ANAL & STOMAL PROCEDURES W CC	1.4516	4.0	5.1	
349	 06	SURG	ANAL & STOMAL PROCEDURES W/O CC/MCC	0.9544	2.3	2.9	
350	 06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W MCC	2.4335	5.8	7.6	
351	 06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W CC	1.4025	3.5	4.3	
352	 06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC	1.0062	2.1	2.6	
353	 06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W MCC	2.8778	6.2	8.0	
354	 06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC	1.6734	3.9	4.8	
355	 06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC	1.2710	2.5	3.0	
356	 06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC	3.8422	8.3	11.2	
357	 06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC	2.0727	5.1	6.4	
358	 06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC	1.3537	3.1	4.0	
368	 06	MED	MAJOR ESOPHAGEAL DISORDERS W MCC	1.8670	4.8	6.3	
369	 06	MED	MAJOR ESOPHAGEAL DISORDERS W CC	1.0558	3.2	3.9	
370	 06	MED	MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC	0.7461	2.3	2.8	
371	 06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC	1.7445	5.7	7.4	
372	 06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC	1.0848	4.3	5.2	
373	 06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC	0.7697	3.3	3.9	
374	 06	MED	DIGESTIVE MALIGNANCY W MCC	2.0306	5.8	7.8	
375	 06	MED	DIGESTIVE MALIGNANCY W CC	1.2248	3.9	5.1	
376	 06	MED	DIGESTIVE MALIGNANCY W/O CC/MCC	0.8509	2.6	3.3	
377	 06	MED	G.I. HEMORRHAGE W MCC	1.7722	4.7	6.0	
378	 06	MED	G.I. HEMORRHAGE W CC	0.9850	3.2	3.7	
379	 06	MED	G.I. HEMORRHAGE W/O CC/MCC	0.6556	2.2	2.6	
380	 06	MED	COMPLICATED PEPTIC ULCER W MCC	2.0131	5.4	7.1	
381	 06	MED	COMPLICATED PEPTIC ULCER W CC	1.0747	3.5	4.2	
382	 06	MED	COMPLICATED PEPTIC ULCER W/O CC/MCC	0.7644	2.6	3.2	
383	 06	MED	UNCOMPLICATED PEPTIC ULCER W MCC	1.3277	4.1	5.1	
384	 06	MED	UNCOMPLICATED PEPTIC ULCER W/O MCC	0.8631	2.8	3.3	
385	 06	MED	INFLAMMATORY BOWEL DISEASE W MCC	1.6184	5.3	7.0	
386	 06	MED	INFLAMMATORY BOWEL DISEASE W CC	0.9717	3.7	4.6	
387	 06	MED	INFLAMMATORY BOWEL DISEASE W/O CC/MCC	0.7376	2.9	3.5	
388	 06	MED	G.I. OBSTRUCTION W MCC	1.5493	5.1	6.7	
389	 06	MED	G.I. OBSTRUCTION W CC	0.8582	3.4	4.2	
390	 06	MED	G.I. OBSTRUCTION W/O CC/MCC	0.6016	2.6	3.1	
391	 06	MED	ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC	1.1949	3.8	5.0	
392	 06	MED	ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC	0.7403	2.7	3.3	
393	 06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC	1.6681	4.6	6.4	
394	 06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W CC	0.9347	3.3	4.1	
395	 06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC	0.6586	2.4	2.9	
405	 07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W MCC	5.4338	10.3	13.7	
406	 07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W CC	2.7813	5.7	7.1	
407	 07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W/O CC/MCC	2.0096	4.1	4.9	
408	 07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W MCC	3.8973	9.4	11.8	
409	 07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC	2.1916	5.9	7.0	
410	 07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC	1.6729	4.3	5.0	
411	 07	SURG	CHOLECYSTECTOMY W C.D.E. W MCC	3.5600	8.6	10.3	
412	 07	SURG	CHOLECYSTECTOMY W C.D.E. W CC	2.3763	6.2	7.1	
413	 07	SURG	CHOLECYSTECTOMY W C.D.E. W/O CC/MCC	1.7816	4.2	5.0	
414	 07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC	3.4988	8.4	10.3	
415	 07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC	2.0180	5.5	6.4	
416	 07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC	1.3259	3.3	3.9	
417	 07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC	2.3960	5.6	7.0	
418	 07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC	1.6509	3.9	4.6	
419	 07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC	1.2624	2.5	3.0	
420	 07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W MCC	3.4835	7.6	10.8	
421	 07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC	1.6915	4.1	5.5	
422	 07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W/O CC/MCC	1.4320	2.7	3.5	
423	 07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W MCC	4.1549	9.5	12.9	
424	 07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W CC	2.3425	5.9	7.9	
425	 07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC	1.4745	3.4	3.9	
432	 07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC	1.7022	4.7	6.2	
433	 07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W CC	0.9278	3.2	4.0	
434	 07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC	0.6132	2.4	3.0	
435	 07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC	1.7387	5.0	6.6	
436	 07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC	1.1443	3.8	4.8	
437	 07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W/O CC/MCC	0.9328	2.7	3.4	
438	 07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC	1.6546	4.9	6.6	
439	 07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC	0.8707	3.4	4.1	
440	 07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC	0.6300	2.6	3.1	
441	 07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W MCC	1.8885	5.0	6.8	
442	 07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC	0.9119	3.3	4.1	
443	 07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC/MCC	0.6642	2.5	3.1	
444	 07	MED	DISORDERS OF THE BILIARY TRACT W MCC	1.5946	4.5	5.9	
445	 07	MED	DISORDERS OF THE BILIARY TRACT W CC	1.0334	3.2	4.0	
446	 07	MED	DISORDERS OF THE BILIARY TRACT W/O CC/MCC	0.7644	2.4	2.8	
453	 08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC	10.8765	8.7	10.7	
454	 08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC	8.1922	4.7	5.5	
455	 08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC	6.3674	2.9	3.3	
456	 08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC	9.8856	9.5	11.6	
457	 08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W CC	7.1062	5.5	6.4	
458	 08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W/O CC/MCC	5.3739	3.3	3.7	
459	 08	SURG	SPINAL FUSION EXCEPT CERVICAL W MCC	6.6058	6.7	8.3	
460	 08	SURG	SPINAL FUSION EXCEPT CERVICAL W/O MCC	4.0079	2.9	3.4	
461	 08	SURG	BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC	5.1477	6.7	8.6	
462	 08	SURG	BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC	3.2787	3.1	3.3	
463	 08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC	5.3984	10.3	14.0	
464	 08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC	3.0683	6.1	7.7	
465	 08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC	2.0512	3.8	4.6	
466	 08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W MCC	5.0520	6.6	8.2	
467	 08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W CC	3.4447	3.6	4.2	
468	 08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC	2.7969	2.6	2.8	
469	 08	SURG	MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC	3.2956	5.8	6.9	
470	 08	SURG	MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC	2.0662	2.6	2.9	
471	 08	SURG	CERVICAL SPINAL FUSION W MCC	4.8406	6.3	8.8	
472	 08	SURG	CERVICAL SPINAL FUSION W CC	2.8909	2.4	3.3	
473	 08	SURG	CERVICAL SPINAL FUSION W/O CC/MCC	2.3042	1.5	1.8	
474	 08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC	3.7652	8.9	11.3	
475	 08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC	2.0629	5.7	7.0	
476	 08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W/O CC/MCC	1.0825	3.0	3.8	
477	 08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC	3.0529	8.2	10.2	
478	 08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC	2.2392	5.4	6.6	
479	 08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC	1.7456	3.6	4.3	
480	 08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC	3.0087	6.6	7.8	
481	 08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC	2.0063	4.6	5.0	
482	 08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC	1.6384	3.7	4.0	
483	 08	SURG	MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES	2.4118	1.8	2.2	
485	 08	SURG	KNEE PROCEDURES W PDX OF INFECTION W MCC	3.0594	7.7	9.4	
486	 08	SURG	KNEE PROCEDURES W PDX OF INFECTION W CC	2.0647	5.2	6.0	
487	 08	SURG	KNEE PROCEDURES W PDX OF INFECTION W/O CC/MCC	1.5460	3.9	4.4	
488	 08	SURG	KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC	1.7461	3.3	4.0	
489	 08	SURG	KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC	1.2875	2.1	2.4	
492	 08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W MCC	3.2145	6.3	7.8	
493	 08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W CC	2.1358	4.0	4.7	
494	 08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W/O CC/MCC	1.6293	2.7	3.2	
495	 08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W MCC	3.0901	7.4	9.6	
496	 08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC	1.7863	4.0	5.1	
497	 08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W/O CC/MCC	1.2631	2.1	2.6	
498	 08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC	2.3575	5.4	7.1	
499	 08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W/O CC/MCC	1.1361	2.3	2.8	
500	 08	SURG	SOFT TISSUE PROCEDURES W MCC	3.1166	7.5	9.9	
501	 08	SURG	SOFT TISSUE PROCEDURES W CC	1.6331	4.3	5.4	
502	 08	SURG	SOFT TISSUE PROCEDURES W/O CC/MCC	1.1980	2.5	3.0	
503	 08	SURG	FOOT PROCEDURES W MCC	2.4169	6.7	8.2	
504	 08	SURG	FOOT PROCEDURES W CC	1.5672	4.9	5.9	
505	 08	SURG	FOOT PROCEDURES W/O CC/MCC	1.3102	2.9	3.5	
506	 08	SURG	MAJOR THUMB OR JOINT PROCEDURES	1.3263	3.6	4.7	
507	 08	SURG	MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC	1.9617	4.3	5.5	
508	 08	SURG	MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC	1.6921	2.3	2.8	
509	 08	SURG	ARTHROSCOPY	1.7349	3.6	4.8	
510	 08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W MCC	2.4655	4.8	5.9	
511	 08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W CC	1.7473	3.3	3.9	
512	 08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W/O CC/MCC	1.4127	2.2	2.6	
513	 08	SURG	HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC	1.4910	4.0	5.0	
514	 08	SURG	HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC	0.9704	2.4	2.8	
515	 08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC	3.1234	6.8	8.6	
516	 08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC	2.0725	4.3	5.3	
517	 08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC	1.7951	2.6	3.2	
518	 08	SURG	BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM	2.9035	3.6	5.5	
519	 08	SURG	BACK & NECK PROC EXC SPINAL FUSION W CC	1.7115	3.2	4.0	
520	 08	SURG	BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC	1.2252	1.9	2.3	
533	 08	MED	FRACTURES OF FEMUR W MCC	1.3625	4.2	5.5	
534	 08	MED	FRACTURES OF FEMUR W/O MCC	0.7578	2.9	3.5	
535	 08	MED	FRACTURES OF HIP & PELVIS W MCC	1.1955	4.0	5.0	
536	 08	MED	FRACTURES OF HIP & PELVIS W/O MCC	0.7231	3.0	3.4	
537	 08	MED	SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W CC/MCC	0.9215	3.3	4.0	
538	 08	MED	SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W/O CC/MCC	0.6916	2.4	2.8	
539	 08	MED	OSTEOMYELITIS W MCC	1.9392	6.1	8.2	
540	 08	MED	OSTEOMYELITIS W CC	1.3071	4.6	5.8	
541	 08	MED	OSTEOMYELITIS W/O CC/MCC	0.9509	3.7	4.6	
542	 08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC	1.8392	5.5	7.4	
543	 08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC	1.1072	3.9	4.9	
544	 08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC	0.7766	3.0	3.5	
545	 08	MED	CONNECTIVE TISSUE DISORDERS W MCC	2.4449	5.9	8.3	
546	 08	MED	CONNECTIVE TISSUE DISORDERS W CC	1.1337	3.7	4.7	
547	 08	MED	CONNECTIVE TISSUE DISORDERS W/O CC/MCC	0.7964	2.7	3.2	
548	 08	MED	SEPTIC ARTHRITIS W MCC	1.8589	5.7	7.3	
549	 08	MED	SEPTIC ARTHRITIS W CC	1.1626	4.1	5.2	
550	 08	MED	SEPTIC ARTHRITIS W/O CC/MCC	0.8645	3.0	3.8	
551	 08	MED	MEDICAL BACK PROBLEMS W MCC	1.5646	4.6	6.0	
552	 08	MED	MEDICAL BACK PROBLEMS W/O MCC	0.8699	3.1	3.7	
553	 08	MED	BONE DISEASES & ARTHROPATHIES W MCC	1.1945	4.1	5.2	
554	 08	MED	BONE DISEASES & ARTHROPATHIES W/O MCC	0.7301	2.8	3.4	
555	 08	MED	SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W MCC	1.2609	3.8	4.9	
556	 08	MED	SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC	0.7445	2.6	3.2	
557	 08	MED	TENDONITIS, MYOSITIS & BURSITIS W MCC	1.3747	4.8	5.9	
558	 08	MED	TENDONITIS, MYOSITIS & BURSITIS W/O MCC	0.8413	3.3	3.9	
559	 08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC	1.8766	4.9	6.6	
560	 08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC	1.0675	3.4	4.3	
561	 08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC	0.7299	2.3	2.8	
562	 08	MED	FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W MCC	1.3237	4.1	5.2	
563	 08	MED	FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC	0.7892	3.0	3.5	
564	 08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC	1.5832	4.7	6.3	
565	 08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC	0.9628	3.5	4.3	
566	 08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC	0.7230	2.6	3.2	
570	 09	SURG	SKIN DEBRIDEMENT W MCC	2.3652	7.0	8.9	
571	 09	SURG	SKIN DEBRIDEMENT W CC	1.4444	5.0	6.0	
572	 09	SURG	SKIN DEBRIDEMENT W/O CC/MCC	1.0490	3.7	4.4	
573	 09	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W MCC	3.6930	8.4	12.2	
574	 09	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC	2.8652	7.3	9.4	
575	 09	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC	1.4809	4.4	5.4	
576	 09	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W MCC	4.2586	8.1	12.0	
577	 09	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W CC	2.2814	4.4	6.4	
578	 09	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC	1.3787	2.7	3.5	
579	 09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC	2.6948	7.0	9.0	
580	 09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W CC	1.6319	4.2	5.4	
581	 09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC	1.2547	2.3	3.0	
582	 09	SURG	MASTECTOMY FOR MALIGNANCY W CC/MCC	1.4881	2.3	3.1	
583	 09	SURG	MASTECTOMY FOR MALIGNANCY W/O CC/MCC	1.2936	1.7	2.0	
584	 09	SURG	BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC	1.7820	3.6	4.8	
585	 09	SURG	BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC	1.5855	2.1	2.5	
592	 09	MED	SKIN ULCERS W MCC	1.4043	5.0	6.4	
593	 09	MED	SKIN ULCERS W CC	0.9907	4.0	4.9	
594	 09	MED	SKIN ULCERS W/O CC/MCC	0.7298	3.1	3.8	
595	 09	MED	MAJOR SKIN DISORDERS W MCC	2.0071	5.6	7.5	
596	 09	MED	MAJOR SKIN DISORDERS W/O MCC	0.9668	3.6	4.5	
597	 09	MED	MALIGNANT BREAST DISORDERS W MCC	1.7387	5.2	7.0	
598	 09	MED	MALIGNANT BREAST DISORDERS W CC	1.2002	3.8	5.1	
599	 09	MED	MALIGNANT BREAST DISORDERS W/O CC/MCC	0.7155	2.4	3.2	
600	 09	MED	NON-MALIGNANT BREAST DISORDERS W CC/MCC	1.0094	3.6	4.6	
601	 09	MED	NON-MALIGNANT BREAST DISORDERS W/O CC/MCC	0.6629	2.7	3.2	
602	 09	MED	CELLULITIS W MCC	1.4566	4.9	6.1	
603	 09	MED	CELLULITIS W/O MCC	0.8432	3.4	4.1	
604	 09	MED	TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W MCC	1.3463	3.9	5.1	
605	 09	MED	TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC	0.8161	2.7	3.3	
606	 09	MED	MINOR SKIN DISORDERS W MCC	1.3956	4.2	5.8	
607	 09	MED	MINOR SKIN DISORDERS W/O MCC	0.7707	2.9	3.7	
614	 10	SURG	ADRENAL & PITUITARY PROCEDURES W CC/MCC	2.4058	3.9	5.5	
615	 10	SURG	ADRENAL & PITUITARY PROCEDURES W/O CC/MCC	1.4147	2.0	2.3	
616	 10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W MCC	4.0476	10.5	12.7	
617	 10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W CC	1.9973	6.0	7.2	
618	 10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W/O CC/MCC	1.2118	3.6	4.5	
619	 10	SURG	O.R. PROCEDURES FOR OBESITY W MCC	3.0853	3.8	6.0	
620	 10	SURG	O.R. PROCEDURES FOR OBESITY W CC	1.7821	2.3	2.8	
621	 10	SURG	O.R. PROCEDURES FOR OBESITY W/O CC/MCC	1.5408	1.7	1.9	
622	 10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC	3.7065	9.0	12.0	
623	 10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC	1.9004	5.5	6.9	
624	 10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W/O CC/MCC	1.0709	3.7	4.4	
625	 10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W MCC	2.6749	5.1	7.5	
626	 10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W CC	1.4965	2.4	3.5	
627	 10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC	1.0119	1.5	1.7	
628	 10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC	3.3599	6.9	9.6	
629	 10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC	2.1682	6.0	7.1	
630	 10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC/MCC	1.4811	2.8	3.6	
637	 10	MED	DIABETES W MCC	1.3586	4.0	5.3	
638	 10	MED	DIABETES W CC	0.8386	3.0	3.7	
639	 10	MED	DIABETES W/O CC/MCC	0.5971	2.2	2.6	
640	 10	MED	MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC	1.1442	3.3	4.5	
641	 10	MED	MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC	0.7167	2.7	3.3	
642	 10	MED	INBORN AND OTHER DISORDERS OF METABOLISM	1.2009	3.3	4.5	
643	 10	MED	ENDOCRINE DISORDERS W MCC	1.5648	5.1	6.4	
644	 10	MED	ENDOCRINE DISORDERS W CC	0.9983	3.7	4.5	
645	 10	MED	ENDOCRINE DISORDERS W/O CC/MCC	0.7276	2.8	3.3	
652	 11	SURG	KIDNEY TRANSPLANT	3.3047	5.5	6.5	
653	 11	SURG	MAJOR BLADDER PROCEDURES W MCC	5.6843	11.7	14.4	
654	 11	SURG	MAJOR BLADDER PROCEDURES W CC	3.0694	7.1	8.0	
655	 11	SURG	MAJOR BLADDER PROCEDURES W/O CC/MCC	2.1614	4.6	5.2	
656	 11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC	3.4351	6.5	8.5	
657	 11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC	2.0118	4.1	4.9	
658	 11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC	1.5260	2.5	2.9	
659	 11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC	3.3729	7.5	10.1	
660	 11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC	1.8856	4.0	5.3	
661	 11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC	1.4235	2.2	2.7	
662	 11	SURG	MINOR BLADDER PROCEDURES W MCC	2.8880	7.2	9.6	
663	 11	SURG	MINOR BLADDER PROCEDURES W CC	1.5132	3.8	5.1	
664	 11	SURG	MINOR BLADDER PROCEDURES W/O CC/MCC	1.2217	2.0	2.5	
665	 11	SURG	PROSTATECTOMY W MCC	3.0686	8.2	10.3	
666	 11	SURG	PROSTATECTOMY W CC	1.7655	4.6	6.2	
667	 11	SURG	PROSTATECTOMY W/O CC/MCC	0.9982	2.3	2.9	
668	 11	SURG	TRANSURETHRAL PROCEDURES W MCC	2.4560	6.3	8.2	
669	 11	SURG	TRANSURETHRAL PROCEDURES W CC	1.3061	3.0	4.0	
670	 11	SURG	TRANSURETHRAL PROCEDURES W/O CC/MCC	0.9647	2.2	2.7	
671	 11	SURG	URETHRAL PROCEDURES W CC/MCC	1.5599	4.1	5.2	
672	 11	SURG	URETHRAL PROCEDURES W/O CC/MCC	0.9831	2.1	2.6	
673	 11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC	3.3435	7.4	10.2	
674	 11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W CC	2.2529	5.2	6.8	
675	 11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC	1.5339	2.5	3.3	
682	 11	MED	RENAL FAILURE W MCC	1.5004	4.5	6.0	
683	 11	MED	RENAL FAILURE W CC	0.9194	3.4	4.2	
684	 11	MED	RENAL FAILURE W/O CC/MCC	0.6180	2.4	2.9	
685	 11	MED	ADMIT FOR RENAL DIALYSIS	1.0421	2.9	3.7	
686	 11	MED	KIDNEY & URINARY TRACT NEOPLASMS W MCC	1.6784	5.3	6.9	
687	 11	MED	KIDNEY & URINARY TRACT NEOPLASMS W CC	1.0620	3.5	4.6	
688	 11	MED	KIDNEY & URINARY TRACT NEOPLASMS W/O CC/MCC	0.6877	2.1	2.6	
689	 11	MED	KIDNEY & URINARY TRACT INFECTIONS W MCC	1.0645	4.0	4.9	
690	 11	MED	KIDNEY & URINARY TRACT INFECTIONS W/O MCC	0.7770	3.1	3.7	
691	 11	MED	URINARY STONES W ESW LITHOTRIPSY W CC/MCC	1.6136	3.0	4.0	
692	 11	MED	URINARY STONES W ESW LITHOTRIPSY W/O CC/MCC	1.2670	1.9	2.3	
693	 11	MED	URINARY STONES W/O ESW LITHOTRIPSY W MCC	1.3222	3.8	5.0	
694	 11	MED	URINARY STONES W/O ESW LITHOTRIPSY W/O MCC	0.7408	2.0	2.5	
695	 11	MED	KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W MCC	1.2166	3.9	5.1	
696	 11	MED	KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC	0.6933	2.5	3.1	
697	 11	MED	URETHRAL STRICTURE	0.8541	2.6	3.3	
698	 11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC	1.5652	5.0	6.3	
699	 11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC	1.0293	3.5	4.4	
700	 11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC	0.7356	2.7	3.2	
707	 12	SURG	MAJOR MALE PELVIC PROCEDURES W CC/MCC	1.8049	2.7	3.6	
708	 12	SURG	MAJOR MALE PELVIC PROCEDURES W/O CC/MCC	1.3496	1.4	1.6	
709	 12	SURG	PENIS PROCEDURES W CC/MCC	2.1818	4.5	6.9	
710	 12	SURG	PENIS PROCEDURES W/O CC/MCC	1.4487	1.7	2.2	
711	 12	SURG	TESTES PROCEDURES W CC/MCC	2.1306	5.8	7.5	
712	 12	SURG	TESTES PROCEDURES W/O CC/MCC	1.0719	2.6	3.2	
713	 12	SURG	TRANSURETHRAL PROSTATECTOMY W CC/MCC	1.5885	3.5	5.0	
714	 12	SURG	TRANSURETHRAL PROSTATECTOMY W/O CC/MCC	0.8334	1.7	2.0	
715	 12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W CC/MCC	2.0678	5.1	7.1	
716	 12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W/O CC/MCC	1.1714	1.6	1.9	
717	 12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC	1.6484	4.3	5.7	
718	 12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W/O CC/MCC	1.0310	2.4	3.1	
722	 12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W MCC	1.7007	5.2	7.0	
723	 12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W CC	1.0872	3.8	4.8	
724	 12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.6808	2.1	2.8	
725	 12	MED	BENIGN PROSTATIC HYPERTROPHY W MCC	1.3132	4.4	5.7	
726	 12	MED	BENIGN PROSTATIC HYPERTROPHY W/O MCC	0.7231	2.7	3.3	
727	 12	MED	INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC	1.3778	4.7	6.0	
728	 12	MED	INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC	0.8065	3.1	3.8	
729	 12	MED	OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W CC/MCC	1.0762	3.5	4.7	
730	 12	MED	OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W/O CC/MCC	0.6540	2.2	2.8	
734	 13	SURG	PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W CC/MCC	2.7203	4.7	6.9	
735	 13	SURG	PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W/O CC/MCC	1.2378	1.8	2.2	
736	 13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W MCC	4.1873	9.6	11.7	
737	 13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W CC	1.9537	4.9	5.7	
738	 13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC	1.3833	3.0	3.4	
739	 13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC	3.4770	7.0	9.2	
740	 13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC	1.7063	3.2	4.2	
741	 13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC/MCC	1.2294	1.8	2.1	
742	 13	SURG	UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC	1.6079	3.1	4.1	
743	 13	SURG	UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC	1.0094	1.8	2.0	
744	 13	SURG	D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC	1.6807	4.1	5.4	
745	 13	SURG	D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W/O CC/MCC	1.0472	2.2	2.6	
746	 13	SURG	VAGINA, CERVIX & VULVA PROCEDURES W CC/MCC	1.4782	3.4	4.8	
747	 13	SURG	VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC	0.9235	1.6	2.0	
748	 13	SURG	FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES	1.1892	1.7	2.1	
749	 13	SURG	OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W CC/MCC	2.7424	5.8	8.3	
750	 13	SURG	OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC	1.2996	2.5	3.1	
754	 13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W MCC	1.9177	5.7	7.9	
755	 13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC	1.1236	3.7	4.8	
756	 13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.6601	2.3	2.8	
757	 13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W MCC	1.4527	5.3	6.6	
758	 13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W CC	1.0417	4.0	5.0	
759	 13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.7045	2.8	3.4	
760	 13	MED	MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W CC/MCC	0.8686	2.8	3.6	
761	 13	MED	MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W/O CC/MCC	0.5538	1.8	2.1	
765	 14	SURG	CESAREAN SECTION W CC/MCC	1.1227	3.7	4.7	
766	 14	SURG	CESAREAN SECTION W/O CC/MCC	0.8069	2.8	3.0	
767	 14	SURG	VAGINAL DELIVERY W STERILIZATION &/OR D&C	0.8292	2.4	2.9	
768	 14	SURG	VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C	1.2703	4.7	5.8	
769	 14	SURG	POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE	2.0935	4.1	6.2	
770	 14	SURG	ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY	0.9875	2.1	2.7	
774	 14	MED	VAGINAL DELIVERY W COMPLICATING DIAGNOSES	0.7947	2.6	3.2	
775	 14	MED	VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES	0.6053	2.1	2.3	
776	 14	MED	POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE	0.7047	2.5	3.2	
777	 14	MED	ECTOPIC PREGNANCY	0.9901	1.9	2.3	
778	 14	MED	THREATENED ABORTION	0.5957	2.1	3.2	
779	 14	MED	ABORTION W/O D&C	0.6337	1.8	2.3	
780	 14	MED	FALSE LABOR	0.5766	1.5	3.2	
781	 14	MED	OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS	0.8155	2.7	4.0	
782	 14	MED	OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS	0.4709	1.7	2.7	
789	 15	MED	NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY	1.5967	1.8	1.8	
790	 15	MED	EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE	5.2652	17.9	17.9	
791	 15	MED	PREMATURITY W MAJOR PROBLEMS	3.5959	13.3	13.3	
792	 15	MED	PREMATURITY W/O MAJOR PROBLEMS	2.1697	8.6	8.6	
793	 15	MED	FULL TERM NEONATE W MAJOR PROBLEMS	3.6939	4.7	4.7	
794	 15	MED	NEONATE W OTHER SIGNIFICANT PROBLEMS	1.3074	3.4	3.4	
795	 15	MED	NORMAL NEWBORN	0.1770	3.1	3.1	
799	 16	SURG	SPLENECTOMY W MCC	4.9775	8.4	11.1	
800	 16	SURG	SPLENECTOMY W CC	2.8596	5.3	7.0	
801	 16	SURG	SPLENECTOMY W/O CC/MCC	1.6621	2.7	3.3	
802	 16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W MCC	3.0826	7.4	9.9	
803	 16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W CC	1.7994	4.5	5.8	
804	 16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W/O CC/MCC	1.2413	2.4	3.0	
808	 16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC	2.1493	5.7	7.7	
809	 16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC	1.1958	3.7	4.7	
810	 16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC	0.9152	2.8	3.4	
811	 16	MED	RED BLOOD CELL DISORDERS W MCC	1.3318	3.7	5.0	
812	 16	MED	RED BLOOD CELL DISORDERS W/O MCC	0.8628	2.8	3.5	
813	 16	MED	COAGULATION DISORDERS	1.7933	3.7	5.1	
814	 16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W MCC	1.6952	4.7	6.6	
815	 16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC	0.9645	3.2	4.0	
816	 16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC	0.7290	2.4	2.9	
820	 17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC	5.9286	12.0	16.5	
821	 17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC	2.3274	4.5	6.3	
822	 17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W/O CC/MCC	1.2154	2.0	2.6	
823	 17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W MCC	4.4248	10.8	14.2	
824	 17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC	2.2496	5.8	7.6	
825	 17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC/MCC	1.3579	3.0	3.9	
826	 17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W MCC	4.8445	10.7	13.9	
827	 17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC	2.3393	5.0	6.4	
828	 17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC/MCC	1.4709	2.8	3.4	
829	 17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R. PROC W CC/MCC	3.3630	7.0	10.6	
830	 17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R. PROC W/O CC/MCC	1.5141	3.0	3.8	
834	 17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC	5.6069	10.1	16.8	
835	 17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC	2.2271	4.8	7.7	
836	 17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W/O CC/MCC	1.1933	2.9	4.3	
837	 17	MED	CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH DOSE CHEMO AGENT W MCC	5.9921	15.2	21.1	
838	 17	MED	CHEMO W ACUTE LEUKEMIA AS SDX W CC OR HIGH DOSE CHEMO AGENT	2.6444	6.6	9.3	
839	 17	MED	CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC	1.3394	4.8	5.3	
840	 17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W MCC	3.1028	7.5	10.3	
841	 17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W CC	1.6851	4.7	6.1	
842	 17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC	1.1358	3.1	3.9	
843	 17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W MCC	1.8004	5.5	7.5	
844	 17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC	1.1852	4.0	5.3	
845	 17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC/MCC	0.8600	2.9	3.7	
846	 17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC	2.4599	6.0	8.1	
847	 17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC	1.2444	3.5	4.0	
848	 17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W/O CC/MCC	0.9172	2.9	3.4	
849	 17	MED	RADIOTHERAPY	1.7512	5.1	6.5	
853	 18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC	5.1069	10.5	13.5	
854	 18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC	2.3596	6.4	7.8	
855	 18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W/O CC/MCC	1.5498	3.6	4.5	
856	 18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC	4.6344	9.7	12.8	
857	 18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC	2.0782	5.6	6.9	
858	 18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC	1.4360	4.0	4.9	
862	 18	MED	POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC	1.8079	5.3	6.9	
863	 18	MED	POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC	0.9894	3.7	4.5	
864	 18	MED	FEVER	0.8395	2.8	3.5	
865	 18	MED	VIRAL ILLNESS W MCC	1.3185	3.9	5.3	
866	 18	MED	VIRAL ILLNESS W/O MCC	0.7688	2.7	3.4	
867	 18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC	2.6336	6.7	9.1	
868	 18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W CC	1.0511	3.7	4.6	
869	 18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W/O CC/MCC	0.6700	2.6	3.1	
870	 18	MED	SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS	5.8938	12.6	14.6	
871	 18	MED	SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC	1.7670	4.9	6.4	
872	 18	MED	SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC	1.0339	3.8	4.5	
876	 19	SURG	O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS	3.4042	7.8	13.7	
880	 19	MED	ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION	0.7400	2.5	3.3	
881	 19	MED	DEPRESSIVE NEUROSES	0.6672	3.5	4.6	
882	 19	MED	NEUROSES EXCEPT DEPRESSIVE	0.7303	3.4	4.7	
883	 19	MED	DISORDERS OF PERSONALITY & IMPULSE CONTROL	1.2976	4.5	7.9	
884	 19	MED	ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY	1.1781	4.3	6.3	
885	 19	MED	PSYCHOSES	1.0861	5.6	7.9	
886	 19	MED	BEHAVIORAL & DEVELOPMENTAL DISORDERS	0.8195	4.1	6.1	
887	 19	MED	OTHER MENTAL DISORDER DIAGNOSES	1.0130	2.9	4.6	
894	 20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA	0.4833	2.1	2.9	
895	 20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY	1.2896	9.4	12.1	
896	 20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC	1.6091	4.9	6.8	
897	 20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC	0.7485	3.4	4.2	
901	 21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W MCC	4.1812	9.1	13.3	
902	 21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W CC	1.8936	5.2	7.1	
903	 21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC	1.1104	3.1	4.0	
904	 21	SURG	SKIN GRAFTS FOR INJURIES W CC/MCC	3.2518	7.3	10.4	
905	 21	SURG	SKIN GRAFTS FOR INJURIES W/O CC/MCC	1.3834	3.4	4.3	
906	 21	SURG	HAND PROCEDURES FOR INJURIES	1.4980	3.0	4.4	
907	 21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W MCC	3.8698	7.4	10.2	
908	 21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W CC	2.0463	4.3	5.7	
909	 21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC	1.3010	2.6	3.3	
913	 21	MED	TRAUMATIC INJURY W MCC	1.2506	3.6	4.8	
914	 21	MED	TRAUMATIC INJURY W/O MCC	0.7638	2.5	3.1	
915	 21	MED	ALLERGIC REACTIONS W MCC	1.6028	3.8	5.1	
916	 21	MED	ALLERGIC REACTIONS W/O MCC	0.5935	1.8	2.2	
917	 21	MED	POISONING & TOXIC EFFECTS OF DRUGS W MCC	1.4313	3.5	4.9	
918	 21	MED	POISONING & TOXIC EFFECTS OF DRUGS W/O MCC	0.7060	2.3	3.0	
919	 21	MED	COMPLICATIONS OF TREATMENT W MCC	1.7700	4.5	6.2	
920	 21	MED	COMPLICATIONS OF TREATMENT W CC	1.0060	3.1	4.0	
921	 21	MED	COMPLICATIONS OF TREATMENT W/O CC/MCC	0.6941	2.2	2.8	
922	 21	MED	OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC	1.4348	3.8	5.5	
923	 21	MED	OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC	0.8229	2.5	3.5	
927	 22	SURG	EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV >96 HRS W SKIN GRAFT	14.1554	21.9	29.2	
928	 22	SURG	FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC/MCC	5.2383	10.5	14.4	
929	 22	SURG	FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W/O CC/MCC	2.5378	5.5	7.6	
933	 22	MED	EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV >96 HRS W/O SKIN GRAFT	3.1407	2.4	6.4	
934	 22	MED	FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ	1.6605	4.2	6.5	
935	 22	MED	NON-EXTENSIVE BURNS	1.6543	3.5	5.4	
939	 23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W MCC	3.2896	6.8	9.9	
940	 23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC	1.9642	3.7	5.4	
941	 23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC	1.4228	2.3	2.9	
945	 23	MED	REHABILITATION W CC/MCC	1.2336	8.7	10.3	
946	 23	MED	REHABILITATION W/O CC/MCC	1.0557	7.1	8.0	
947	 23	MED	SIGNS & SYMPTOMS W MCC	1.1404	3.6	4.8	
948	 23	MED	SIGNS & SYMPTOMS W/O MCC	0.7462	2.7	3.4	
949	 23	MED	AFTERCARE W CC/MCC	0.9278	3.0	4.2	
950	 23	MED	AFTERCARE W/O CC/MCC	0.5664	2.2	2.7	
951	 23	MED	OTHER FACTORS INFLUENCING HEALTH STATUS	0.9141	2.6	5.8	
955	 24	SURG	CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA	5.4488	7.5	10.7	
956	 24	SURG	LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA	3.7395	6.4	7.8	
957	 24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC	6.8946	9.9	13.6	
958	 24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC	3.8533	7.0	8.4	
959	 24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC	2.5313	4.2	4.9	
963	 24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC	2.5743	5.3	7.7	
964	 24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W CC	1.4139	4.1	5.0	
965	 24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC	0.9499	2.9	3.5	
969	 25	SURG	HIV W EXTENSIVE O.R. PROCEDURE W MCC	5.8071	11.4	16.1	
970	 25	SURG	HIV W EXTENSIVE O.R. PROCEDURE W/O MCC	2.3123	5.6	7.3	
974	 25	MED	HIV W MAJOR RELATED CONDITION W MCC	2.6636	6.6	9.3	
975	 25	MED	HIV W MAJOR RELATED CONDITION W CC	1.2745	4.3	5.8	
976	 25	MED	HIV W MAJOR RELATED CONDITION W/O CC/MCC	0.8815	3.2	4.0	
977	 25	MED	HIV W OR W/O OTHER RELATED CONDITION	1.2402	3.6	5.0	
981	PRE	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	4.9431	9.6	12.6	
982	PRE	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC	2.7313	5.4	7.0	
983	PRE	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.7770	2.7	3.5	
984	PRE	SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	3.3981	8.6	11.7	
985	PRE	SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC	1.7900	4.5	6.3	
986	PRE	SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.1008	2.2	3.0	
987	PRE	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	3.3198	8.2	11.1	
988	PRE	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC	1.7108	4.5	6.1	
989	PRE	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.0633	2.3	3.0	
998	  	**	PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS	 	 	 	
999	  	**	UNGROUPABLE	 	 	 	

Exhibit #2 	
Hospital Base Rates and Cost to Charge Ratios (CCR)	
For Hospital Inpatient  Discharge Dates of Service on and after 1/1/2017	
Provider Number	Name	 Base Rate 	Total CCR	
60001	NORTH COLORADO MEDICAL CENTER	 $                      6,646.23 	0.254	
60003	LONGMONT UNITED HOSPITAL	 $                      6,162.43 	0.309	
60004	PLATTE VALLEY MEDICAL CENTER	 $                      6,212.02 	0.34	
60006	MONTROSE MEMORIAL HOSPITAL	 $                      6,065.16 	0.411	
60008	SAN LUIS VALLEY HEALTH	 $                      6,065.70 	0.424	
60009	LUTHERAN MEDICAL CENTER	 $                      6,285.53 	0.235	
60010	POUDRE VALLEY HOSPITAL	 $                      6,293.26 	0.352	
60011	DENVER HEALTH MEDICAL CENTER	 $                      8,194.61 	0.289	
60012	CENTURA HEALTH-ST MARY CORWIN MEDICAL CENTER	 $                      6,533.57 	0.256	
60013	MERCY REGIONAL MEDICAL CENTER	 $                      6,043.42 	0.369	
60014	PRESBYTERIAN ST LUKES MEDICAL CENTER	 $                      6,747.07 	0.195	
60015	CENTURA HEALTH-ST ANTHONY HOSPITAL	 $                      6,176.23 	0.214	
60016	CENTURA HEALTH-ST THOMAS MORE HOSPITAL	 $                      6,073.76 	0.414	
60020	PARKVIEW MEDICAL CENTER INC	 $                      6,386.79 	0.179	
60022	UNIVERSITY COLO HEALTH MEMORIAL HOSPITAL CENTRAL	 $                      6,231.77 	0.292	
60023	ST MARYS MEDICAL CENTER	 $                      6,428.28 	0.303	
60024	UNIVERSITY OF COLORADO HOSPITAL ANSCHUTZ INPATIENT	 $                      7,956.31 	0.189	
60027	FOOTHILLS HOSPITAL	 $                      6,091.04 	0.237	
60028	SAINT JOSEPH HOSPITAL	 $                      6,923.02 	0.214	
60030	MCKEE MEDICAL CENTER	 $                      6,283.75 	0.37	
60031	CENTURA HEALTH-PENROSE ST FRANCIS HEALTH SERVICES	 $                      6,154.89 	0.227	
60032	ROSE MEDICAL CENTER	 $                      6,586.98 	0.16	
60034	SWEDISH MEDICAL CENTER	 $                      6,335.48 	0.139	
60036	ARKANSAS VALLEY REGIONAL MEDICAL CENTER	 $                      6,065.70 	0.527	
60043	KEEFE MEMORIAL HOSPITAL	 $                      5,901.90 	0.483	
60044	COLORADO PLAINS MEDICAL CENTER	 $                      6,065.70 	0.276	
60049	YAMPA VALLEY MEDICAL CENTER	 $                      5,997.45 	0.549	
60054	COMMUNITY HOSPITAL	 $                      5,901.90 	0.393	
60064	CENTURA HEALTH-PORTER ADVENTIST HOSPITAL	 $                      6,131.10 	0.204	
60065	NORTH SUBURBAN MEDICAL CENTER	 $                      6,430.10 	0.143	
60071	DELTA COUNTY MEMORIAL HOSPITAL	 $                      6,056.37 	0.431	
60075	VALLEY VIEW HOSPITAL ASSOCIATION	 $                      6,065.70 	0.506	
60076	STERLING REGIONAL MEDCENTER	 $                      6,065.70 	0.524	
60096	VAIL VALLEY MEDICAL CENTER	 $                      6,065.46 	0.485	
60100	MEDICAL CENTER OF AURORA, THE	 $                      6,283.21 	0.161	
60103	CENTURA HEALTH-AVISTA ADVENTIST HOSPITAL	 $                      6,334.99 	0.28	
60104	ST ANTHONY NORTH HEALTH CAMPUS	 $                      6,935.30 	0.262	
60107	NATIONAL JEWISH HEALTH	 $                      6,212.02 	0.236	
60112	SKY RIDGE MEDICAL CENTER	 $                      6,057.57 	0.148	
60113	CENTURA HEALTH-LITTLETON ADVENTIST HOSPITAL	 $                      6,056.39 	0.183	
60114	PARKER ADVENTIST HOSPITAL	 $                      6,133.69 	0.21	
60116	GOOD SAMARITAN MEDICAL CENTER	 $                      6,000.08 	0.21	
60117	ANIMAS SURGICAL HOSPITAL, LLC	 $                      5,901.90 	0.395	
60118	ST ANTHONY SUMMIT MEDICAL CENTER	 $                      6,113.95 	0.335	
60119	MEDICAL CENTER OF THE ROCKIES	 $                      6,117.45 	0.311	
60124	ORTHOCOLORADO HOSPITAL AT ST ANTHONY MED CAMPUS	 $                      6,044.27 	0.221	
60125	CASTLE ROCK ADVENTIST HOSPITAL	 $                      6,044.27 	0.33	
60126	BANNER FORT COLLINS MEDICAL CENTER	 $                      6,058.34 	0.251	
69999	Any New hospital	 	 	

Exhibit #3	
Effective for Dates of Service on and after 1/2017 	
Critical Access Hospitals	
Hospital Name	Location in Colorado	
Aspen Valley Hospital	Aspen	
Colorado Canyon Hospital and Medical Center	Fruita	
East Morgan County Hospital	Brush	
Estes Park Medical Center	Estes Park	
Grand River Hospital District	Rifle	
Gunnison Valley Hospital	Gunnison	
Haxtun Hospital District	Haxtun	
Heart of the Rockies Regional Medical Center	Salida	
Kit Carson County Memorial Hospital	Burlington	
Lincoln Community Hospital	Hugo	
Melissa Memorial Hospital	Holyoke	
Middle Park Medical Center	Kremmling/Granby	
Mt San Rafael Hospital	Trinidad	
Pagosa Springs Medical Center	Pagosa Springs	
Pikes Peak Regional Hospital	Woodland Park	
Pioneers Medical Center	Meeker	
Prowers Medical Center	Lamar	
Rangely District Hospital	Rangely	
Rio Grande Hospital	Del Norte	
San Luis Valley Hospital	La Jara	
Sedgwick County Health Center	Julesburg	
Southeast Colorado Hospital	Springfield	
Southwest Memorial Hospital 	Cortez 	
Spanish Peaks Regional Health Center	Walsenburg	
St Vincent General Hospital District 	Leadville	
The Memorial Hospital	Craig	
Weisbrod Memorial County Hospital	Eads 	
Wray Community District Hospital 	Wray	
Yuma District Hospital	Yuma	

Exhibit #4 	
Effective for Dates of Service on and after 1/1/2017	
APC	APC Title	Hospital Payment Rate	ASC Payment Rate	Notes 	
5011	Level 1 Examinations and Related Services 	$97.94	$83.25	 	
5012	Level 2 Examinations and Related Services 	$183.82	$156.24	 	
5013	Level 3 Examinations and Related Services 	$865.24	$735.46	 	
5021	Level 1 Type A ED Visits	$106.74	$90.73	 	
5022	Level 2 Type A ED Visits	$197.10	$167.54	 	
5023	Level 3 Type A ED Visits	$352.76	$299.85	 	
5024	Level 4 Type A ED Visits	$588.58	$500.29	 	
5025	Level 5 Type A ED Visits	$874.87	$743.64	 	
5031	Level 1 Type B ED Visits	$142.60	$121.21	 	
5032	Level 2 Type B ED Visits	$137.11	$116.54	 	
5033	Level 3 Type B ED Visits	$207.36	$176.26	 	
5034	Level 4 Type B ED Visits	$353.25	$300.26	 	
5035	Level 5 Type B ED Visits	$568.58	$483.30	 	
5041	Critical Care	$1,199.29	$1,019.39	 	
5045	Trauma Response with Critical Care	$1,532.52	$1,302.64	See Trauma Activation fees under Rule 18-6(J)(6)(b)(v)	
5051	Level 1 Skin Procedures	$212.09	$180.28	 	
5052	Level 2 Skin Procedures	$405.99	$345.09	 	
5053	Level 3 Skin Procedures	$771.61	$655.87	 	
5054	Level 4 Skin Procedures	$2,540.18	$2,159.15	 	
5055	Level 5 Skin Procedures	$3,847.48	$3,270.36	 	
5061	Hyperbaric Oxygen	$193.88	$164.80	 	
5071	Level 1 Excision/ Biopsy/ Incision and Drainage	$410.89	$349.25	 	
5072	Level 2 Excision/ Biopsy/ Incision and Drainage	$865.15	$735.38	 	
5073	Level 3 Excision/ Biopsy/ Incision and Drainage	$1,695.56	$1,441.23	 	
5074	Level 4 Excision/ Biopsy/ Incision and Drainage	$2,545.70	$2,163.85	 	
5091	Level 1 Breast/Lymphatic Surgery and Related Procedures	$3,938.29	$3,347.55	 	
5092	Level 2 Breast/Lymphatic Surgery and Related Procedures	$6,564.71	$5,580.00	 	
5093	Level 3 Breast/Lymphatic Surgery and Related Procedures	$13,603.95	$11,563.36	 	
5101	Level 1 Strapping and Cast Application	$214.63	$182.44	 	
5102	Level 2 Strapping and Cast Application	$374.18	$318.06	 	
5111	Level 1 Closed Treatment Fracture and Related Services	$310.19	$263.66	 	
5112	Level 2 Closed Treatment Fracture and Related Services	$427.50	$363.38	 	
5113	Level 3 Closed Treatment Fracture and Related Services	$1,973.61	$1,677.57	 	
5121	Level1 Musculoskeletal Procedures 	$2,619.47	$2,226.55	 	
5122	Level 2 Musculoskeletal Procedures 	$4,312.06	$3,665.25	 	
5123	Level 3 Musculoskeletal Procedures 	$8,944.67	$7,602.97	Applies to other "C" status indicator spine fusion operative procedures. Replaces the Division's previous APC #210	
5124	Level 4 Musculoskeletal Procedures 	$12,715.33	$10,808.03	 	
5125	Level 5 Musculoskeletal Procedures, including fusions	$18,968.22	$16,122.99	 	
5141	Thoracoscopy	$5,675.26	$4,823.97	 	
5151	Level 1 Airway Endoscopy	$254.36	$216.20	 	
5152	Level 2 Airway Endoscopy	$675.23	$573.95	 	
5153	Level 3 Airway Endoscopy	$1,867.50	$1,587.38	 	
5154	Level 4 Airway Endoscopy	$3,585.46	$3,047.64	 	
5155	Level 5 Airway Endoscopy	$5,519.66	$4,691.71	 	
5161	Level 1 ENT Procedures	$232.72	$197.81	 	
5162	Level 2 ENT Procedures	$563.27	$478.78	 	
5163	Level 3 ENT Procedures	$1,241.33	$1,055.13	 	
5164	Level 4 ENT Procedures	$2,910.42	$2,473.86	 	
5165	Level 5 ENT Procedures	$7,120.76	$6,052.65	 	
5166	Level 6 ENT Procedures	$54,769.64	$46,554.20	 	
5181	Level 1 Vascular Procedures	$1,552.52	$1,319.64	 	
5182	Level 2 Vascular Procedures	$4,045.19	$3,438.41	 	
5183	Level 3 Vascular Procedures	$6,831.50	$5,806.78	 	
5188	Diagnostic Cardiac Catheterization	$4,588.42	$3,900.15	 	
5191	Level 1 Endovascular Procedures	$8,265.87	$7,025.99	 	
5192	Level 2 Endovascular Procedures	$17,176.23	$14,599.80	 	
5193	Level 3 Endovascular Procedures	$26,301.91	$22,356.62	 	
5211	Level 1 Electrophysiologic Procedures	$1,521.07	$1,292.91	 	
5212	Level 2 Electrophysiologic Procedures	$8,456.35	$7,187.89	 	
5213	Level 3 Electrophysiologic Procedures	$28,010.00	$23,808.50	 	
5221	Level1 Pacemaker and Similar Procedures	$4,481.44	$3,809.23	 	
5222	Level 2 Pacemaker and Similar Procedures	$12,054.33	$10,246.18	 	
5223	Level 3 Pacemaker and Similar Procedures	$16,692.12	$14,188.30	 	
5224	Level 4 Pacemaker and Similar Procedures	$30,445.92	$25,879.03	 	
5231	Level 1 ICD and Similar Procedures	$39,474.05	$33,552.95	 	
5232	Level 2 ICD and Similar Procedures	$54,881.60	$46,649.36	 	
5241	Transfusion	$628.45	$534.18	 	
5271	Blood Product Exchange and Related Services	$1,885.97	$1,603.07	 	
5281	Apheresis/Stem Cell and Related Services	$5,427.11	$4,613.04	 	
5291	Thrombolysis and Other Device Revisions 	$359.64	$305.69	 	
5301	Level 1 Upper GI Procedures	$1,341.65	$1,140.40	 	
5302	Level 2 Upper GI Procedures 	$1,958.40	$1,664.64	 	
5303	Level 3 Upper GI Procedures	$3,564.77	$3,030.06	 	
5311	Level 1 Lower GI Procedures 	$886.41	$753.45	 	
5312	Level 2 Lower GI Procedures 	$1,354.97	$1,151.72	 	
5313	Level 3 Lower GI Procedures 	$2,990.70	$2,542.10	 	
5314	Level 4 Lower GI Procedures 	$4,187.95	$3,559.76	 	
5331	Complex GI Procedures	$6,504.43	$5,528.76	 	
5341	Peritoneal and Abdominal Procedures 	$4,702.63	$3,997.23	 	
5351	Level 1 Percutaneous Abdominal/Biliary Procedures and Related Procedures	$3,918.80	$3,330.98	 	
5352	Level 2 Percutaneous Abdominal/Biliary Procedures and Related Procedures	$7,412.81	$6,300.89	 	
5361	Level 1 Laparoscopy	$7,202.07	$6,121.76	 	
5362	Level 2 Laparoscopy	$12,349.64	$10,497.19	 	
5371	Level 1 Urology and Related Services	$371.90	$316.11	 	
5372	Level 2 Urology and Related Services	$944.06	$802.45	 	
5373	Level 3 Urology and Related Services	$2,711.56	$2,304.82	 	
5374	Level 4 Urology and Related Services	$4,038.28	$3,432.54	 	
5375	Level 5 Urology and Related Services	$6,108.71	$5,192.41	 	
5376	Level 6 Urology and Related Services	$13,370.89	$11,365.25	 	
5377	Level 7 Urology and Related Services	$25,358.44	$21,554.67	 	
5391	Level 1 Tube/Catheter Changes/Thoracentesis/Lavage	$869.09	$738.73	 	
5392	Level 2 Tube/Catheter Changes/Thoracentesis/Lavage	$2,173.95	$1,847.86	 	
5401	Dialysis	$984.01	$836.41	 	
5411	Level 1 Gynecologic Procedures	$253.06	$215.10	 	
5412	Level 2 Gynecologic Procedures	$451.62	$383.88	 	
5413	Level 3 Gynecologic Procedures	$1,146.31	$974.37	 	
5414	Level 4 Gynecologic Procedures	$3,350.12	$2,847.61	 	
5415	Level 5 Gynecologic Procedures	$6,588.36	$5,600.11	 	
5416	Level 6 Gynecologic Procedures	$10,258.11	$8,719.39	 	
5431	Level 1 Nerve Procedures	$2,506.61	$2,130.62	 	
5432	Level 2 Nerve Procedures	$6,114.20	$5,197.07	 	
5441	Level 1 Nerve Injections	$402.77	$342.35	 	
5442	Level 2 Nerve Injections	$1,053.31	$895.31	 	
5443	Level 3 Nerve Injections	$1,479.78	$1,257.81	 	
5461	Level 1 Neurostimulator and Related Procedures	$3,939.55	$3,348.62	 	
5462	Level 2 Neurostimulator and Related Procedures	$9,439.87	$8,023.89	 	
5463	Level 3 Neurostimulator and Related Procedures	$31,246.87	$26,559.84	 	
5464	Level 4 Neurostimulator and Related Procedures	$48,111.10	$40,894.44	 	
5471	Implantation of Drug Infusion Device	$27,630.40	$23,485.84	 	
5481	Laser Eye Procedures	$792.68	$673.78	 	
5491	Level 1 Intraocular Procedures	$3,142.26	$2,670.92	 	
5492	Level 2 Intraocular Procedures	$6,085.39	$5,172.58	 	
5493	Level 3 Intraocular Procedures	$16,917.16	$14,379.58	 	
5494	Level 4 Intraocular Procedures	$31,591.49	$26,852.77	 	
5501	Level 1 Extraocular, Repair, and Plastic Eye Procedures	$469.85	$399.38	 	
5502	Level 2 Extraocular, Repair, and Plastic Eye Procedures	$1,254.08	$1,065.97	 	
5503	Level 3 Extraocular, Repair, and Plastic Eye Procedures	$2,522.09	$2,143.77	 	
5504	Level 4 Extraocular, Repair, and Plastic Eye Procedures	$4,518.63	$3,840.84	 	
5521	Level 1 X-Ray and Related Services	$109.44	$93.02	 	
5522	Level 2 X-Ray and Related Services	$181.24	$154.06	 	
5523	Level 3 X-Ray and Related Services 	$345.55	$293.71	 	
5524	Level 4 X-Ray and Related Services 	$633.08	$538.12	 	
5525	Level 5 X-Ray and Related Services	$1,202.27	$1,021.93	 	
5526	Level 6 X-Ray and Related Services	$4,893.89	$4,159.81	 	
5531	Level 1 Ultrasound and Related Services	$165.73	$140.87	 	
5532	Level 2 Ultrasound and Related Services	$276.44	$234.98	 	
5533	Level 3 Ultrasound and Related Services	$750.24	$637.70	 	
5534	Level 4 Ultrasound and Related Services	$1,257.57	$1,068.93	 	
5561	Level 1 Echocardiogram with Contrast	$817.29	$694.70	 	
5562	Level 2 Echocardiogram with Contrast	$1,207.73	$1,026.57	 	
5570	Computed Tomography without Contrast	$202.48	$172.11	 	
5571	Level 1 Computed Tomography with Contrast and Computed Tomography Angiography	$426.35	$362.40	 	
5572	Level 2 Computed Tomography with Contrast and Computed Tomography Angiography	$625.90	$532.01	 	
5581	Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast	$492.37	$418.52	 	
5582	Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast	$817.78	$695.11	 	
5591	Level 1 Nuclear Medicine and Related Services 	$598.77	$508.95	 	
5592	Level 2 Nuclear Medicine and Related Services	$794.45	$675.28	 	
5593	Level 3 Nuclear Medicine and Related Services 	$1,995.23	$1,695.94	 	
5594	Level 4 Nuclear Medicine and Related Services	$2,313.31	$1,966.31	 	
5611	Level 1 Therapeutic Radiation Treatment Preparation	$193.32	$164.32	 	
5612	Level 2 Therapeutic Radiation Treatment Preparation	$299.97	$254.97	 	
5613	Level 3 Therapeutic Radiation Treatment Preparation	$525.19	$446.41	 	
5614	Level 4 Therapeutic Radiation Treatment Preparation	$1,848.26	$1,571.02	 	
5621	Level 1 Radiation Therapy	$198.61	$168.82	 	
5622	Level 2 Radiation Therapy	$349.83	$297.36	 	
5623	Level 3 Radiation Therapy	$909.92	$773.43	 	
5624	Level 4 Radiation Therapy	$1,253.18	$1,065.20	 	
5625	Level 5 Radiation Therapy	$2,071.24	$1,760.56	 	
5626	Level 6 Radiation Therapy	$3,009.44	$2,558.02	 	
5627	Level 7 Radiation Therapy	$13,140.43	$11,169.37	 	
5661	Therapeutic Nuclear Medicine	$449.96	$382.47	 	
5671	Level 1 Pathology	$85.95	$73.06	 	
5672	Level 2 Pathology	$183.96	$156.37	 	
5673	Level 3 Pathology	$376.96	$320.41	 	
5674	Level 4 Pathology	$792.95	$674.01	 	
5681	Transfusion Laboratory Procedures	$185.44	$157.62	 	
5691	Level 1 Drug Administration	$55.57	$47.23	 	
5692	Level 2 Drug Administration	$76.16	$64.73	 	
5693	Level 3 Drug Administration	$166.32	$141.37	 	
5694	Level 4 Drug Administration	$311.72	$264.97	 	
5695	Level 5 Drug Administration	$504.49	$428.81	 	
5701	Dosimetric Drug Administration	$3,548.90	$3,016.56	 	
5721	Level1 Diagnostic Tests and Related Services	$233.55	$198.52	 	
5722	Level 2 Diagnostic Tests and Related Services	$396.63	$337.14	 	
5723	Level 3 Diagnostic Tests and Related Services	$713.74	$606.68	 	
5724	Level 4 Diagnostic Tests and Related Services	$1,541.59	$1,310.35	 	
5731	Level 1 Minor Procedures	$22.86	$19.43	 	
5732	Level 2 Minor Procedures	$54.92	$46.68	 	
5733	Level 3 Minor Procedures	$100.69	$85.59	 	
5734	Level 4 Minor Procedures	$164.12	$139.51	 	
5741	Level 1 Electronic Analysis of Devices	$60.52	$51.44	 	
5742	Level 2 Electronic Analysis of Devices	$191.59	$162.85	 	
5743	Level 3 Electronic Analysis of Devices	$434.12	$369.01	 	
5771	Cardiac Rehabilitation	$187.06	$159.00	 	
5781	Resuscitation and Cardioversion	$840.76	$714.65	 	
5791	Pulmonary Treatment	$269.03	$228.67	 	
5801	Ventilation Initiation and Management	$822.80	$699.38	 	
5811	Manipulation Therapy	$41.31	$35.11	 	
5821	Level 1 Health and Behavior Services	$48.82	$41.49	 	
5822	Level 2 Health and Behavior Services	$125.37	$106.56	 	
5841	Psychotherapy	$225.07	$191.31	 	
5871	Dental Procedures	$668.18	$567.95	 	
5881	Ancillary Outpatient Services When Patient Dies	$11,058.75	$9,399.94	 	
8001	LDR Prostate Brachytherapy Composite	$6,093.79	$5,179.72	 	
8004	Ultrasound Composite	$517.07	$439.51	 	
8005	CT and CTA without Contrast Composite	$511.42	$434.70	 	
8006	CT and CTA with Contrast Composite	$889.04	$755.68	 	
8007	MRI and MRA without Contrast Composite	$1,018.91	$866.07	 	
8008	MRI and MRA with Contrast Composite	$1,552.03	$1,319.23	 	
8011	Comprehensive Observation Services	$3,913.45	$3,326.43	 	

Exhibit #5	
Effective for Dates of Service on and after 1/1/2017	
Rural Health Clinics	
AKRON CLINIC	 	 	 	
82 MAIN	 	 	 	 	
AKRON, CO 80720 - WASHINGTON COUNTY	
Telephone: (970)345-6336, Fax: (970)345-6576	
 	 	 	 	 	
ARKANSAS VALLEY FAMILY PRACTICE, LLC	 	
2317 SAN JUAN AVE	 	 	 	
LA JUNTA, CO 81050 - OTERO COUNTY	 	
Telephone: (719)383-2325, Fax: (719)383-2327	
 	 	 	 	 	
BASIN CLINIC	 	 	 	
421 WEST ADAMS ROAD	 	 	
NATURITA, CO 81422 - MONTROSE COUNTY	
Telephone: (970)865-2665, Fax: (970)825-2674	
 	 	 	 	 	
BRUSH FAMILY CLINIC	 	 	
2400 W EDISON	 	 	 	
BRUSH, CO 80723 - MORGAN COUNTY	 	
Telephone: (970)842-6740, Fax: (970)842-6241	
 	 	 	 	 	
BUENA VISTA HEALTH CENTER	 	 	
28374 COUNTY ROAD 317	 	 	
BUENA VISTA, CO 81211 - CHAFFEE COUNTY	
Telephone: (719)395-9048, Fax: (719)395-9064	
 	 	 	 	 	
BUTTON FAMILY PRACTICE	 	 	
715 SOUTH 9TH STREET	 	 	
CANON CITY, CO 81212 - FREMONT COUNTY	
Telephone: (719)269-8820, Fax: (719)204-0230	
 	 	 	 	 	
CENTENNIAL FAMILY HEALTH CENTER	 	
319 MAIN STREET	 	 	 	
ORDWAY, CO 81063 - CROWLEY COUNTY	 	
Telephone: (719)267-3503, Fax: (719)267-4153	
 	 	 	 	 	
CORTEZ PRIMARY CARE CLINIC	 	 	
118 NORTH CHESTNUT	 	 	
CORTEZ, CO 81321 - MONTEZUMA COUNTY	
Telephone: (970)564-9777, Fax: (970)564-8833	
 	 	 	 	 	
CREEDE FAMILY PRACTICE OF RIO GRANDE HOSPITAL	
802 RIO GRANDE AVENUE	 	 	
CREEDE, CO 81130 - MINERAL COUNTY	 	
Telephone: (719)658-0929, Fax: (719)657-2851	
 	 	 	 	 	
CUSTER COUNTY MEDICAL CENTER	 	
704 EDWARDS	 	 	 	
WESTCLIFFE, CO 81252 - CUSTER COUNTY	 	
Telephone: (719)783-2380, Fax: (719)783-2377	
 	 	 	 	 	
DOLORES MEDICAL CENTER	 	 	
507 CENTRAL AVENUE	 	 	
DOLORES, CO 81323 - MONTEZUMA COUNTY	
Telephone: (970)882-7221, Fax: (970)882-4243	
 	 	 	 	 	
EADS MEDICAL CLINIC	 	 	
1211 LUTHER STREET	 	 	
EADS, CO 81036 - KIOWA COUNTY	 	
Telephone: (719)438-2251, Fax: (719)438-2254	
 	 	 	 	 	
EASTERN PLAINS MEDICAL CLINIC OF CALHAN	
560 CRYSTOLA STREET	 	 	
CALHAN, CO 80808 - EL PASO COUNTY	 	
Telephone: (719)347-0100, Fax: (719)347-0551	
 	 	 	 	 	
FAMILY CARE CLINIC	 	 	 	
615 FAIRHURST	 	 	 	
STERLING, CO 80751 - LOGAN COUNTY	 	
Telephone: (970)521-3223, Fax: (970)521-3266	
 	 	 	 	 	
FAMILY PRACTICE OF HOLYOKE	 	 	
1001 EAST JOHNSON STREET	 	 	
HOLYOKE, CO 80734 - PHILLIPS COUNTY	 	
Telephone: (970)854-2500, Fax: (970)854-3440	
 	 	 	 	 	
FLORENCE MEDICAL CENTER	 	 	
501 W 5TH ST	 	 	 	
FLORENCE, CO 81226 - FREMONT COUNTY	
Telephone: (719)784-4816, Fax: (719)784-6014	
 	 	 	 	 	
FORT MORGAN PEDIATRIC CLINIC, PC	 	
1000 LINCOLN STREET, STE 202	 	 	
FORT MORGAN, CO 80701 - MORGAN COUNTY	
Telephone: (970)542-9187, Fax: (970)867-9187	
 	 	 	 	 	
GRAND RIVER HEALTH CLINIC WEST	 	
201 SIPPERELLE DRIVE	 	 	
PARACHUTE, CO 81635 - GARFIELD COUNTY	
Telephone: (970)285-7046, Fax: (970)285-6064	
 	 	 	 	 	
GRAND RIVER PRIMARY CARE	 	 	
501 AIRPORT ROAD	 	 	 	
RIFLE, CO 81650 - GARFIELD COUNTY	 	
Telephone: (970)625-1100, Fax: (970)625-0725	
 	 	 	 	 	
KIT CARSON CLINIC	 	 	 	
102 EAST 2ND AVENUE	 	 	
KIT CARSON, CO 80825 - CHEYENNE COUNTY	
Telephone: (719)962-3501, Fax: (719)962-3403	
 	 	 	 	 	
LAKE CITY AREA MEDICAL CENTER	 	
700 N HENSON STREET	 	 	
LAKE CITY, CO 81235 - HINSDALE COUNTY	 	
Telephone: (970)944-2331, Fax: (970)944-2320	
 	 	 	 	 	
LAMAR MEDICAL CLINIC	 	 	
403 KENDALL DRIVE	 	 	 	
LAMAR, CO 81052 - PROWERS COUNTY	 	
Telephone: (719)336-6767, Fax: (719)336-7217	
 	 	 	 	 	
LAS ANIMAS FAMILY PRACTICE	 	 	
304 Carson Avenue	 	 	 	
Las Animas, C) 81054 - BENT COUNTY	 	
Telephone: (719)456-6000, Fax (719)456-9701	
 	 	 	 	 	
MANCOS VALLEY HEALTH CENTER	 	
111 RAILROAD AVE	 	 	 	
MANCOS, CO 81328 - MONTEZUMA COUNTY	
Telephone: (970)564-2104, Fax: (970)564-2134	
 	 	 	 	 	
MEEKER FAMILY HEALTH CENTER	 	
345 CLEVELAND STREET	 	 	
MEEKER, CO 81641 - RIO BLANCO COUNTY	
Telephone: (970)878-4014, Fax: (970)878-3285	
 	 	 	 	 	
MT SAN RAFAEL HOSPITAL HEALTH CLINIC	 	
400 BENEDICTA STE A	 	 	
TRINIDAD, CO 81082 - LAS ANIMAS COUNTY	
Telephone: (719)846-2206, Fax: (719)846-7823	
 	 	 	 	 	
NORTH PARK MEDICAL CENTER - WALDEN	 	
350 MCKINLEY STREET	 	 	
WALDEN, CO 80480 - JACKSON COUNTY	 	
Telephone: (970)723-4255, Fax: (970)723-4268	
 	 	 	 	 	
PAGOSA MOUNTAIN CLINIC	 	 	
95 SOUTH PAGOSA BLVD	 	 	
PAGOSA SPRINGS, CO 81147 - ARCHULETA COUNTY	
Telephone: (970)731-3700, Fax: (970)731-3707	
 	 	 	 	 	
PARKE HEALTH CLINIC	 	 	
182 16TH ST	 	 	 	
BURLINGTON, CO 80807 - KIT CARSON COUNTY	
Telephone: (719)346-9481, Fax: (719)346-9485	
 	 	 	 	 	
PEDIATRIC ASSOCIATION OF CANON CITY	 	
1335 PHAY AVENUE, SUITE A	 	 	
CANON CITY, CO 81212 - FREMONT COUNTY	
Telephone: (719)269-1727, Fax: (719)269-1730	
 	 	 	 	 	
PRAIRIE VIEW RURAL HEALTH CLINIC	 	
615 WEST 5TH NORTH	 	 	
CHEYENNE WELLS, CO 80810 - CHEYENNE COUNTY	
Telephone: (719)767-5669, Fax: (719)767-5098	
 	 	 	 	 	
R & D MEDICAL MANAGEMENT CORP	 	
109 Latigo Lane, Ste C	 	 	
Canon City, CO 81212 - FREMONT COUNTY	
Telephone: (719)276-3211, Fax (719)276-3011	
 	 	 	 	 	
RIO GRANDE HOSPITAL CLINIC	 	 	
0310C COUNTY RD 14	 	 	
DEL NORTE, CO 81132 - RIO GRANDE COUNTY	
Telephone: (719)657-2418, Fax: (719)658-3001	
 	 	 	 	 	
ROCKY FORD FAMILY HEALTH CENTER	 	
1014 ELM AVENUE	 	 	 	
ROCKY FORD, CO 81067 - OTERO COUNTY	 	
Telephone: (719)254-7421, Fax: (719)254-6966	
 	 	 	 	 	
SABATINI PEDIATRICS PC	 	 	
612 YALE PLACE	 	 	 	
CANON CITY, CO 81212 - FREMONT COUNTY	
Telephone: (719)275-3442, Fax: (719)275-2306	
 	 	 	 	 	
SAN LUIS VALLEY HEALTH ANTONITO CLINIC	
115 MAIN STREET	 	 	 	
ANTONITO, CO 81120 - CONEJOS COUNTY	 	
Telephone: (719)376-2308, Fax: (719)376-2395	
 	 	 	 	 	
SAN LUIS VALLEY LA JARA MEDICAL CLINIC	 	
509 MAIN STREET	 	 	 	
LA JARA, CO 81140 - CONEJOS COUNTY	 	
Telephone: (719)274-5000, Fax: (719)274-4111	
 	 	 	 	 	
SOUTHEAST COLORADO PHYSICIANS CLINIC	
900 CHURCH STREET	 	 	 	
SPRINGFIELD, CO 81073 - BACA COUNTY	 	
Telephone: (719)523-6628, Fax: (719)523-4513	
 	 	 	 	 	
SOUTHWEST MEMORIAL PRIMARY CARE	 	
33 NORTH ELM STREET	 	 	
CORTEZ, CO 81321 - MONTEZUMA COUNTY	
Telephone: (970)565-8556, Fax: (970)564-1134	
 	 	 	 	 	
SOUTHWEST WALK-IN CARE	 	 	
2095 NORTH DOLORES ROAD, STE C	 	
CORTEZ, CO 81321 - MONTEZUMA COUNTY	
Telephone: (970)564-1037, Fax: (970)564-1041	
 	 	 	 	 	
SPANISH PEAKS FAMILY CLINIC	 	 	
23400 US HIGHWAY 160	 	 	
WALSENBURG, CO 81089 - HUERFANO COUNTY	
Telephone: (719)738-4591, Fax: (719)738-4553	
 	 	 	 	 	
STRATTON MEDICAL CLINIC	 	 	
500 NEBRASKA AVENUE	 	 	
STRATTON, CO 80836 - KIT CARSON COUNTY	
Telephone: (719)348-4650, Fax: (719)348-4653	
 	 	 	 	 	
SURFACE CREEK FAMILY PRACTICE	 	
255 SW 8TH AVE	 	 	 	
CEDAREDGE, CO 81413 - DELTA COUNTY	 	
Telephone: (970)856-3146, Fax: (970)856-4385	
 	 	 	 	 	
TRINIDAD FAMILY MEDICAL CENTER	 	
1502 E Main Street	 	 	 	
Trinidad, CO 81082 - LAS ANIMAS COUNTY	 	
 	 	 	 	 	
VALLEY MEDICAL CLINIC	 	 	
116 E NINTH STREET	 	 	 	
JULESBURG, CO 80737 - SEDGWICK COUNTY	
Telephone: (970)474-3376, Fax: (970)474-2461	
 	 	 	 	 	
WALSH MEDICAL CLINIC	 	 	
137 KANSAS STREET	 	 	 	
WALSH, CO 81090 - BACA COUNTY	 	
Telephone: (719)324-5253, Fax: (719)324-5621	
 	 	 	 	 	
WASHINGTON COUNTY CLINIC	 	 	
482 ADAMS AVENUE	 	 	 	
AKRON, CO 80720 - WASHINGTON COUNTY	
Telephone: (970)345-2262, Fax: (970)345-2265	
 	 	 	 	 	
YUMA CLINIC	 	 	 	
1000 W 8TH AVENUE	 	 	
YUMA, CO 80759 - YUMA COUNTY	 	
Telephone: (970)848-4792, Fax: (970)848-5405	

Exhibit # 6
Dental Fee Schedule
Effective January 1, 2017 

CDT 2016	2017 Fees	
D0120	$67.15	
D0140	$112.29	
D0145	$104.19	
D0150	$118.08	
D0160	$237.31	
D0170	$78.72	
D0171	$71.25	
D0180	$128.50	
D0190	$62.00	
D0191	$44.00	
D0210	$187.18	
D0220	$37.68	
D0230	$34.03	
D0240	$58.35	
D0250	$71.72	
D0251	BR	
D0270	$38.89	
D0272	$63.21	
D0273	$76.58	
D0274	$88.74	
D0277	$133.71	
D0290	$218.79	
D0310	$556.70	
D0320	$948.10	
D0321	BR	
D0322	$765.77	
D0330	$165.54	
D0340	$186.38	
D0350	$89.13	
D0351	$73.75	
D0364	$1,251.00	
D0365	$1,251.00	
D0366	$1,251.00	
D0367	$1,251.00	
D0368	$1,831.00	
D0369	$3,274.00	
D0370	$1,102.00	
D0371	BR	
D0380	     $998.00	
D0381	$998.00	
D0382	$998.00	
D0383	$998.00	
D0384	$1,459.00	
D0385	$2,382.00	
D0386	$596.00	
D0391	BR	
D0393	BR	
D0394	BR	
D0395	BR	
D0415	       $72.00	
D0416	$106.00	
D0417	$97.00	
D0418	$100.00	
D0422	BR	
D0423	BR	
D0425	$62.00	
D0431	$100.00	
D0460	$100.00	
D0470	$219.00	
D0472	$137.00	
D0473	$290.00	
D0474	$325.00	
D0475	$175.00	
D0476	$170.00	
D0477	$232.00	
D0478	$212.00	
D0479	$325.00	
D0480	$200.00	
D0481	$858.14	
D0482	$250.00	
D0483	$250.00	
D0484	$375.00	
D0485	$517.00	
D0486	$240.00	
D0502	BR	
D0601	       $93.00	
D0602	       $93.00	
D0603	       $93.00	
D0999	BR	
D1110	     $120.33	
D1120	$83.87	
D1206	$72.93	
D1208	$45.15	
D1310	$70.61	
D1320	$77.56	
D1330	$97.24	
D1351	$78.72	
D1352	$94.50	
D1353	$80.75	
D1354	BR	
D1510	$503.57	
D1515	$704.99	
D1520	$554.51	
D1525	$856.64	
D1550	$108.82	
D1555	$104.19	
D1999	BR	
D2140	$262.55	
D2150	$339.13	
D2160	$410.84	
D2161	$500.79	
D2330	$239.45	
D2331	$306.31	
D2332	$374.38	
D2335	$443.66	
D2390	$491.06	
D2391	$280.78	
D2392	$368.30	
D2393	$457.03	
D2394	$560.35	
D2410	$457.26	
D2420	$762.88	
D2430	$1,322.01	
D2510	$1,209.72	
D2520	$1,372.95	
D2530	$1,582.48	
D2542	$1,551.22	
D2543	$1,623.00	
D2544	$1,687.82	
D2610	$1,423.88	
D2620	$1,502.60	
D2630	$1,601.00	
D2642	$1,555.85	
D2643	$1,677.40	
D2644	$1,779.27	
D2650	$935.36	
D2651	$1,114.80	
D2652	$1,171.52	
D2662	$1,016.40	
D2663	$1,195.82	
D2664	$1,281.49	
D2710	$628.41	
D2712	$628.41	
D2720	$1,548.55	
D2721	$1,451.31	
D2722	$1,482.92	
D2740	$1,588.67	
D2750	$1,568.01	
D2751	$1,459.83	
D2752	$1,495.07	
D2780	$1,503.58	
D2781	$1,414.85	
D2782	$1,461.04	
D2783	$1,546.13	
D2790	$1,512.09	
D2791	$1,433.08	
D2792	$1,459.83	
D2794	$1,548.55	
D2799	$628.41	
D2910	$143.43	
D2915	$143.43	
D2920	$144.65	
D2921	$179.50	
D2929	$543.00	
D2930	$395.04	
D2931	$447.31	
D2932	$476.48	
D2933	$545.76	
D2934	$545.76	
D2940	$150.73	
D2941	$130.00	
D2949	$130.00	
D2950	$376.80	
D2951	$85.08	
D2952	$595.60	
D2953	$297.80	
D2954	$476.48	
D2955	$367.08	
D2957	$238.23	
D2960	$1,152.30	
D2961	$1,306.67	
D2962	$1,419.72	
D2971	$228.51	
D2975	$695.27	
D2980	BR	
D2981	BR	
D2982	BR	
D2983	BR	
D2990	$94.00	
D2999	BR	
D3110	     $131.25	
D3120	$105.35	
D3220	$268.80	
D3221	$295.20	
D3222	$273.20	
D3230	$307.52	
D3240	$379.24	
D3310	$1,207.00	
D3320	$1,479.27	
D3330	$1,834.20	
D3331	$472.84	
D3332	$899.47	
D3333	$414.49	
D3346	$1,609.34	
D3347	$1,893.76	
D3348	$2,343.50	
D3351	$968.76	
D3352	$433.93	
D3353	  $1,335.84	
D3355	$577.25	
D3356	     $259.00	
D3357	BR	
D3410	  $1,920.50	
D3421	  $2,138.07	
D3425	$2,421.29	
D3426	  $818.03	
D3427	$1035.75	
D3428	$1509.25	
D3429	$1439.50	
D3430	$601.67	
D3431	$1772.25	
D3432	$1523.50	
D3450	$1,251.97	
D3460	$4,676.05	
D3470	$2,388.47	
D3910	$334.27	
D3920	$951.74	
D3950	$433.93	
D3999	BR	
D4210	  $1,603.00	
D4211	$712.00	
D4212	$570.00	
D4230	$2,244.00	
D4231	$1,096.39	
D4240	$2,030.00	
D4241	$1,175.00	
D4245	$1,496.00	
D4249	$2,226.00	
D4260	$3,383.00	
D4261	$1,816.00	
D4263	$1,211.00	
D4264	$1,033.00	
D4265	BR	
D4266	  $1,247.00	
D4267	$1,603.00	
D4268	BR	
D4270	  $2,404.00	
D4273	$2,938.00	
D4274	$1,667.00	
D4275	$2,208.00	
D4276	$3,294.00	
D4277	$2,493.00	
D4278	$819.00	
D4283	BR	
D4285	BR	
D4320	$625.99	
D4321	$633.28	
D4341	$361.00	
D4342	$217.57	
D4355	$246.75	
D4381	BR	
D4910	     $222.44	
D4920	$161.66	
D4921	BR	
D4999	BR	
D5110	$2,343.00	
D5120	$2,343.00	
D5130	$2,555.00	
D5140	$2,555.00	
D5211	$1,977.00	
D5212	$2,298.00	
D5213	$2,771.36	
D5214	$2,589.00	
D5221	BR	
D5222	BR	
D5223	BR	
D5224	BR	
D5225	$1,977.00	
D5226	$2,298.00	
D5281	$1,509.00	
D5410	$128.00	
D5411	$128.00	
D5421	$128.00	
D5422	$128.00	
D5510	$274.70	
D5520	$214.00	
D5610	$278.00	
D5620	$316.03	
D5630	$363.00	
D5640	$235.00	
D5650	$321.00	
D5660	$385.00	
D5670	$1,006.44	
D5671	$1,006.44	
D5710	$951.00	
D5711	$909.00	
D5720	   $898.00	
D5721	   $898.00	
D5730	$537.00	
D5731	$537.00	
D5740	$492.00	
D5741	     $492.00	
D5750	     $716.00	
D5751	$716.00	
D5760	$705.00	
D5761	$705.00	
D5810	$1,133.00	
D5811	$1,218.00	
D5820	$876.00	
D5821	$930.00	
D5850	$224.00	
D5851	$224.00	
D5862	BR	
D5863	$2,295.25	
D5864	BR	
D5865	$2,295.25	
D5866	  $3,146.00	
D5867	BR	
D5875	BR	
D5899	BR	
D5911	$594.00	
D5912	$594.00	
D5913	$12,514.00	
D5914	$12,514.00	
D5915	$16,935.00	
D5916	$4,517.00	
D5919	BR	
D5922	BR	
D5923	BR	
D5924	BR	
D5925	BR	
D5926	    BR	
D5927	BR	
D5928	BR	
D5929	BR	
D5931	$6,738.00	
D5932	$12,602.00	
D5933	BR	
D5934	$11,486.00	
D5935	$9,994.00	
D5936	$11,225.00	
D5937	$1,411.50	
D5951	$1,834.00	
D5952	$5,956.00	
D5953	$11,310.00	
D5954	$10,481.00	
D5955	$9,694.00	
D5958	BR	
D5959	BR	
D5960	BR	
D5982	  $997.93	
D5983	 $2,416.43	
D5984	  $2,416.43	
D5985	 $2,416.43	
D5986	 $241.00	
D5987	$3,627.07	
D5988	$641.00	
D5991	$246.00	
D5992	BR	
D5993	BR	
D5994	$227.50	
D5999	BR	
D6010	$3,914.00	
D6011	BR	
D6012	$3,698.00	
D6013	$3,623.00	
D6040	$14,418.34	
D6050	$10,047.00	
D6051	BR	
D6052	$1,535.25	
D6055	$1,176.00	
D6056	$812.00	
D6057	$1,005.00	
D6058	$2,253.00	
D6059	$2,379.96	
D6060	$2,249.90	
D6061	$2,294.88	
D6062	$2,286.36	
D6063	$1,963.04	
D6064	$2,079.74	
D6065	$2,217.00	
D6066	$2,311.89	
D6067	$2,242.61	
D6068	$2,234.00	
D6069	$2,379.96	
D6070	  $2,249.90	
D6071	  $2,144.00	
D6072	  $2,343.50	
D6073	  $2,121.06	
D6074	  $2,106.00	
D6075	$2,217.00	
D6076	$2,311.89	
D6077	$2,242.61	
D6080	$184.00	
D6090	BR	
D6091	$887.00	
D6092	$173.00	
D6093	$271.00	
D6094	$1,887.68	
D6095	BR	
D6100	BR	
D6101	$587.50	
D6102	$769.75	
D6103	$672.50	
D6104	$672.50	
D6110	$2,705.00	
D6111	$2,705.00	
D6112	$2,705.00	
D6113	$2,705.00	
D6114	BR	
D6115	BR	
D6116	BR	
D6117	BR	
D6190	$395.00	
D6194	$1,817.00	
D6199	BR	
D6205	$1,016.16	
D6210	$1,553.41	
D6211	$1,454.96	
D6212	$1,514.52	
D6214	$1,563.15	
D6240	$1,533.97	
D6241	$1,416.06	
D6242	$1,493.86	
D6245	$1,582.59	
D6250	$1,514.52	
D6251	$1,396.62	
D6252	$1,441.59	
D6253	$652.72	
D6545	$610.19	
D6548	$651.00	
D6549	$377.21	
D6600	$1,186.33	
D6601	$1,266.56	
D6602	$1,294.51	
D6603	$1,424.58	
D6604	$1,268.99	
D6605	$1,344.35	
D6606	$1,248.32	
D6607	$1,385.67	
D6608	$1,277.00	
D6609	$1,355.29	
D6610	$1,396.62	
D6611	$1,527.89	
D6612	$1,389.33	
D6613	$1,452.53	
D6614	$1,358.93	
D6615	$1,413.64	
D6624	$1,294.51	
D6634	$1,358.93	
D6710	$1,345.00	
D6720	$1,619.06	
D6721	$1,535.18	
D6722	$1,563.15	
D6740	$1,650.00	
D6750	$1,656.73	
D6751	$1,546.13	
D6752	$1,583.81	
D6780	$1,563.15	
D6781	$1,516.00	
D6782	$1,563.15	
D6783	$1,561.00	
D6790	$1,599.60	
D6791	$1,516.96	
D6792	$1,571.65	
D6793	$637.00	
D6794	  $1,571.65	
D6920	$420.57	
D6930	     $245.53	
D6940	$556.70	
D6950	$1,074.51	
D6980	BR	
D6985	$934.72	
D6999	BR	
D7111	$229.73	
D7140	$305.09	
D7210	$405.98	
D7220	$509.29	
D7230	$678.25	
D7240	$796.15	
D7241	$1,000.37	
D7250	$429.07	
D7251	$770.70	
D7260	$3,182.19	
D7261	$1,104.60	
D7270	$828.45	
D7272	$1,104.60	
D7280	$772.80	
D7282	$386.40	
D7283	$331.80	
D7285	$1,546.65	
D7286	$662.55	
D7287	$265.65	
D7288	$265.65	
D7290	  $662.55	
D7291	$446.76	
D7292	$1,060.50	
D7293	$662.55	
D7294	$552.30	
D7295	BR	
D7310	$1,009.00	
D7311	$883.00	
D7320	$1,640.00	
D7321	$1,388.00	
D7340	$6,938.00	
D7350	$20,182.00	
D7410	$3,027.00	
D7411	$4, 793.00	
D7412	$5,298.00	
D7413	$3,532.00	
D7414	$5,298.00	
D7415	$5,928.00	
D7440	$4,793.00	
D7441	$7,064.00	
D7450	$3,027.00	
D7451	$4,137.00	
D7460	$3,027.00	
D7461	$4,137.00	
D7465	$1,640.00	
D7471	$3,749.00	
D7472	$4,455.00	
D7473	$4,203.00	
D7485	$3,749.00	
D7490	$30,273.00	
D7510	$1,085.00	
D7511	$1,640.00	
D7520	$5,167.00	
D7521	$5,676.00	
D7530	$1,862.00	
D7540	$2,064.00	
D7550	$1,287.00	
D7560	$10,217.00	
D7610	$16,524.00	
D7620	$12,392.00	
D7630	$21,484.00	
D7640	$13,633.00	
D7650	$10,328.00	
D7660	$6,090.00	
D7670	$4,753.00	
D7671	$8,956.00	
D7680	$30,984.00	
D7710	$19,420.00	
D7720	$13,633.00	
D7730	$28,093.00	
D7740	$13,900.00	
D7750	$17,679.00	
D7760	$7,094.00	
D7770	$9,612.00	
D7771	$7,417.00	
D7780	$41,313.00	
D7810	$18,174.00	
D7820	$2,977.00	
D7830	$1,705.00	
D7840	$24,773.00	
D7850	$21,393.00	
D7852	$24,496.00	
D7854	$25,278.00	
D7856	$17,937.00	
D7858	$51,126.00	
D7860	$21,792.00	
D7865	$35,117.00	
D7870	$1,160.00	
D7871	$2,321.00	
D7872	$12,387.00	
D7873	$14,914.00	
D7874	$21,393.00	
D7875	$23,436.00	
D7876	$25,268.00	
D7877	$22,301.00	
D7880	$2,785.00	
D7881	BR	
D7899	BR	
D7910	  $1,655.00	
D7911	$4,132.00	
D7912	$7,437.00	
D7920	$12,185.00	
D7921	$1,125.00	
D7940	BR	
D7941	$31,030.00	
D7943	$28,507.00	
D7944	$25,404.00	
D7945	$33,805.00	
D7946	$41,878.00	
D7947	$35,218.00	
D7948	$45,712.00	
D7949	$59,537.00	
D7950	BR	
D7951	BR	
D7952	BR	
D7953	$858.00	
D7955	BR	
D7960	$1,388.00	
D7963	$2,270.00	
D7970	$2,018.00	
D7971	$757.00	
D7972	$2,825.00	
D7980	$3,179.00	
D7981	BR	
D7982	$7,518.00	
D7983	  $7,215.00	
D7990	  $6,206.00	
D7991	  $5,137.00	
D7995	BR	
D7996	BR	
D7997	  $1,160.00	
D7998	  $5,046.00	
D7999	BR	
D8010	BR	
D8020	BR	
D8030	     BR	
D8040	BR	
D8050	BR	
D8060	BR	
D8070	     BR	
D8080	BR	
D8090	BR	
D8210	BR	
D8220	BR	
D8660	  $700.13	
D8670	     $525.09	
D8680	 $1,154.73	
D8681	BR	
D8690	$545.76	
D8691	     $512.95	
D8692	     $571.28	
D8693	     $528.75	
D8694	BR	
D8999	BR	
D9110	$215.15	
D9120	$243.11	
D9210	$181.65	
D9211	$200.55	
D9212	$312.90	
D9215	$150.15	
D9219	BR	
D9223	BR	
D9243	BR	
D9248	$437.85	
D9310	$487.42	
D9410	     $557.92	
D9420	     $903.13	
D9430	     $151.94	
D9440	$305.09	
D9450	$151.94	
D9610	     BR	
D9612	BR	
D9630	BR	
D9910	$103.03	
D9911	$144.70	
D9920	BR	
D9930	BR	
D9932	BR	
D9933	BR	
D9934	BR	
D9935	BR	
D9940	$940.80	
D9941	$307.52	
D9942	$354.24	
D9943	BR	
D9950	$560.29	
D9951	$251.20	
D9952	$1,179.62	
D9970	$133.13	
D9971	$171.33	
D9972	$590.39	
D9973	$97.24	
D9974	$516.31	
D9975	$576.00	
D9985	BR	
D9986	BR	
D9987	BR	
D9999	BR	

Exhibit # 7 
Evaluation and Management (E&M) Guidelines for Colorado Workers’ Compensation Claims

This E&M Guidelines for Colorado Workers’ Compensation Claims is intended for the physicians who manage injured workers’ medical and non-medical care. Providers may also use the “1997 Documentation Guidelines for Evaluation and Management Services” as developed by Medicare. The Level of Service is determined by:
1. History (Hx), 2. Examination (Exam), and 3. Medical Decision Making (MDM) 
Documentation requirements for any billed office visit:
•	Chief complaint and medical necessity 
•	Patient specific and pertain directly to the current visit.
•	Information copied directly from prior records without change is not considered current or counted.
•	CPT© criteria for a consultation is required to bill a consultation code

Table I – History (Hx) Component:   All three elements in the table must be met and documented.
HISTORY ELEMENTS	Requirements for a Problem Focused (PF) Level	Requirements for an Extended Problem Focused (EPF) Level	Requirements for a Detailed (D) Level	Requirements for a Comprehensive (C) Level	
A. History of Present Illness/Injury (HPI)	Brief 1-3 elements	Brief 1-3 elements	Extended 4+ elements (Requires a detailed patient specific description of the patient's progress with the current TX plan, which should include objective functional gains/losses, ADLs) (Initial visits require(s) an injury causation statement and or an objective functional goal treatment plan.  Follow-up visits require objective functional gains/losses, ADLs etc)	Extended 4+ elements (requires a detailed patient specific description of the patient's progress with the current TX plan, which should include objective functional gains/losses, ADLs) (Initial visits require(s) an injury causation statement and or an objective functional goal treatment plan.  Follow-up visits require objective functional gains/losses, ADLs etc)	
B. Review of Systems (ROS) 
(not required for established patient visits)	None	Problem pertinent-limited to injured body part	2-9 body parts or body systems	Complete 10+	
C. Past Medical, Family and Social/Work History (PMFSH)	None	None	Pertinent 1 of 4 types of histories	2 or more of the 4 types of histories	

A. HPI Elements represents the injured worker relaying their condition to the physician and should include the following:
	1. Location (where?) 
	2. Quality (sharp, dull) 
	3. Severity (pain level 1-10 or pain diagram)
	4. Duration (how long?)
	5. Timing (how often?) 
	6. Context (what ADLs or functions aggravates/relieves?)
	7. Modifying factors (doing what?) 
	8. Associated signs (nausea, when?) 
For the provider to achieve an “extended” or greater HPI in an initial patient/injured workers visit it is necessary required for the provider to discuss the causality of the patient/injured worker’s work related injury(s) to the patient/injured worker’s job duties and or create and implement a treatment plan with objective functional measureable goals. 
For the provider to achieve an “extended” HPI in an established patient/injured worker visit it is necessary required to document a detailed description of the patient’s objective functional gains or losses progress since the last visit with current treatment plan that includes patient pertinent objective functional gains, such as ADLs, physical therapy goals and return to work. 
B. Review of Systems (ROS) : each system/body part is counted once whether positive or negative. Identify, perform and documentation of all pertinent ROS systems with either a “positive or negative” response is necessary to be counted.
	1. Constitutional symptoms (e.g., fever, weight loss)
	 2. Eyes
	 3. Ears, Nose, Mouth, Throat 
	4. Cardiovascular
	 5. Respiratory 
	6. Gastrointestinal 
	7. Genitourinary
	8. Musculoskeletal 
	9. Integumentary (skin and/or breast) 
	10. Neurological 
	11. Psychiatric 
	12. Endocrine 
	13. Hematologic/Lymphatic 
	14. Allergic/Immunologic
C.  PMFSH consists of a review of four areas (NOTE: Employers should not have access to any patient’s or the family’s generic/hereditary diagnoses or testing information, etc.) 
	1. Past history – the patient’s past experiences with illnesses, operations, injuries and 	treatments.
	 2. Family history – a review of medical events in the patient’s family, including diseases 	which may be 	hereditary or place the patient at risk and any family situations that can 	interfere with or support the 	injured worker’s treatment plan and returning to work.
	3. Occupational/Social History/Military – an age appropriate review of past and current 	work 	activities, occupational history, current work status, any work situations that 	support or interfere 	with return to work. For established visits specific updates of 	progress must be discussed. 	
4. Non-Occupational/Social History – Hobbies, current recreational physical activities and the patient’s support relationships, etc. For established visits specific updates of progress must be discussed.

TABLE II: Examination Component: Each bullet is counted only when it is pertinent and related to the workers’ compensation injury and the medical decision making process.
Physician's Examination Component	
Level of Examination Performed and Documented	# of Bullets Required for each level	
Problem Focused	1-5 elements identified by a bullet as indicated in the guideline	
Expanded Problem Focused	6 elements identified by a bullet as indicated in this guideline	
Detailed	7-12 elements identified by a bullet as indicated in this guideline	
Comprehensive	>13 elements identified by a bullet as indicated in this guideline	

Examination Components:
Constitutional Measurement: Vital signs (may be measured and recorded by ancillary staff) – any of three (3) vital signs is counted as one bullet: 
	1. sitting or standing blood pressure 
	2. supine blood pressure
	3. pulse rate and regularity
	4. respiration 
	5. temperature 
	6. height 
	7. weight or BMI 
•	One bullet for commenting on the general appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Musculoskeletal: Each of the six body areas with three (3) assessments is counted as one bullet. 
	1. head and or neck 
	2. spine or ribs and pelvis or all three 
	3. right upper extremity (shoulder, elbow, wrist, entire hand) 
	4. left upper extremity (shoulder, elbow, wrist, entire hand) 
	5. right lower extremity (hip, knee, ankle, entire foot) 
	6. left lower extremity (hip, knee, ankle, entire foot) 

Assessment of a given body area includes: 
•	Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions 
•	Assessment of range of motion with notation of any pain (e.g., straight leg raise), crepitation or contracture 
•	Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
•	Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (fasciculation, tardive dyskinesia)
•	Examination of gait and station 
•	Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechia, ischemia, infections, nodes)
•	 Neck – one bullet for both examinations
•	Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
•	Examination of thyroid (e.g., enlargement, tenderness, mass)

Neurological: One bullet for each neurological examination/assessment(s) per extremity: 
1. Test coordination (e.g., finger/nose, heel/knee/shin, rapid alternating movements in the upper and 	lower extremities)
	 
2. Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes 	(e.g., Babinski)

	3. Examination of sensation (e.g., by touch, pin, vibration, proprioception) 

	4. One bullet for all of the 12 cranial nerves assessments with notations of any deficits 

Cardiovascular: 
	1. One bullet per extremity examination/assessment of peripheral vascular system by: 			a. Observation (e.g., swelling, varicosities)
		b. Palpation (e.g., pulses, temperature, edema, tenderness) 

	2. One bullet for palpation of heart (e.g., location, size, thrills) 	

	3. One bullet for auscultation of heart with notation of abnormal sounds and murmurs 

	4. One bullet for examination of each one of the following: 
		a. carotid arteries (e.g., pulse amplitude, bruits) 
		b. abdominal aorta (e.g., size, bruits)
	 	c. femoral arteries (e.g., pulse amplitude, bruits) 

Skin:  One bullet for pertinent body part(s) inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes, lesions, café au lait spots, ulcers)

Respiratory: (one bullet for each examination/assessment)
	1. Assessment of respiratory effort (e.g., intercostal retractions, use of accessory 	muscles, diaphragmatic movement) 

	2. Percussion of chest (e.g., dullness, flatness, hyperresonance)

	3. Palpation of chest (e.g., tactile fremitus) 

	4. Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

Gastrointestinal:  One bullet for each examination /assessment
	1. Examination of abdomen with notation of presence of masses or tenderness and liver 	and spleen

	2. Examination of presence or absence of hernia 

3. Examination (when indicated) of anus, perineum and rectum, including sphincter tone, present 	of hemorrhoids, rectal masses and/or obtain stool sample of occult blood test when indicated 

Psychiatric: 
	1. One bullet for assessment of mood and affect (e.g., depression, anxiety, agitation) if 	not counted under the Neurological system 

	2. One bullet for a mental status examination which includes: 
		a. Attention span and concentration; and
		b. Language (e.g., naming objects, repeating phrases, spontaneous speech) 			orientation to time, place and person; and
		c. Recent and remote memory; and
		d. Fund of knowledge (e.g., awareness of current events, past history, 				vocabulary)

Eyes: One bullet for both eyes and all three examinations/assessments
	1. Inspection of conjunctivae and lids; and

2. Examination of pupils and irises (e.g., reaction of light and accommodation, size and symmetry); and 

3. Opthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages) 

Ears and Nose, Mouth and Throat: 
1. One bullet for all of the following examinations/assessments 
a.	External inspection of ears and nose (e.g., overall appearance, scars, lesions, asses) 
b.	Otoscopic examination of external auditory canals and tympanic membranes
c.	Assessment of hearing with tuning fork and clinical speech reception thresholds (e.g., 	whispered voice, finger rub, tuning fork) 

	2. One bullet for all of the following examinations/assessments: 
a.	Inspection of nasal mucosa, septum and turbinates
b.	Inspection of lips, teeth and gums 
c.	Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx (e.g., asymmetry, lesions, hydration of mucosal surfaces) 

Genitourinary MALE: One bullet for each of the following examination of the male genitalia
1. The scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass)
	2. Epididymides (e.g., size, symmetry, masses) 	
	3. Testes (e.g., size symmetry, masses)
 	4. Urethral meatus (e.g., size location, lesions, discharge) 
5. Examination of the penis (e.g., lesions, presence of absence of foreskin, foreskin retract ability, 	plaque, masses, scarring, deformities) 
6. Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness) 
	7. Inspection of anus and perineum 	
Genitourinary FEMALE: One bullet for each of the following female pelvic examination(s) (with or without specimen collection for smears and cultures): 
1. Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele rectocele) 
	2. Examination of urethra (e.g., masses, tenderness, scarring) 
	3. Examination of bladder (e.g., fullness, masses, tenderness)
	4. Cervix (e.g., general appearance, lesions, discharge)
5. Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support) 
	6. Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity) 

Chest:  One bullet for both examinations/assessments of both breasts
 	1. Inspection of breasts (e.g., symmetry, nipple discharge); and	
 	2. Palpation of breasts and axillae (e.g., masses or lumps, tenderness) 

Lymphatic palpation of lymph nodes: Two or more areas is counted as one bullet: 
	1. Neck 
	2. Axillae 
	3. Groin 
	4. Other

Verify all of the completed examination components listed in the report documents the relevance/relatedness to the injurty and or “reasonable and necessity” for that specified patient’s condition.  Any examination bullet that is not clearly related to the injury or a patient’s specific condition will not be counted/considered in the total number of bullets for the level of service. 

TABLE III: Medical Decision Making Component (MDM):  TABLES A, B, AND C

TABLE III A:
A.  Number of Diagnosis & Management Options	 	 	 	 	 	
Category of Problem(s)	Occurrence of Problem(s)	 	Value	 	Total	
Self-limited or minor problem	(max 2)	X	1	 	 	
Established problem, stable or improved	 	X	1	 	 	
Established problem, minor worsening with improvement with expected time frames	 	X	2	 	 	
Established problem without improvement within expected time frame that requires treatment plan changes with or without additional workup		X	4			
New problem with no additional workup planned or established patient with worsening of condition and no additional workup planned	(max 1)	X	3	 	 	
New problem, additional workup planned or established patient with worsening of condition and no additional workup planned	 	X	4	 	 	

TABLE III B:
B. Amount and/or Complexity of Data Reviewed	 	
Date Type:	Points	
Lab(s) ordered and/or reports reviewed	1	
X-ray (s) ordered and/or reports reviewed	1	
Discussion of test results with performing physician	1	
Decision to obtain old records and/or obtain history from someone other than the patient	1	
Medicine section (90701-99199) ordered and /or physical therapy records reviewed and commented on progress 9state whether the patient is progressing and how they are functionally progressing or not and document any planned changes to the plan of care	2	
Review and summary of old records and/or discussion with other health provider	2	
Independent visualization of images, tracing or specimen	2	
TOTAL	 	

TABLE III C: 
C.  Table of Risk (the highest one in any one category determines the overall risk for this portion)	
Level of Risk	Presenting Problem(s)	Diagnostic Procedure(s) Ordered or Addressed	Management Option(s) Selected	
Minimal	One self-limited or minor problem, e.g., cold, insect bite, tinea corpori, minor non-sutured laceration	Lab tests requiring venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound
KOH prep	Rest
Gargles
Elastic bandages
Superficial dressings	
Low	Two or more self-limited or minor problems
One stable chronic illness, e.g., well-controlled HTN, NIDDM, cataract, BPH
Acute, uncomplicated illness or injury, e.g., allergic rhinitis or simple sprain cyctitis 
Acute laceration repair	Physiologic tests nor under stress, e.g., PFTs
Non-cardiovascular imaging studies w/contrast, e.g., barium enema
Superficial needle biopsies
Lab tests requiring arterial puncture
Skin biopsies	Over-the-counter drugs
Minor surgery w/no identified risk factors
PT/OT
IV fluids w/o additives
Simple or layered closure
Vaccine injection	
Moderate	One of more chronic illnesses with mild exacerabation, progression or side effects of treatment
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis, e.g., new extremity neurologic complaints
Acute illness with systemic symptoms, e.g., pyelonephritis, colitis
Acute complicated injury, e.g., head injury with brief loss of consciousness	Physiologic tests under stress, e.g. cardiac stress test, 
Discography, stress tests
Diagnostic injections  
Deep needle or incisional biopsies
Cardiovascular imaging studies with contrast and no identified risk factors e.g. arteriogram, cardiac cath
Obtain fluid from body cavity, e.g. lumbar puncture, thoracentesis, culdocentesis
	Minor surgery with identified risk factors
Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
Prescription drug management 
Therapeutic nuclear medicine IV fluids with additives
Closed Tx of Fx or dislocation w/o manipulation
Inability to return the injured worker to work and requires detailed functional improvement plan.	

C.  Table of Risk (the highest one in any one category determines the overall risk for this portion)	
Level of Risk	Presenting Problem(s)	Diagnostic Procedure(s) Ordered or Addressed	Management Option(s) Selected	
High	One or more chronic illness with severe exacerbation, progression or side effects of treatment
Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others;
An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss	Cardiovascular imaging studies with contrast with identified risk factors
Cardiac electrophysiological tests
Diagnostic endoscopies with identified risk factors	Elective major surgery with identified risk factors
Emergency major surgery
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate or to de-escalate care because of poor prognosis,
Potential for significant permanent work restrictions or total disability
Management of addiction behavior or other significant psychiatric condition
Treatment plan for patients with symptoms causing severe functional deficits without supporting physiological \findings or verified related medical diagnosis.	

IV. Time Component: 
•	If greater than fifty percent of a physician’s time at an E&M visit is spent either face-to-face with the patient counseling and/or coordination of care and there is detailed patient specific documentation of the counseling and/or coordination of care, then time can determine the level of service.
•	If time is used to establish the level of visit and total amount of time falls in between two levels, then the provider’s time shall be more than half way to reaching the higher level.
•	The counseling or coordination of care activities must be done 24 hours prior to the actual patient encounter or within seven (7) business days after the actual patient encounter. If these activities are done outside of the 24 hours prior to or 7 business days after the patient encounter, then Rule 18-5(I)(4) “Treating Physician Telephone or On-line Services” or Rule 18-6(A) “Face-to-Face or Telephonic meeting by a Treating Physician with the Employer … With or Without the Injured Workers” is applicable.

A. Counseling:  Primary care physicians should have shared decision making conferences with their 	patients to establish viable functional goals prior to making referrals for diagnostic testing and/or to specialists. Shared decision making occurs when the physician shares with the patient all the treatment alternatives reflected in the Colorado Medical Treatment Guidelines as well as any possible side effects or limitations, and the patient shares with the primary physician their desired outcome from the treatment. Patients should be encouraged to express their goals, outcome expectations and desires from treatment as well as any personal habits or traits that may be impacted by procedures or their possible side effects.
1. The physician’s time spent face-to-face with the patient and/or their family counseling him/her or them in one or more of the following:
•	Injury/disease education that includes discussion of diagnostic tests results and a disease specific treatment plan.
•	Return to work
•	Temporary and/or permanent restrictions
•	Self-management of symptoms while at home and/or work
•	Correct posture/mechanics to perform work functions
•	Job task exercises for muscle strengthening and stretching
•	Appropriate tool and equipment use to prevent re-injury and/or worsening of the existing injury/condition
•	Patient/injured worker expectations and specific goals
•	Family and other interpersonal relationships and how they relate to psychological/social issues
•	Discussion of pharmaceutical management (includes drug dosage, specific drug side effects and potential of addiction /problems
•	Assessment of vocational plans (i.e., restrictions as they relate to current and future employment job requirements)

B. Coordination of Care:  Coordination of care requires the physician to either call another health care provider (outside of their own clinic) regarding the patient’s diagnosis and/or treatment or the physician telephones or visits the employer in person to safely return the patient to work.

Table V:  New Patient/Office Consultations Level of Service: CPT consultation criteria must be met before a consultation can be billed for any level of service.
New Patient/Level of Service (Requires all three key components at the same level or higher)	 History	Examination	Medical Decision Making (MDM)	Avg. time (minutes) as listed for the specific  CPT code	
99201/99241	Problem Focused (PF)	PF	Straight Forward (SF)	10	
99202/99242	Extended Problem Focused (EPF)	EPF	SF	20	
99203/99243	Detailed (D)	D	Low	30	
99204/99244	Comprehensive(C)	C	Moderate	45	
99205/99245	C	C	High	60	

Table VI: Established Patient Office Visit Level of Service
Established Patient/Level of Service  (Requires at least two of the three key components at the same level or higher and one of the two must be MDM)	 History	Examination	Medical Decision Making (MDM)	Avg. time (minutes) as listed for the specific  CPT code	
99211	N/A	N/A	N/A	5	
99212	PF	PF	SF	10	
99213	EPF	EPF	Low	15	
99214	D	D	Moderate	25	
99215	C	C	High	40	

Exhibit #8 - Pathology Laboratory Maximum Fees	
Effective for Dates of Service on and after 1/1/2017	
HCPCS	Modifier	 Maximum Fee	Procedure Description	
36415	 	 $                       5.40 	Routine venipuncture	
78267	 	 $                     19.28 	Breath tst attain/anal c-14	
78268	 	 $                    165.15 	Breath test analysis c-14	
80047	 	 $                     20.74 	Metabolic panel ionized ca	
80047	QW	 $                     20.74 	Metabolic panel ionized ca	
80048	 	 $                     20.74 	Metabolic panel total ca	
80048	QW	 $                     20.74 	Metabolic panel total ca	
80051	 	 $                     17.19 	Electrolyte panel	
80051	QW	 $                     17.19 	Electrolyte panel	
80053	 	 $                     25.90 	Comprehen metabolic panel	
80053	QW	 $                     25.90 	Comprehen metabolic panel	
80055	 	 $                    117.22 	Obstetric panel	
80061	 	 $                     32.83 	Lipid panel	
80061	QW	 $                     32.83 	Lipid panel	
80069	 	 $                     21.29 	Renal function panel	
80069	QW	 $                     21.29 	Renal function panel	
80074	 	 $                    116.80 	Acute hepatitis panel	
80076	 	 $                     20.03 	Hepatic function panel	
80081	 	 $                    183.55 	Obstetric panel	
80150	 	 $                     36.97 	Assay of amikacin	
80155	 	 $                     34.69 	Drug screen quant caffeine	
80156	 	 $                     35.71 	Assay carbamazepine total	
80157	 	 $                     32.51 	Assay carbamazepine free	
80158	 	 $                     44.26 	Assay of cyclosporine	
80159	 	 $                     45.34 	Drug screen quant clozapine	
80162	 	 $                     32.56 	Assay of digoxin	
80163	 	 $                     32.56 	Assay of digoxin free	
80164	 	 $                     33.23 	Assay dipropylacetic acid	
80165	 	 $                     33.23 	Dipropylacetic acid free	
80168	 	 $                     40.07 	Assay of ethosuximide	
80169	 	 $                     33.68 	Drug screen quant everolimus	
80170	 	 $                     40.18 	Assay of gentamicin	
80171	 	 $                     32.51 	Drug screen quant gabapentin	
80173	 	 $                     35.71 	Assay of haloperidol	
80175	 	 $                     32.51 	Drug screen quan lamotrigine	
80176	 	 $                     36.02 	Assay of lidocaine	
80177	 	 $                     32.51 	Drug scrn quan levetiracetam	
80178	 	 $                     16.22 	Assay of lithium	
80178	QW	 $                     16.22 	Assay of lithium	
80180	 	 $                     44.26 	Drug scrn quan mycophenolate	
80183	 	 $                     32.51 	Drug scrn quant oxcarbazepin	
80184	 	 $                     28.08 	Assay of phenobarbital	
80185	 	 $                     32.51 	Assay of phenytoin total	
80186	 	 $                     33.75 	Assay of phenytoin free	
80188	 	 $                     40.70 	Assay of primidone	
80190	 	 $                     41.08 	Assay of procainamide	
80192	 	 $                     41.08 	Assay of procainamide	
80194	 	 $                     35.80 	Assay of quinidine	
80195	 	 $                     33.68 	Assay of sirolimus	
80197	 	 $                     33.68 	Assay of tacrolimus	
80198	 	 $                     34.69 	Assay of theophylline	
80199	 	 $                     44.28 	Drug screen quant tiagabine	
80200	 	 $                     39.53 	Assay of tobramycin	
80201	 	 $                     29.23 	Assay of topiramate	
80202	 	 $                     33.23 	Assay of vancomycin	
80203	 	 $                     32.51 	Drug screen quant zonisamide	
80299	 	 $                     33.59 	Quantitative assay drug	
80400	 	 $                     79.97 	Acth stimulation panel	
80402	 	 $                    213.21 	Acth stimulation panel	
80406	 	 $                    153.16 	Acth stimulation panel	
80408	 	 $                    307.71 	Aldosterone suppression eval	
80410	 	 $                    196.99 	Calcitonin stimul panel	
80412	 	 $                    808.24 	CRH stimulation panel	
80414	 	 $                    126.61 	Testosterone response	
80415	 	 $                    137.03 	Estradiol response panel	
80416	 	 $                    323.57 	Renin stimulation panel	
80417	 	 $                    107.86 	Renin stimulation panel	
80418	 	 $                 1,421.15 	Pituitary evaluation panel	
80420	 	 $                    176.65 	Dexamethasone panel	
80422	 	 $                    112.97 	Glucagon tolerance panel	
80424	 	 $                    123.82 	Glucagon tolerance panel	
80426	 	 $                    363.89 	Gonadotropin hormone panel	
80428	 	 $                    163.55 	Growth hormone panel	
80430	 	 $                    192.44 	Growth hormone panel	
80432	 	 $                    289.26 	Insulin suppression panel	
80434	 	 $                    248.08 	Insulin tolerance panel	
80435	 	 $                    252.59 	Insulin tolerance panel	
80436	 	 $                    223.52 	Metyrapone panel	
80438	 	 $                    123.61 	TRH stimulation panel	
80439	 	 $                    164.81 	TRH stimulation panel	
81000	 	 $                       7.78 	Urinalysis nonauto w/scope	
81001	 	 $                       7.78 	Urinalysis auto w/scope	
81002	 	 $                       6.26 	Urinalysis nonauto w/o scope	
81003	 	 $                       5.51 	Urinalysis auto w/o scope	
81003	QW	 $                       5.51 	Urinalysis auto w/o scope	
81005	 	 $                       5.31 	Urinalysis	
81007	 	 $                       6.28 	Urine screen for bacteria	
81007	QW	 $                       6.28 	Urine screen for bacteria	
81015	 	 $                       7.47 	Microscopic exam of urine	
81020	 	 $                       9.04 	Urinalysis glass test	
81025	 	 $                     15.50 	Urine pregnancy test	
81050	 	 $                       7.36 	Urinalysis volume measure	
81161	 	 $                    252.25 	Dmd dup/delet analysis	
81162	 	 $                 4,474.55 	Brca1&2 seq & full dup/del	
81170	 	 $                    593.12 	Abl1 gene	
81206	 	 $                    402.03 	Bcr/abl1 gene major bp	
81207	 	 $                    355.14 	Bcr/abl1 gene minor bp	
81208	 	 $                    394.38 	Bcr/abl1 gene other bp	
81210	 	 $                    322.16 	Braf gene	
81211	 	 $                 3,924.40 	Brca1&2 seq & com dup/del	
81212	 	 $                    317.59 	Brca1&2 185&5385&6174 var	
81213	 	 $                 1,047.31 	Brca1&2 uncom dup/del var	
81214	 	 $                 2,584.75 	Brca1 full seq & com dup/del	
81215	 	 $                    167.58 	Brca1 gene known fam variant	
81217	 	 $                    167.58 	Brca2 gene known fam variant	
81218	 	 $                    593.12 	Cebpa gene full sequence	
81219	 	 $                    298.22 	Calr gene com variants	
81225	 	 $                    524.45 	Cyp2c19 gene com variants	
81226	 	 $                    811.64 	Cyp2d6 gene com variants	
81227	 	 $                    314.66 	Cyp2c9 gene com variants	
81235	 	 $                    593.12 	Egfr gene com variants	
81240	 	 $                    120.65 	F2 gene	
81241	 	 $                    149.83 	F5 gene	
81245	 	 $                    298.22 	Flt3 gene	
81246	 	 $                    149.47 	Flt3 gene analysis	
81256	 	 $                    160.27 	Hfe gene	
81261	 	 $                    485.46 	Igh gene rearrange amp meth	
81262	 	 $                    107.03 	Igh gene rearrang dir probe	
81263	 	 $                    722.14 	Igh vari regional mutation	
81264	 	 $                    366.14 	Igk rearrangeabn clonal pop	
81265	 	 $                    527.29 	Str markers specimen anal	
81267	 	 $                    508.68 	Chimerism anal no cell selec	
81268	 	 $                    639.43 	Chimerism anal w/cell select	
81270	 	 $                    224.77 	Jak2 gene	
81272	 	 $                    593.12 	Kit gene targeted seq analys	
81273	 	 $                    224.77 	Kit gene analys d816 variant	
81275	 	 $                    354.94 	Kras gene	
81276	 	 $                    354.94 	Kras gene addl variants	
81287	 	 $                    149.56 	Mgmt gene methylation anal	
81288	 	 $                    287.35 	Mlh1 gene	
81291	 	 $                    107.03 	Mthfr gene	
81292	 	 $                 1,161.47 	Mlh1 gene full seq	
81293	 	 $                    465.61 	Mlh1 gene known variants	
81294	 	 $                    342.70 	Mlh1 gene dup/delete variant	
81295	 	 $                    272.66 	Msh2 gene full seq	
81296	 	 $                    232.81 	Msh2 gene known variants	
81297	 	 $                    272.66 	Msh2 gene dup/delete variant	
81298	 	 $                    517.32 	Msh6 gene full seq	
81299	 	 $                    289.80 	Msh6 gene known variants	
81300	 	 $                    290.59 	Msh6 gene dup/delete variant	
81301	 	 $                    709.99 	Microsatellite instability	
81310	 	 $                    444.19 	Npm1 gene	
81311	 	 $                    532.42 	Nras gene variants exon 2&3	
81313	 	 $                    468.47 	Pca3/klk3 antigen	
81314	 	 $                    593.12 	Pdgfra gene	
81315	 	 $                    508.32 	Pml/raralpha com breakpoints	
81316	 	 $                    775.33 	Pml/raralpha 1 breakpoint	
81317	 	 $                 1,404.22 	Pms2 gene full seq analysis	
81318	 	 $                    331.79 	Pms2 known familial variants	
81319	 	 $                    398.39 	Pms2 gene dup/delet variants	
81321	 	 $                 1,079.64 	Pten gene full sequence	
81322	 	 $                    104.96 	Pten gene known fam variant	
81323	 	 $                    157.45 	Pten gene dup/delet variant	
81332	 	 $                    107.03 	Serpina1 gene	
81340	 	 $                    512.26 	Trb@ gene rearrange amplify	
81341	 	 $                    121.59 	Trb@ gene rearrange dirprobe	
81342	 	 $                    494.06 	Trg gene rearrangement anal	
81370	 	 $                    986.00 	Hla i & ii typing lr	
81371	 	 $                    590.17 	Hla i & ii type verify lr	
81372	 	 $                    541.64 	Hla i typing complete lr	
81373	 	 $                    273.06 	Hla i typing 1 locus lr	
81374	 	 $                    178.38 	Hla i typing 1 antigen lr	
81375	 	 $                    541.26 	Hla ii typing ag equiv lr	
81376	 	 $                    299.68 	Hla ii typing 1 locus lr	
81377	 	 $                    225.11 	Hla ii type 1 ag equiv lr	
81378	 	 $                    847.31 	Hla i & ii typing hr	
81379	 	 $                    822.35 	Hla i typing complete hr	
81380	 	 $                    434.61 	Hla i typing 1 locus hr	
81381	 	 $                    231.91 	Hla i typing 1 allele hr	
81382	 	 $                    303.26 	Hla ii typing 1 loc hr	
81383	 	 $                    267.59 	Hla ii typing 1 allele hr	
81410	 	 $                          -   	Aortic dysfunction/dilation	
81411	 	 $                          -   	Aortic dysfunction/dilation	
81412	 	 $                          -   	Ashkenazi jewish assoc dis	
81415	 	 $                          -   	Exome sequence analysis	
81416	 	 $                          -   	Exome sequence analysis	
81417	 	 $                          -   	Exome re-evaluation	
81420	 	 $                          -   	Fetal chrmoml aneuploidy	
81425	 	 $                          -   	Genome sequence analysis	
81426	 	 $                          -   	Genome sequence analysis	
81427	 	 $                          -   	Genome re-evaluation	
81430	 	 $                          -   	Hearing loss sequence analys	
81431	 	 $                          -   	Hearing loss dup/del analys	
81432	 	 $                          -   	Hrdtry brst ca-rlatd dsordrs	
81433	 	 $                          -   	Hrdtry brst ca-rlatd dsordrs	
81434	 	 $                          -   	Hereditary retinal disorders	
81435	 	 $                 1,434.15 	Hereditary colon cancer	
81436	 	 $                 1,434.15 	Hereditary colon ca synd	
81437	 	 $                          -   	Heredtry nurondcrn tum dsrdr	
81438	 	 $                          -   	Heredtry nurondcrn tum dsrdr	
81440	 	 $                          -   	Mitochondrial gene	
81442	 	 $                          -   	Noonan spectrum disorders	
81445	 	 $                 1,076.24 	Targeted genomic seq analys	
81450	 	 $                 1,167.12 	Targeted genomic seq analys	
81455	 	 $                          -   	Targeted genomic seq analys	
81460	 	 $                          -   	Whole mitochondrial genome	
81465	 	 $                          -   	Whole mitochondrial genome	
81470	 	 $                          -   	X-linked intellectual dblt	
81471	 	 $                          -   	X-linked intellectual dblt	
81490	 	 $                          -   	Autoimmune rheumatoid arthr	
81493	 	 $                          -   	Cor artery disease mrna	
81519	 	 $                 6,154.96 	Oncology breast mrna	
81525	 	 $                          -   	Oncology colon mrna	
81528	 	 $                    915.97 	Oncology colorectal scr	
81535	 	 $                 1,043.03 	Oncology gynecologic	
81536	 	 $                    319.61 	Oncology gynecologic	
81538	 	 $                          -   	Oncology lung	
81540	 	 $                          -   	Oncology tum unknown origin	
81545	 	 $                          -   	Oncology thyroid	
81595	 	 $                          -   	Cardiology hrt trnspl mrna	
82009	 	 $                     11.09 	Test for acetone/ketones	
82010	 	 $                     20.03 	Acetone assay	
82010	QW	 $                     20.03 	Acetone assay	
82013	 	 $                     27.38 	Acetylcholinesterase assay	
82016	 	 $                     34.00 	Acylcarnitines qual	
82017	 	 $                       6.46 	Acylcarnitines quant	
82024	 	 $                     94.70 	Assay of acth	
82030	 	 $                     34.74 	Assay of adp & amp	
82040	 	 $                     12.13 	Assay of serum albumin	
82040	QW	 $                     12.13 	Assay of serum albumin	
82042	 	 $                       7.11 	Assay of urine albumin	
82042	QW	 $                       7.11 	Assay of urine albumin	
82043	 	 $                     14.17 	Microalbumin quantitative	
82043	QW	 $                     14.17 	Microalbumin quantitative	
82044	 	 $                     11.21 	Microalbumin semiquant	
82044	QW	 $                     11.21 	Microalbumin semiquant	
82045	 	 $                     79.96 	Albumin ischemia modified	
82075	 	 $                     29.54 	Assay of breath ethanol	
82085	 	 $                     23.80 	Assay of aldolase	
82088	 	 $                     99.92 	Assay of aldosterone	
82103	 	 $                     32.94 	Alpha-1-antitrypsin total	
82104	 	 $                     35.46 	Alpha-1-antitrypsin pheno	
82105	 	 $                     41.13 	Alpha-fetoprotein serum	
82106	 	 $                     41.13 	Alpha-fetoprotein amniotic	
82107	 	 $                    157.93 	Alpha-fetoprotein l3	
82108	 	 $                     62.48 	Assay of aluminum	
82120	 	 $                       4.23 	Amines vaginal fluid qual	
82120	QW	 $                       4.23 	Amines vaginal fluid qual	
82127	 	 $                     34.00 	Amino acid single qual	
82128	 	 $                     34.00 	Amino acids mult qual	
82131	 	 $                     41.36 	Amino acids single quant	
82135	 	 $                     40.34 	Assay aminolevulinic acid	
82136	 	 $                       6.46 	Amino acids quant 2-5	
82139	 	 $                       6.46 	Amino acids quan 6 or more	
82140	 	 $                     35.73 	Assay of ammonia	
82143	 	 $                     16.83 	Amniotic fluid scan	
82150	 	 $                     15.89 	Assay of amylase	
82150	QW	 $                     15.89 	Assay of amylase	
82154	 	 $                     36.59 	Androstanediol glucuronide	
82157	 	 $                     71.78 	Assay of androstenedione	
82160	 	 $                     61.31 	Assay of androsterone	
82163	 	 $                     50.33 	Assay of angiotensin II	
82164	 	 $                     35.80 	Angiotensin I enzyme test	
82172	 	 $                     38.00 	Assay of apolipoprotein	
82175	 	 $                     46.51 	Assay of arsenic	
82180	 	 $                     24.23 	Assay of ascorbic acid	
82190	 	 $                     36.56 	Atomic absorption	
82232	 	 $                     39.67 	Assay of beta-2 protein	
82239	 	 $                     20.68 	Bile acids total	
82240	 	 $                     31.37 	Bile acids cholylglycine	
82247	 	 $                     12.29 	Bilirubin total	
82247	QW	 $                     12.29 	Bilirubin total	
82248	 	 $                     12.29 	Bilirubin direct	
82252	 	 $                       3.44 	Fecal bilirubin test	
82261	 	 $                       6.46 	Assay of biotinidase	
82270	 	 $                       7.97 	Occult blood feces	
82271	 	 $                       7.97 	Occult blood other sources	
82271	QW	 $                       7.97 	Occult blood other sources	
82272	 	 $                       7.97 	Occult bld feces 1-3 tests	
82272	QW	 $                       7.97 	Occult bld feces 1-3 tests	
82274	 	 $                     39.01 	Assay test for blood fecal	
82274	QW	 $                     39.01 	Assay test for blood fecal	
82286	 	 $                     16.88 	Assay of bradykinin	
82300	 	 $                     56.74 	Assay of cadmium	
82306	 	 $                     72.59 	Vitamin d 25 hydroxy	
82308	 	 $                     65.68 	Assay of calcitonin	
82310	 	 $                     12.65 	Assay of calcium	
82310	QW	 $                     12.65 	Assay of calcium	
82330	 	 $                     33.53 	Assay of calcium	
82330	QW	 $                     33.53 	Assay of calcium	
82331	 	 $                     12.69 	Calcium infusion test	
82340	 	 $                     14.78 	Assay of calcium in urine	
82355	 	 $                     28.39 	Calculus analysis qual	
82360	 	 $                     31.55 	Calculus assay quant	
82365	 	 $                     31.61 	Calculus spectroscopy	
82370	 	 $                     30.71 	X-ray assay calculus	
82373	 	 $                     44.28 	Assay c-d transfer measure	
82374	 	 $                       6.97 	Assay blood carbon dioxide	
82374	QW	 $                       6.97 	Assay blood carbon dioxide	
82375	 	 $                     30.20 	Assay carboxyhb quant	
82376	 	 $                     12.22 	Assay carboxyhb qual	
82378	 	 $                     46.51 	Carcinoembryonic antigen	
82379	 	 $                       6.46 	Assay of carnitine	
82380	 	 $                     22.63 	Assay of carotene	
82382	 	 $                     42.16 	Assay urine catecholamines	
82383	 	 $                     61.45 	Assay blood catecholamines	
82384	 	 $                     61.92 	Assay three catecholamines	
82387	 	 $                     19.82 	Assay of cathepsin-d	
82390	 	 $                     26.33 	Assay of ceruloplasmin	
82397	 	 $                     19.82 	Chemiluminescent assay	
82415	 	 $                     31.07 	Assay of chloramphenicol	
82435	 	 $                       6.82 	Assay of blood chloride	
82435	QW	 $                       6.82 	Assay of blood chloride	
82436	 	 $                     12.33 	Assay of urine chloride	
82438	 	 $                     11.99 	Assay other fluid chlorides	
82441	 	 $                     14.72 	Test for chlorohydrocarbons	
82465	 	 $                     10.66 	Assay bld/serum cholesterol	
82465	QW	 $                     10.66 	Assay bld/serum cholesterol	
82480	 	 $                     19.31 	Assay serum cholinesterase	
82482	 	 $                     18.83 	Assay rbc cholinesterase	
82485	 	 $                     43.54 	Assay chondroitin sulfate	
82495	 	 $                     49.73 	Assay of chromium	
82507	 	 $                     68.17 	Assay of citrate	
82523	 	 $                     45.83 	Collagen crosslinks	
82523	QW	 $                     45.83 	Collagen crosslinks	
82525	 	 $                     30.42 	Assay of copper	
82528	 	 $                     55.21 	Assay of corticosterone	
82530	 	 $                     40.97 	Cortisol free	
82533	 	 $                     39.98 	Total cortisol	
82540	 	 $                     11.38 	Assay of creatine	
82542	 	 $                     44.28 	Column chromotography quant	
82550	 	 $                     15.97 	Assay of ck (cpk)	
82550	QW	 $                     15.97 	Assay of ck (cpk)	
82552	 	 $                     32.85 	Assay of cpk in blood	
82553	 	 $                     28.31 	Creatine mb fraction	
82554	 	 $                     29.11 	Creatine isoforms	
82565	 	 $                     12.56 	Assay of creatinine	
82565	QW	 $                     12.56 	Assay of creatinine	
82570	 	 $                     12.69 	Assay of urine creatinine	
82570	QW	 $                     12.69 	Assay of urine creatinine	
82575	 	 $                     23.18 	Creatinine clearance test	
82585	 	 $                     17.37 	Assay of cryofibrinogen	
82595	 	 $                     15.86 	Assay of cryoglobulin	
82600	 	 $                     47.57 	Assay of cyanide	
82607	 	 $                     36.97 	Vitamin B-12	
82608	 	 $                     35.12 	B-12 binding capacity	
82610	 	 $                     13.90 	Cystatin c	
82615	 	 $                     20.02 	Test for urine cystines	
82626	 	 $                     61.96 	Dehydroepiandrosterone	
82627	 	 $                     54.52 	Dehydroepiandrosterone	
82633	 	 $                     75.96 	Desoxycorticosterone	
82634	 	 $                     71.78 	Deoxycortisol	
82638	 	 $                     30.02 	Assay of dibucaine number	
82652	 	 $                     94.39 	Vit d 1 25-dihydroxy	
82656	 	 $                     28.28 	Pancreatic elastase fecal	
82657	 	 $                     44.28 	Enzyme cell activity	
82658	 	 $                     44.28 	Enzyme cell activity ra	
82664	 	 $                     84.24 	Electrophoretic test	
82668	 	 $                     46.08 	Assay of erythropoietin	
82670	 	 $                     68.51 	Assay of estradiol	
82671	 	 $                     79.20 	Assay of estrogens	
82672	 	 $                     53.21 	Assay of estrogen	
82677	 	 $                     59.29 	Assay of estriol	
82679	 	 $                     61.20 	Assay of estrone	
82679	QW	 $                     61.20 	Assay of estrone	
82693	 	 $                     36.52 	Assay of ethylene glycol	
82696	 	 $                     57.82 	Assay of etiocholanolone	
82705	 	 $                     12.47 	Fats/lipids feces qual	
82710	 	 $                     41.20 	Fats/lipids feces quant	
82715	 	 $                     24.37 	Assay of fecal fat	
82725	 	 $                     32.63 	Assay of blood fatty acids	
82726	 	 $                     44.28 	Long chain fatty acids	
82728	 	 $                     33.43 	Assay of ferritin	
82731	 	 $                    157.93 	Assay of fetal fibronectin	
82735	 	 $                     45.45 	Assay of fluoride	
82746	 	 $                     36.05 	Assay of folic acid serum	
82747	 	 $                     42.19 	Assay of folic acid rbc	
82757	 	 $                     19.12 	Assay of semen fructose	
82759	 	 $                     38.20 	Assay of rbc galactokinase	
82760	 	 $                     27.45 	Assay of galactose	
82775	 	 $                     51.66 	Assay galactose transferase	
82776	 	 $                     13.99 	Galactose transferase test	
82777	 	 $                     53.93 	Galectin-3	
82784	 	 $                     13.99 	Assay iga/igd/igg/igm each	
82785	 	 $                     40.37 	Assay of ige	
82787	 	 $                     11.27 	Igg 1 2 3 or 4 each	
82800	 	 $                     20.75 	Blood pH	
82803	 	 $                     47.45 	Blood gases any combination	
82805	 	 $                     69.57 	Blood gases w/o2 saturation	
82810	 	 $                     21.40 	Blood gases o2 sat only	
82820	 	 $                     23.76 	Hemoglobin-oxygen affinity	
82930	 	 $                     13.36 	Gastric analy w/ph ea spec	
82938	 	 $                     43.38 	Gastrin test	
82941	 	 $                     43.24 	Assay of gastrin	
82943	 	 $                     35.03 	Assay of glucagon	
82945	 	 $                       9.63 	Glucose other fluid	
82946	 	 $                     32.69 	Glucagon tolerance test	
82947	 	 $                       9.63 	Assay glucose blood quant	
82947	QW	 $                       9.63 	Assay glucose blood quant	
82948	 	 $                       7.78 	Reagent strip/blood glucose	
82950	 	 $                     11.65 	Glucose test	
82950	QW	 $                     11.65 	Glucose test	
82951	 	 $                     15.73 	Glucose tolerance test (GTT)	
82951	QW	 $                     15.73 	Glucose tolerance test (GTT)	
82952	 	 $                       9.61 	GTT-added samples	
82952	QW	 $                       9.61 	GTT-added samples	
82955	 	 $                     23.78 	Assay of g6pd enzyme	
82960	 	 $                     14.83 	Test for G6PD enzyme	
82962	 	 $                       4.41 	Glucose blood test	
82963	 	 $                     52.69 	Assay of glucosidase	
82965	 	 $                     18.94 	Assay of gdh enzyme	
82977	 	 $                     17.66 	Assay of GGT	
82977	QW	 $                     17.66 	Assay of GGT	
82978	 	 $                     26.10 	Assay of glutathione	
82979	 	 $                     16.88 	Assay rbc glutathione	
82985	 	 $                     36.97 	Assay of glycated protein	
82985	QW	 $                     36.97 	Assay of glycated protein	
83001	 	 $                     45.56 	Assay of gonadotropin (fsh)	
83001	QW	 $                     45.56 	Assay of gonadotropin (fsh)	
83002	 	 $                     45.40 	Assay of gonadotropin (lh)	
83002	QW	 $                     45.40 	Assay of gonadotropin (lh)	
83003	 	 $                     40.90 	Assay growth hormone (hgh)	
83006	 	 $                     53.93 	Growth stimulation gene 2	
83009	 	 $                    165.15 	H pylori (c-13) blood	
83010	 	 $                     16.25 	Assay of haptoglobin quant	
83012	 	 $                     42.16 	Assay of haptoglobins	
83013	 	 $                    165.15 	H pylori (c-13) breath	
83014	 	 $                     19.28 	H pylori drug admin	
83015	 	 $                     46.17 	Heavy metal screen	
83018	 	 $                     53.86 	Quantitative screen metals	
83020	 	 $                     28.49 	Hemoglobin electrophoresis	
83021	 	 $                     44.28 	Hemoglobin chromotography	
83026	 	 $                       5.80 	Hemoglobin copper sulfate	
83030	 	 $                     20.27 	Fetal hemoglobin chemical	
83033	 	 $                     14.62 	Fetal hemoglobin assay qual	
83036	 	 $                     23.80 	Glycosylated hemoglobin test	
83036	QW	 $                     23.80 	Glycosylated hemoglobin test	
83037	 	 $                     23.80 	Glycosylated hb home device	
83037	QW	 $                     23.80 	Glycosylated hb home device	
83045	 	 $                     12.15 	Blood methemoglobin test	
83050	 	 $                     17.96 	Blood methemoglobin assay	
83051	 	 $                       8.59 	Assay of plasma hemoglobin	
83060	 	 $                     20.27 	Blood sulfhemoglobin assay	
83065	 	 $                     16.88 	Assay of hemoglobin heat	
83068	 	 $                     20.75 	Hemoglobin stability screen	
83069	 	 $                       9.68 	Assay of urine hemoglobin	
83070	 	 $                     11.65 	Assay of hemosiderin qual	
83080	 	 $                       6.46 	Assay of b hexosaminidase	
83088	 	 $                     72.41 	Assay of histamine	
83090	 	 $                     41.36 	Assay of homocystine	
83150	 	 $                     47.45 	Assay of homovanillic acid	
83491	 	 $                     42.97 	Assay of corticosteroids 17	
83497	 	 $                     31.61 	Assay of 5-hiaa	
83498	 	 $                     66.62 	Assay of progesterone 17-d	
83499	 	 $                     61.81 	Assay of progesterone 20-	
83500	 	 $                     55.53 	Assay free hydroxyproline	
83505	 	 $                     59.62 	Assay total hydroxyproline	
83516	 	 $                     28.28 	Immunoassay nonantibody	
83516	QW	 $                     28.28 	Immunoassay nonantibody	
83518	 	 $                     20.77 	Immunoassay dipstick	
83518	QW	 $                     20.77 	Immunoassay dipstick	
83519	 	 $                     33.12 	Ria nonantibody	
83520	 	 $                     31.73 	Immunoassay quant nos nonab	
83520	QW	 $                     31.73 	Immunoassay quant nos nonab	
83525	 	 $                     28.03 	Assay of insulin	
83527	 	 $                     31.05 	Assay of insulin	
83528	 	 $                     39.01 	Assay of intrinsic factor	
83540	 	 $                     15.88 	Assay of iron	
83550	 	 $                     21.44 	Iron binding test	
83570	 	 $                     21.69 	Assay of idh enzyme	
83582	 	 $                     34.76 	Assay of ketogenic steroids	
83586	 	 $                     31.39 	Assay 17- ketosteroids	
83593	 	 $                     64.48 	Fractionation ketosteroids	
83605	 	 $                       3.44 	Assay of lactic acid	
83605	QW	 $                       3.44 	Assay of lactic acid	
83615	 	 $                     14.80 	Lactate (LD) (LDH) enzyme	
83625	 	 $                     14.56 	Assay of ldh enzymes	
83630	 	 $                     48.13 	Lactoferrin fecal (qual)	
83631	 	 $                     48.13 	Lactoferrin fecal (quant)	
83632	 	 $                     49.57 	Placental lactogen	
83633	 	 $                     13.48 	Test urine for lactose	
83655	 	 $                     29.68 	Assay of lead	
83655	QW	 $                     29.68 	Assay of lead	
83661	 	 $                     24.37 	L/s ratio fetal lung	
83662	 	 $                     46.37 	Foam stability fetal lung	
83663	 	 $                     46.37 	Fluoro polarize fetal lung	
83664	 	 $                     46.37 	Lamellar bdy fetal lung	
83670	 	 $                     22.46 	Assay of lap enzyme	
83690	 	 $                     16.88 	Assay of lipase	
83695	 	 $                     31.73 	Assay of lipoprotein(a)	
83698	 	 $                     79.96 	Assay lipoprotein pla2	
83700	 	 $                     24.23 	Lipopro bld electrophoretic	
83701	 	 $                     60.88 	Lipoprotein bld hr fraction	
83704	 	 $                     77.36 	Lipoprotein bld by nmr	
83718	 	 $                     20.09 	Assay of lipoprotein	
83718	QW	 $                     20.09 	Assay of lipoprotein	
83719	 	 $                     28.53 	Assay of blood lipoprotein	
83721	 	 $                     23.40 	Assay of blood lipoprotein	
83721	QW	 $                     23.40 	Assay of blood lipoprotein	
83727	 	 $                     42.16 	Assay of lrh hormone	
83735	 	 $                     16.42 	Assay of magnesium	
83775	 	 $                     18.07 	Assay malate dehydrogenase	
83785	 	 $                     60.32 	Assay of manganese	
83789	 	 $                     44.28 	Mass spectrometry quant	
83825	 	 $                     39.85 	Assay of mercury	
83835	 	 $                     41.53 	Assay of metanephrines	
83857	 	 $                     26.33 	Assay of methemalbumin	
83861	 	 $                     40.50 	Microfluid analy tears	
83861	QW	 $                     40.50 	Microfluid analy tears	
83864	 	 $                     48.83 	Mucopolysaccharides	
83872	 	 $                     14.36 	Assay synovial fluid mucin	
83873	 	 $                     42.19 	Assay of csf protein	
83874	 	 $                     31.66 	Assay of myoglobin	
83876	 	 $                     79.96 	Assay myeloperoxidase	
83880	 	 $                     79.96 	Assay of natriuretic peptide	
83880	QW	 $                     79.96 	Assay of natriuretic peptide	
83883	 	 $                     13.90 	Assay nephelometry not spec	
83885	 	 $                     60.08 	Assay of nickel	
83915	 	 $                     27.34 	Assay of nucleotidase	
83916	 	 $                     49.30 	Oligoclonal bands	
83918	 	 $                     40.34 	Organic acids total quant	
83919	 	 $                     40.34 	Organic acids qual each	
83921	 	 $                     40.34 	Organic acid single quant	
83930	 	 $                     16.22 	Assay of blood osmolality	
83935	 	 $                     16.72 	Assay of urine osmolality	
83937	 	 $                     36.59 	Assay of osteocalcin	
83945	 	 $                     31.55 	Assay of oxalate	
83950	 	 $                    157.93 	Oncoprotein her-2/neu	
83951	 	 $                    157.93 	Oncoprotein dcp	
83970	 	 $                    101.21 	Assay of parathormone	
83986	 	 $                       8.78 	Assay ph body fluid nos	
83986	QW	 $                       8.78 	Assay ph body fluid nos	
83987	 	 $                     38.93 	Exhaled breath condensate	
83992	 	 $                     36.04 	Assay for phencyclidine	
83993	 	 $                     48.13 	Assay for calprotectin fecal	
84030	 	 $                     13.48 	Assay of blood pku	
84035	 	 $                       7.51 	Assay of phenylketones	
84060	 	 $                     18.11 	Assay acid phosphatase	
84061	 	 $                     19.39 	Phosphatase forensic exam	
84066	 	 $                     23.69 	Assay prostate phosphatase	
84075	 	 $                     12.69 	Assay alkaline phosphatase	
84075	QW	 $                     12.69 	Assay alkaline phosphatase	
84078	 	 $                     17.91 	Assay alkaline phosphatase	
84080	 	 $                     36.25 	Assay alkaline phosphatases	
84081	 	 $                     40.50 	Assay phosphatidylglycerol	
84085	 	 $                     16.52 	Assay of rbc pg6d enzyme	
84087	 	 $                     25.33 	Assay phosphohexose enzymes	
84100	 	 $                     11.63 	Assay of phosphorus	
84105	 	 $                     12.69 	Assay of urine phosphorus	
84106	 	 $                     10.42 	Test for porphobilinogen	
84110	 	 $                     20.70 	Assay of porphobilinogen	
84112	 	 $                    157.93 	Placenta alpha micro ig c/v	
84119	 	 $                     21.13 	Test urine for porphyrins	
84120	 	 $                     36.07 	Assay of urine porphyrins	
84126	 	 $                     62.46 	Assay of feces porphyrins	
84132	 	 $                     11.27 	Assay of serum potassium	
84132	QW	 $                     11.27 	Assay of serum potassium	
84133	 	 $                     10.55 	Assay of urine potassium	
84134	 	 $                     13.90 	Assay of prealbumin	
84135	 	 $                     46.91 	Assay of pregnanediol	
84138	 	 $                     46.42 	Assay of pregnanetriol	
84140	 	 $                     36.59 	Assay of pregnenolone	
84143	 	 $                     36.59 	Assay of 17-hydroxypregneno	
84144	 	 $                     38.20 	Assay of progesterone	
84145	 	 $                     65.68 	Procalcitonin (pct)	
84146	 	 $                     47.52 	Assay of prolactin	
84150	 	 $                     61.20 	Assay of prostaglandin	
84152	 	 $                     45.11 	Assay of psa complexed	
84153	 	 $                     45.11 	Assay of psa total	
84154	 	 $                     45.11 	Assay of psa free	
84155	 	 $                       9.00 	Assay of protein serum	
84155	QW	 $                       9.00 	Assay of protein serum	
84156	 	 $                       9.00 	Assay of protein urine	
84157	 	 $                       9.00 	Assay of protein other	
84157	QW	 $                       9.00 	Assay of protein other	
84160	 	 $                     12.69 	Assay of protein any source	
84163	 	 $                     36.92 	Pappa serum	
84165	 	 $                     26.33 	Protein e-phoresis serum	
84166	 	 $                     43.72 	Protein e-phoresis/urine/csf	
84181	 	 $                     41.76 	Western blot test	
84182	 	 $                     44.14 	Protein western blot test	
84202	 	 $                     35.17 	Assay RBC protoporphyrin	
84203	 	 $                     21.11 	Test RBC protoporphyrin	
84206	 	 $                     43.54 	Assay of proinsulin	
84207	 	 $                     68.89 	Assay of vitamin b-6	
84210	 	 $                     26.62 	Assay of pyruvate	
84220	 	 $                     23.15 	Assay of pyruvate kinase	
84228	 	 $                     28.53 	Assay of quinine	
84233	 	 $                    157.93 	Assay of estrogen	
84234	 	 $                    159.08 	Assay of progesterone	
84235	 	 $                    128.34 	Assay of endocrine hormone	
84238	 	 $                     89.68 	Assay nonendocrine receptor	
84244	 	 $                     53.93 	Assay of renin	
84252	 	 $                     49.63 	Assay of vitamin b-2	
84255	 	 $                     62.60 	Assay of selenium	
84260	 	 $                     45.59 	Assay of serotonin	
84270	 	 $                     53.30 	Assay of sex hormone globul	
84275	 	 $                     32.94 	Assay of sialic acid	
84285	 	 $                     57.73 	Assay of silica	
84295	 	 $                     11.81 	Assay of serum sodium	
84295	QW	 $                     11.81 	Assay of serum sodium	
84300	 	 $                     11.93 	Assay of urine sodium	
84302	 	 $                     11.93 	Assay of sweat sodium	
84305	 	 $                     48.15 	Assay of somatomedin	
84307	 	 $                     44.82 	Assay of somatostatin	
84311	 	 $                     17.14 	Spectrophotometry	
84315	 	 $                       6.16 	Body fluid specific gravity	
84375	 	 $                       5.87 	Chromatogram assay sugars	
84376	 	 $                     13.48 	Sugars single qual	
84377	 	 $                     13.48 	Sugars multiple qual	
84378	 	 $                     28.26 	Sugars single quant	
84379	 	 $                     28.26 	Sugars multiple quant	
84392	 	 $                     11.65 	Assay of urine sulfate	
84402	 	 $                     62.44 	Assay of free testosterone	
84403	 	 $                     63.31 	Assay of total testosterone	
84425	 	 $                     52.06 	Assay of vitamin b-1	
84430	 	 $                     28.53 	Assay of thiocyanate	
84431	 	 $                     41.20 	Thromboxane urine	
84432	 	 $                     37.48 	Assay of thyroglobulin	
84436	 	 $                     16.83 	Assay of total thyroxine	
84437	 	 $                     15.86 	Assay of neonatal thyroxine	
84439	 	 $                     19.98 	Assay of free thyroxine	
84442	 	 $                     28.49 	Assay of thyroid activity	
84443	 	 $                     41.20 	Assay thyroid stim hormone	
84443	QW	 $                     41.20 	Assay thyroid stim hormone	
84445	 	 $                    124.69 	Assay of tsi globulin	
84446	 	 $                     34.76 	Assay of vitamin e	
84449	 	 $                     36.59 	Assay of transcortin	
84450	 	 $                     12.69 	Transferase (AST) (SGOT)	
84450	QW	 $                     12.69 	Transferase (AST) (SGOT)	
84460	 	 $                     13.00 	Alanine amino (ALT) (SGPT)	
84460	QW	 $                     13.00 	Alanine amino (ALT) (SGPT)	
84466	 	 $                     31.30 	Assay of transferrin	
84478	 	 $                     14.09 	Assay of triglycerides	
84478	QW	 $                     14.09 	Assay of triglycerides	
84479	 	 $                     15.86 	Assay of thyroid (t3 or t4)	
84480	 	 $                     34.76 	Assay triiodothyronine (t3)	
84481	 	 $                     41.53 	Free assay (FT-3)	
84482	 	 $                     38.65 	T3 reverse	
84484	 	 $                     16.40 	Assay of troponin quant	
84485	 	 $                     10.42 	Assay duodenal fluid trypsin	
84488	 	 $                     10.42 	Test feces for trypsin	
84490	 	 $                     13.99 	Assay of feces for trypsin	
84510	 	 $                     25.51 	Assay of tyrosine	
84512	 	 $                     18.88 	Assay of troponin qual	
84520	 	 $                       9.68 	Assay of urea nitrogen	
84520	QW	 $                       9.68 	Assay of urea nitrogen	
84525	 	 $                       4.23 	Urea nitrogen semi-quant	
84540	 	 $                     11.65 	Assay of urine/urea-n	
84545	 	 $                     16.20 	Urea-N clearance test	
84550	 	 $                     11.09 	Assay of blood/uric acid	
84550	QW	 $                     11.09 	Assay of blood/uric acid	
84560	 	 $                     11.65 	Assay of urine/uric acid	
84577	 	 $                     30.60 	Assay of feces/urobilinogen	
84578	 	 $                       3.44 	Test urine urobilinogen	
84580	 	 $                     17.39 	Assay of urine urobilinogen	
84583	 	 $                     12.33 	Assay of urine urobilinogen	
84585	 	 $                     38.00 	Assay of urine vma	
84586	 	 $                     36.59 	Assay of vip	
84588	 	 $                     79.96 	Assay of vasopressin	
84590	 	 $                     28.46 	Assay of vitamin a	
84591	 	 $                     28.46 	Assay of nos vitamin	
84597	 	 $                     33.64 	Assay of vitamin k	
84600	 	 $                     39.42 	Assay of volatiles	
84620	 	 $                     29.05 	Xylose tolerance test	
84630	 	 $                     27.92 	Assay of zinc	
84681	 	 $                     42.61 	Assay of c-peptide	
84702	 	 $                     36.92 	Chorionic gonadotropin test	
84703	 	 $                     17.14 	Chorionic gonadotropin assay	
84703	QW	 $                     17.14 	Chorionic gonadotropin assay	
84704	 	 $                     36.92 	Hcg free betachain test	
84830	 	 $                     24.59 	Ovulation tests	
85002	 	 $                     11.05 	Bleeding time test	
85004	 	 $                     12.22 	Automated diff wbc count	
85007	 	 $                       8.42 	Bl smear w/diff wbc count	
85008	 	 $                       8.42 	Bl smear w/o diff wbc count	
85009	 	 $                       9.13 	Manual diff wbc count b-coat	
85013	 	 $                       5.81 	Spun microhematocrit	
85014	 	 $                       5.81 	Hematocrit	
85014	QW	 $                       5.81 	Hematocrit	
85018	 	 $                       5.81 	Hemoglobin	
85018	QW	 $                       5.81 	Hemoglobin	
85025	 	 $                     17.33 	Complete cbc w/auto diff wbc	
85027	 	 $                     12.22 	Complete cbc automated	
85032	 	 $                     10.55 	Manual cell count each	
85041	 	 $                       7.40 	Automated rbc count	
85044	 	 $                     10.55 	Manual reticulocyte count	
85045	 	 $                       9.81 	Automated reticulocyte count	
85046	 	 $                     13.66 	Reticyte/hgb concentrate	
85048	 	 $                       6.23 	Automated leukocyte count	
85049	 	 $                     10.98 	Automated platelet count	
85055	 	 $                     44.37 	Reticulated platelet assay	
85130	 	 $                     17.33 	Chromogenic substrate assay	
85170	 	 $                       8.87 	Blood clot retraction	
85175	 	 $                     11.16 	Blood clot lysis time	
85210	 	 $                     31.84 	Clot factor ii prothrom spec	
85220	 	 $                     43.27 	Blooc clot factor v test	
85230	 	 $                     43.90 	Clot factor vii proconvertin	
85240	 	 $                     43.90 	Clot factor viii ahg 1 stage	
85244	 	 $                     50.08 	Clot factor viii reltd antgn	
85245	 	 $                     56.25 	Clot factor viii vw ristoctn	
85246	 	 $                     56.25 	Clot factor viii vw antigen	
85247	 	 $                     56.25 	Clot factor viii multimetric	
85250	 	 $                     46.69 	Clot factor ix ptc/chrstmas	
85260	 	 $                     43.90 	Clot factor x stuart-power	
85270	 	 $                     43.90 	Clot factor xi pta	
85280	 	 $                     47.45 	Clot factor xii hageman	
85290	 	 $                     40.07 	Clot factor xiii fibrin stab	
85291	 	 $                     21.82 	Clot factor xiii fibrin scrn	
85292	 	 $                     46.44 	Clot factor fletcher fact	
85293	 	 $                     46.44 	Clot factor wght kininogen	
85300	 	 $                     29.07 	Antithrombin iii activity	
85301	 	 $                     26.51 	Antithrombin iii antigen	
85302	 	 $                     29.47 	Clot inhibit prot c antigen	
85303	 	 $                     33.91 	Clot inhibit prot c activity	
85305	 	 $                     28.46 	Clot inhibit prot s total	
85306	 	 $                     37.58 	Clot inhibit prot s free	
85307	 	 $                     37.58 	Assay activated protein c	
85335	 	 $                     22.59 	Factor inhibitor test	
85337	 	 $                     25.56 	Thrombomodulin	
85345	 	 $                     10.55 	Coagulation time lee & white	
85347	 	 $                     10.44 	Coagulation time activated	
85348	 	 $                       9.14 	Coagulation time otr method	
85360	 	 $                     11.36 	Euglobulin lysis	
85362	 	 $                     16.88 	Fibrin degradation products	
85366	 	 $                     21.13 	Fibrinogen test	
85370	 	 $                     27.85 	Fibrinogen test	
85378	 	 $                     17.50 	Fibrin degrade semiquant	
85379	 	 $                     19.85 	Fibrin degradation quant	
85380	 	 $                     19.85 	Fibrin degradj d-dimer	
85384	 	 $                     20.83 	Fibrinogen activity	
85385	 	 $                     20.83 	Fibrinogen antigen	
85390	 	 $                     10.42 	Fibrinolysins screen i&r	
85397	 	 $                     56.25 	Clotting funct activity	
85400	 	 $                     21.69 	Fibrinolytic plasmin	
85410	 	 $                     17.37 	Fibrinolytic antiplasmin	
85415	 	 $                     42.16 	Fibrinolytic plasminogen	
85420	 	 $                     16.02 	Fibrinolytic plasminogen	
85421	 	 $                     24.98 	Fibrinolytic plasminogen	
85441	 	 $                     10.31 	Heinz bodies direct	
85445	 	 $                     16.72 	Heinz bodies induced	
85460	 	 $                     18.97 	Hemoglobin fetal	
85461	 	 $                     16.27 	Hemoglobin fetal	
85475	 	 $                     21.76 	Hemolysin acid	
85520	 	 $                     26.10 	Heparin assay	
85525	 	 $                     29.03 	Heparin neutralization	
85530	 	 $                     34.76 	Heparin-protamine tolerance	
85536	 	 $                     15.86 	Iron stain peripheral blood	
85540	 	 $                     21.10 	Wbc alkaline phosphatase	
85547	 	 $                     21.10 	RBC mechanical fragility	
85549	 	 $                     45.97 	Muramidase	
85555	 	 $                     16.38 	RBC osmotic fragility	
85557	 	 $                     32.76 	RBC osmotic fragility	
85576	 	 $                     52.69 	Blood platelet aggregation	
85576	QW	 $                     52.69 	Blood platelet aggregation	
85597	 	 $                     37.67 	Phospholipid pltlt neutraliz	
85598	 	 $                     37.67 	Hexagnal phosph pltlt neutrl	
85610	 	 $                       9.65 	Prothrombin time	
85610	QW	 $                       9.65 	Prothrombin time	
85611	 	 $                       9.67 	Prothrombin test	
85612	 	 $                     23.49 	Viper venom prothrombin time	
85613	 	 $                     23.49 	Russell viper venom diluted	
85635	 	 $                     24.14 	Reptilase test	
85651	 	 $                       8.69 	Rbc sed rate nonautomated	
85652	 	 $                       6.62 	Rbc sed rate automated	
85660	 	 $                     13.52 	RBC sickle cell test	
85670	 	 $                     14.15 	Thrombin time plasma	
85675	 	 $                     16.78 	Thrombin time titer	
85705	 	 $                     17.14 	Thromboplastin inhibition	
85730	 	 $                     14.72 	Thromboplastin time partial	
85732	 	 $                     15.86 	Thromboplastin time partial	
85810	 	 $                     28.62 	Blood viscosity examination	
86000	 	 $                     17.12 	Agglutinins febrile antigen	
86001	 	 $                     11.74 	Allergen specific igg	
86003	 	 $                     11.74 	Allergen specific IgE	
86005	 	 $                     17.17 	Allergen specific IgE	
86021	 	 $                     36.92 	WBC antibody identification	
86022	 	 $                     45.04 	Platelet antibodies	
86023	 	 $                     30.55 	Immunoglobulin assay	
86038	 	 $                     29.65 	Antinuclear antibodies	
86039	 	 $                     27.36 	Antinuclear antibodies (ANA)	
86060	 	 $                     13.81 	Antistreptolysin o titer	
86063	 	 $                       8.73 	Antistreptolysin o screen	
86140	 	 $                     12.69 	C-reactive protein	
86141	 	 $                     31.73 	C-reactive protein hs	
86146	 	 $                     37.48 	Beta-2 glycoprotein antibody	
86147	 	 $                     37.48 	Cardiolipin antibody ea ig	
86148	 	 $                     39.40 	Anti-phospholipid antibody	
86152	 	 $                    602.46 	Cell enumeration & id	
86155	 	 $                     38.20 	Chemotaxis assay	
86156	 	 $                     16.42 	Cold agglutinin screen	
86157	 	 $                     19.76 	Cold agglutinin titer	
86160	 	 $                     29.43 	Complement antigen	
86161	 	 $                     29.43 	Complement/function activity	
86162	 	 $                     49.82 	Complement total (ch50)	
86171	 	 $                     24.55 	Complement fixation each	
86185	 	 $                     21.94 	Counterimmunoelectrophoresis	
86200	 	 $                     31.73 	Ccp antibody	
86215	 	 $                     32.49 	Deoxyribonuclease antibody	
86225	 	 $                     33.68 	Dna antibody native	
86226	 	 $                     29.68 	Dna antibody single strand	
86235	 	 $                     36.63 	Nuclear antigen antibody	
86243	 	 $                     50.31 	Fc receptor	
86255	 	 $                     29.54 	Fluorescent antibody screen	
86256	 	 $                     29.54 	Fluorescent antibody titer	
86277	 	 $                     38.59 	Growth hormone antibody	
86280	 	 $                     20.09 	Hemagglutination inhibition	
86294	 	 $                     48.11 	Immunoassay tumor qual	
86294	QW	 $                     48.11 	Immunoassay tumor qual	
86300	 	 $                     51.03 	Immunoassay tumor ca 15-3	
86301	 	 $                     51.03 	Immunoassay tumor ca 19-9	
86304	 	 $                     51.03 	Immunoassay tumor ca 125	
86305	 	 $                     51.03 	Human epididymis protein 4	
86308	 	 $                     12.69 	Heterophile antibody screen	
86308	QW	 $                     12.69 	Heterophile antibody screen	
86309	 	 $                     15.86 	Heterophile antibody titer	
86310	 	 $                     18.07 	Heterophile antibody absrbj	
86316	 	 $                     51.03 	Immunoassay tumor other	
86317	 	 $                     36.76 	Immunoassay infectious agent	
86318	 	 $                     31.73 	Immunoassay infectious agent	
86318	QW	 $                     31.73 	Immunoassay infectious agent	
86320	 	 $                     54.95 	Serum immunoelectrophoresis	
86325	 	 $                     54.85 	Other immunoelectrophoresis	
86327	 	 $                     55.64 	Immunoelectrophoresis assay	
86329	 	 $                     34.43 	Immunodiffusion nes	
86331	 	 $                     29.38 	Immunodiffusion ouchterlony	
86332	 	 $                     42.23 	Immune complex assay	
86334	 	 $                     54.79 	Immunofix e-phoresis serum	
86335	 	 $                     71.95 	Immunfix e-phorsis/urine/csf	
86336	 	 $                     31.77 	Inhibin A	
86337	 	 $                     52.49 	Insulin antibodies	
86340	 	 $                     36.97 	Intrinsic factor antibody	
86341	 	 $                     32.92 	Islet cell antibody	
86343	 	 $                     30.56 	Leukocyte histamine release	
86344	 	 $                     19.58 	Leukocyte phagocytosis	
86352	 	 $                    333.13 	Cell function assay w/stim	
86353	 	 $                    120.22 	Lymphocyte transformation	
86355	 	 $                     43.54 	B cells total count	
86356	 	 $                     44.37 	Mononuclear cell antigen	
86357	 	 $                     43.54 	Nk cells total count	
86359	 	 $                     43.54 	T cells total count	
86360	 	 $                     87.07 	T cell absolute count/ratio	
86361	 	 $                     44.37 	T cell absolute count	
86367	 	 $                     43.54 	Stem cells total count	
86376	 	 $                     35.68 	Microsomal antibody each	
86378	 	 $                     48.29 	Migration inhibitory factor	
86382	 	 $                     41.47 	Neutralization test viral	
86384	 	 $                     27.92 	Nitroblue tetrazolium dye	
86386	 	 $                     39.17 	Nuclear matrix protein 22	
86386	QW	 $                     39.17 	Nuclear matrix protein 22	
86403	 	 $                     17.14 	Particle agglut antbdy scrn	
86406	 	 $                     26.08 	Particle agglut antbdy titr	
86430	 	 $                     13.91 	Rheumatoid factor test qual	
86431	 	 $                     13.91 	Rheumatoid factor quant	
86480	 	 $                    151.97 	Tb test cell immun measure	
86481	 	 $                    183.73 	Tb ag response t-cell susp	
86590	 	 $                     26.10 	Streptokinase antibody	
86592	 	 $                     10.48 	Syphilis test non-trep qual	
86593	 	 $                     10.78 	Syphilis test non-trep quant	
86602	 	 $                     24.97 	Antinomyces antibody	
86603	 	 $                     27.50 	Adenovirus antibody	
86606	 	 $                     34.49 	Aspergillus antibody	
86609	 	 $                     31.59 	Bacterium antibody	
86611	 	 $                     24.97 	Bartonella antibody	
86612	 	 $                     27.50 	Blastomyces antibody	
86615	 	 $                     32.35 	Bordetella antibody	
86617	 	 $                     37.98 	Lyme disease antibody	
86618	 	 $                     41.76 	Lyme disease antibody	
86618	QW	 $                     41.76 	Lyme disease antibody	
86619	 	 $                     32.80 	Borrelia antibody	
86622	 	 $                     20.05 	Brucella antibody	
86625	 	 $                     32.17 	Campylobacter antibody	
86628	 	 $                     29.43 	Candida antibody	
86631	 	 $                     29.00 	Chlamydia antibody	
86632	 	 $                     31.10 	Chlamydia igm antibody	
86635	 	 $                     27.50 	Coccidioides antibody	
86638	 	 $                     27.50 	Q fever antibody	
86641	 	 $                     17.14 	Cryptococcus antibody	
86644	 	 $                     35.30 	CMV antibody	
86645	 	 $                     35.01 	Cmv antibody igm	
86648	 	 $                     37.30 	Diphtheria antibody	
86651	 	 $                     32.35 	Encephalitis californ antbdy	
86652	 	 $                     32.35 	Encephaltis east eqne anbdy	
86653	 	 $                     32.35 	Encephaltis st louis antbody	
86654	 	 $                     32.35 	Encephaltis west eqne antbdy	
86658	 	 $                     27.50 	Enterovirus antibody	
86663	 	 $                     32.17 	Epstein-barr antibody	
86664	 	 $                     35.01 	Epstein-barr nuclear antigen	
86665	 	 $                     35.01 	Epstein-barr capsid vca	
86666	 	 $                     24.97 	Ehrlichia antibody	
86668	 	 $                     19.12 	Francisella tularensis	
86671	 	 $                     27.50 	Fungus nes antibody	
86674	 	 $                     35.01 	Giardia lamblia antibody	
86677	 	 $                     35.59 	Helicobacter pylori antibody	
86682	 	 $                     25.36 	Helminth antibody	
86684	 	 $                     17.14 	Hemophilus influenza antibdy	
86687	 	 $                     20.57 	Htlv-i antibody	
86688	 	 $                     24.46 	Htlv-ii antibody	
86689	 	 $                     47.47 	Htlv/hiv confirmj antibody	
86692	 	 $                     42.08 	Hepatitis delta agent antbdy	
86694	 	 $                     35.30 	Herpes simplex nes antbdy	
86695	 	 $                     32.35 	Herpes simplex type 1 test	
86696	 	 $                     47.47 	Herpes simplex type 2 test	
86698	 	 $                     27.50 	Histoplasma antibody	
86701	 	 $                     21.80 	Hiv-1antibody	
86701	QW	 $                     21.80 	Hiv-1antibody	
86702	 	 $                     24.46 	Hiv-2 antibody	
86703	 	 $                     24.46 	Hiv-1/hiv-2 1 result antbdy	
86704	 	 $                     29.54 	Hep b core antibody total	
86705	 	 $                     28.87 	Hep b core antibody igm	
86706	 	 $                     26.33 	Hep b surface antibody	
86707	 	 $                     28.37 	Hepatitis be antibody	
86708	 	 $                     30.37 	Hepatitis a total antibody	
86709	 	 $                     27.59 	Hepatitis a igm antibody	
86710	 	 $                     33.23 	Influenza virus antibody	
86711	 	 $                     35.30 	John cunningham antibody	
86713	 	 $                     35.01 	Legionella antibody	
86717	 	 $                     30.02 	Leishmania antibody	
86720	 	 $                     32.35 	Leptospira antibody	
86723	 	 $                     32.35 	Listeria monocytogenes	
86727	 	 $                     27.50 	Lymph choriomeningitis ab	
86729	 	 $                     29.29 	Lympho venereum antibody	
86732	 	 $                     32.35 	Mucormycosis antibody	
86735	 	 $                     31.99 	Mumps antibody	
86738	 	 $                     32.47 	Mycoplasma antibody	
86741	 	 $                     32.35 	Neisseria meningitidis	
86744	 	 $                     32.35 	Nocardia antibody	
86747	 	 $                     36.86 	Parvovirus antibody	
86750	 	 $                     32.35 	Malaria antibody	
86753	 	 $                     25.36 	Protozoa antibody nos	
86756	 	 $                     31.59 	Respiratory virus antibody	
86757	 	 $                     47.47 	Rickettsia antibody	
86759	 	 $                     32.35 	Rotavirus antibody	
86762	 	 $                     35.30 	Rubella antibody	
86765	 	 $                     31.59 	Rubeola antibody	
86768	 	 $                     32.35 	Salmonella antibody	
86771	 	 $                     32.35 	Shigella antibody	
86774	 	 $                     36.29 	Tetanus antibody	
86777	 	 $                     35.30 	Toxoplasma antibody	
86778	 	 $                     35.01 	Toxoplasma antibody igm	
86780	 	 $                     32.45 	Treponema pallidum	
86780	QW	 $                     32.45 	Treponema pallidum	
86784	 	 $                     15.59 	Trichinella antibody	
86787	 	 $                     31.59 	Varicella-zoster antibody	
86788	 	 $                     35.01 	West nile virus ab igm	
86789	 	 $                     35.30 	West nile virus antibody	
86790	 	 $                     31.59 	Virus antibody nos	
86793	 	 $                     32.35 	Yersinia antibody	
86800	 	 $                     39.01 	Thyroglobulin antibody	
86803	 	 $                     34.99 	Hepatitis c ab test	
86803	QW	 $                     34.99 	Hepatitis c ab test	
86804	 	 $                     37.98 	Hep c ab test confirm	
86805	 	 $                    128.21 	Lymphocytotoxicity assay	
86806	 	 $                    116.69 	Lymphocytotoxicity assay	
86807	 	 $                     97.04 	Cytotoxic antibody screening	
86808	 	 $                     72.77 	Cytotoxic antibody screening	
86812	 	 $                     63.29 	Hla typing a b or c	
86813	 	 $                     78.30 	Hla typing a b or c	
86816	 	 $                     68.31 	Hla typing dr/dq	
86817	 	 $                    157.86 	Hla typing dr/dq	
86821	 	 $                    138.44 	Lymphocyte culture mixed	
86822	 	 $                     89.64 	Lymphocyte culture primed	
86825	 	 $                    133.11 	Hla x-math non-cytotoxic	
86826	 	 $                     44.37 	Hla x-match noncytotoxc addl	
86828	 	 $                     97.04 	Hla class i&ii antibody qual	
86829	 	 $                     72.77 	Hla class i/ii antibody qual	
86830	 	 $                    197.96 	Hla class i phenotype qual	
86831	 	 $                    169.69 	Hla class ii phenotype qual	
86832	 	 $                    311.09 	Hla class i high defin qual	
86833	 	 $                    282.82 	Hla class ii high defin qual	
86834	 	 $                    876.73 	Hla class i semiquant panel	
86835	 	 $                    791.87 	Hla class ii semiquant panel	
86850	 	 $                       9.38 	Rbc antibody screen	
86880	 	 $                     13.19 	Coombs test direct	
86885	 	 $                     14.04 	Coombs test indirect qual	
86886	 	 $                     12.69 	Coombs test indirect titer	
86900	 	 $                       7.33 	Blood typing abo	
86901	 	 $                       7.33 	Blood typing rh (d)	
86902	 	 $                       9.38 	Blood type antigen donor ea	
86904	 	 $                     23.33 	Blood typing patient serum	
86905	 	 $                       9.38 	Blood typing rbc antigens	
86906	 	 $                     15.73 	Blood typing rh phenotype	
86940	 	 $                     20.11 	Hemolysins/agglutinins auto	
86941	 	 $                     29.68 	Hemolysins/agglutinins	
87003	 	 $                     41.27 	Small animal inoculation	
87015	 	 $                     16.36 	Specimen infect agnt concntj	
87040	 	 $                     25.33 	Blood culture for bacteria	
87045	 	 $                     23.15 	Feces culture aerobic bact	
87046	 	 $                     23.15 	Stool cultr aerobic bact ea	
87070	 	 $                     21.13 	Culture othr specimn aerobic	
87071	 	 $                     23.15 	Culture aerobic quant other	
87073	 	 $                     23.15 	Culture bacteria anaerobic	
87075	 	 $                     23.22 	Cultr bacteria except blood	
87076	 	 $                     17.37 	Culture anaerobe ident each	
87077	 	 $                     17.37 	Culture aerobic identify	
87077	QW	 $                     17.37 	Culture aerobic identify	
87081	 	 $                     16.25 	Culture screen only	
87084	 	 $                     21.13 	Culture of specimen by kit	
87086	 	 $                     19.80 	Urine culture/colony count	
87088	 	 $                     19.85 	Urine bacteria culture	
87101	 	 $                     18.90 	Skin fungi culture	
87102	 	 $                     20.61 	Fungus isolation culture	
87103	 	 $                     22.10 	Blood fungus culture	
87106	 	 $                     25.33 	Fungi identification yeast	
87107	 	 $                     25.33 	Fungi identification mold	
87109	 	 $                     37.73 	Mycoplasma	
87110	 	 $                     48.04 	Chlamydia culture	
87116	 	 $                     26.48 	Mycobacteria culture	
87118	 	 $                     26.84 	Mycobacteric identification	
87140	 	 $                     13.66 	Culture type immunofluoresc	
87143	 	 $                     30.71 	Culture typing glc/hplc	
87147	 	 $                     12.69 	Culture type immunologic	
87149	 	 $                     49.18 	Dna/rna direct probe	
87150	 	 $                     86.04 	Dna/rna amplified probe	
87152	 	 $                     12.83 	Culture type pulse field gel	
87153	 	 $                    282.85 	Dna/rna sequencing	
87158	 	 $                     12.83 	Culture typing added method	
87164	 	 $                     26.33 	Dark field examination	
87166	 	 $                     27.68 	Dark field examination	
87168	 	 $                     10.48 	Macroscopic exam arthropod	
87169	 	 $                     10.48 	Macroscopic exam parasite	
87172	 	 $                     10.48 	Pinworm exam	
87176	 	 $                     14.42 	Tissue homogenization cultr	
87177	 	 $                     21.82 	Ova and parasites smears	
87181	 	 $                     11.65 	Microbe susceptible diffuse	
87184	 	 $                     16.90 	Microbe susceptible disk	
87185	 	 $                     11.65 	Microbe susceptible enzyme	
87186	 	 $                     21.20 	Microbe susceptible mic	
87187	 	 $                     25.42 	Microbe susceptible mlc	
87188	 	 $                     16.27 	Microbe suscept macrobroth	
87190	 	 $                     10.42 	Microbe suscept mycobacteri	
87197	 	 $                     36.85 	Bactericidal level serum	
87205	 	 $                     10.48 	Smear gram stain	
87206	 	 $                     13.19 	Smear fluorescent/acid stai	
87207	 	 $                     13.99 	Smear special stain	
87209	 	 $                     41.96 	Smear complex stain	
87210	 	 $                     10.48 	Smear wet mount saline/ink	
87210	QW	 $                     10.48 	Smear wet mount saline/ink	
87220	 	 $                     10.48 	Tissue exam for fungi	
87230	 	 $                     48.42 	Assay toxin or antitoxin	
87250	 	 $                     47.97 	Virus inoculate eggs/animal	
87252	 	 $                     63.92 	Virus inoculation tissue	
87253	 	 $                     49.54 	Virus inoculate tissue addl	
87254	 	 $                     47.97 	Virus inoculation shell via	
87255	 	 $                     83.03 	Genet virus isolate hsv	
87260	 	 $                     29.39 	Adenovirus ag if	
87265	 	 $                     29.39 	Pertussis ag if	
87267	 	 $                     29.39 	Enterovirus antibody dfa	
87269	 	 $                     29.39 	Giardia ag if	
87270	 	 $                     29.39 	Chlamydia trachomatis ag if	
87271	 	 $                     29.39 	Cytomegalovirus dfa	
87272	 	 $                     29.39 	Cryptosporidium ag if	
87273	 	 $                     29.39 	Herpes simplex 2 ag if	
87274	 	 $                     29.39 	Herpes simplex 1 ag if	
87275	 	 $                     29.39 	Influenza b ag if	
87276	 	 $                     29.39 	Influenza a ag if	
87277	 	 $                     29.39 	Legionella micdadei ag if	
87278	 	 $                     29.39 	Legion pneumophilia ag if	
87279	 	 $                     29.39 	Parainfluenza ag if	
87280	 	 $                     29.39 	Respiratory syncytial ag if	
87281	 	 $                     29.39 	Pneumocystis carinii ag if	
87283	 	 $                     29.39 	Rubeola ag if	
87285	 	 $                     29.39 	Treponema pallidum ag if	
87290	 	 $                     29.39 	Varicella zoster ag if	
87299	 	 $                     29.39 	Antibody detection nos if	
87300	 	 $                     29.39 	Ag detection polyval if	
87301	 	 $                     29.39 	Adenovirus ag eia	
87305	 	 $                     29.39 	Aspergillus ag eia	
87320	 	 $                     29.39 	Chylmd trach ag eia	
87324	 	 $                     29.39 	Clostridium ag eia	
87327	 	 $                     29.39 	Cryptococcus neoform ag eia	
87328	 	 $                     29.39 	Cryptosporidium ag eia	
87329	 	 $                     29.39 	Giardia ag eia	
87332	 	 $                     29.39 	Cytomegalovirus ag eia	
87335	 	 $                     29.39 	E coli 0157 ag eia	
87336	 	 $                     29.39 	Entamoeb hist dispr ag eia	
87337	 	 $                     29.39 	Entamoeb hist group ag eia	
87338	 	 $                     29.43 	Hpylori stool eia	
87339	 	 $                     29.39 	H pylori ag eia	
87340	 	 $                     25.33 	Hepatitis b surface ag eia	
87341	 	 $                     25.33 	Hepatitis b surface ag eia	
87350	 	 $                     28.26 	Hepatitis be ag eia	
87380	 	 $                     40.25 	Hepatitis delta ag eia	
87385	 	 $                     29.39 	Histoplasma capsul ag eia	
87389	 	 $                     59.04 	Hiv-1 ag w/hiv-1 & hiv-2 ab	
87389	QW	 $                     59.04 	Hiv-1 ag w/hiv-1 & hiv-2 ab	
87390	 	 $                     43.25 	Hiv-1 ag eia	
87391	 	 $                     43.25 	Hiv-2 ag eia	
87400	 	 $                     29.39 	Influenza a/b ag eia	
87420	 	 $                     29.39 	Resp syncytial ag eia	
87425	 	 $                     29.39 	Rotavirus ag eia	
87427	 	 $                     29.39 	Shiga-like toxin ag eia	
87430	 	 $                     29.39 	Strep a ag eia	
87449	 	 $                     29.39 	Ag detect nos eia mult	
87449	QW	 $                     29.39 	Ag detect nos eia mult	
87450	 	 $                     23.53 	Ag detect nos eia single	
87451	 	 $                     23.53 	Ag detect polyval eia mult	
87470	 	 $                     49.18 	Bartonella dna dir probe	
87471	 	 $                     86.04 	Bartonella dna amp probe	
87472	 	 $                    105.03 	Bartonella dna quant	
87475	 	 $                     49.18 	Lyme dis dna dir probe	
87476	 	 $                     86.04 	Lyme dis dna amp probe	
87477	 	 $                    105.03 	Lyme dis dna quant	
87480	 	 $                     49.18 	Candida dna dir probe	
87481	 	 $                     86.04 	Candida dna amp probe	
87482	 	 $                    102.38 	Candida dna quant	
87485	 	 $                     49.18 	Chylmd pneum dna dir probe	
87486	 	 $                     86.04 	Chylmd pneum dna amp probe	
87487	 	 $                    105.03 	Chylmd pneum dna quant	
87490	 	 $                     49.18 	Chylmd trach dna dir probe	
87491	 	 $                     86.04 	Chylmd trach dna amp probe	
87492	 	 $                     85.72 	Chylmd trach dna quant	
87493	 	 $                     86.04 	C diff amplified probe	
87495	 	 $                     49.18 	Cytomeg dna dir probe	
87496	 	 $                     86.04 	Cytomeg dna amp probe	
87497	 	 $                    105.03 	Cytomeg dna quant	
87498	 	 $                     86.04 	Enterovirus probe&revrs trns	
87500	 	 $                     86.04 	Vanomycin dna amp probe	
87501	 	 $                    125.82 	Influenza dna amp prob 1+	
87502	 	 $                    208.66 	Influenza dna amp probe	
87502	QW	 $                    208.66 	Influenza dna amp probe	
87503	 	 $                     50.92 	Influenza dna amp prob addl	
87505	 	 $                    314.57 	Nfct agent detection gi	
87506	 	 $                    523.33 	Iadna-dna/rna probe tq 6-11	
87507	 	 $                 1,021.95 	Iadna-dna/rna probe tq 12-25	
87510	 	 $                     49.18 	Gardner vag dna dir probe	
87511	 	 $                     86.04 	Gardner vag dna amp probe	
87512	 	 $                    102.38 	Gardner vag dna quant	
87515	 	 $                     49.18 	Hepatitis b dna dir probe	
87516	 	 $                     86.04 	Hepatitis b dna amp probe	
87517	 	 $                    105.03 	Hepatitis b dna quant	
87520	 	 $                     49.18 	Hepatitis c rna dir probe	
87521	 	 $                     86.04 	Hepatitis c probe&rvrs trnsc	
87522	 	 $                    105.03 	Hepatitis c revrs trnscrpj	
87525	 	 $                     49.18 	Hepatitis g dna dir probe	
87526	 	 $                     86.04 	Hepatitis g dna amp probe	
87527	 	 $                    102.38 	Hepatitis g dna quant	
87528	 	 $                     49.18 	Hsv dna dir probe	
87529	 	 $                     86.04 	Hsv dna amp probe	
87530	 	 $                    105.03 	Hsv dna quant	
87531	 	 $                     49.18 	Hhv-6 dna dir probe	
87532	 	 $                     86.04 	Hhv-6 dna amp probe	
87533	 	 $                    102.38 	Hhv-6 dna quant	
87534	 	 $                     49.18 	Hiv-1 dna dir probe	
87535	 	 $                     86.04 	Hiv-1 probe&reverse trnscrpj	
87536	 	 $                    208.66 	Hiv-1 quant&revrse trnscrpj	
87537	 	 $                     49.18 	Hiv-2 dna dir probe	
87538	 	 $                     86.04 	Hiv-2 probe&revrse trnscripj	
87539	 	 $                    105.03 	Hiv-2 quant&revrse trnscripj	
87540	 	 $                     49.18 	Legion pneumo dna dir prob	
87541	 	 $                     86.04 	Legion pneumo dna amp prob	
87542	 	 $                    102.38 	Legion pneumo dna quant	
87550	 	 $                     49.18 	Mycobacteria dna dir probe	
87551	 	 $                     86.04 	Mycobacteria dna amp probe	
87552	 	 $                    105.03 	Mycobacteria dna quant	
87555	 	 $                     49.18 	M.tuberculo dna dir probe	
87556	 	 $                     86.04 	M.tuberculo dna amp probe	
87557	 	 $                    105.03 	M.tuberculo dna quant	
87560	 	 $                     49.18 	M.avium-intra dna dir prob	
87561	 	 $                     86.04 	M.avium-intra dna amp prob	
87562	 	 $                    105.03 	M.avium-intra dna quant	
87580	 	 $                     49.18 	M.pneumon dna dir probe	
87581	 	 $                     86.04 	M.pneumon dna amp probe	
87582	 	 $                    102.38 	M.pneumon dna quant	
87590	 	 $                     49.18 	N.gonorrhoeae dna dir prob	
87591	 	 $                     86.04 	N.gonorrhoeae dna amp prob	
87592	 	 $                    105.03 	N.gonorrhoeae dna quant	
87623	 	 $                     86.04 	Hpv low-risk types	
87624	 	 $                     86.04 	Hpv high-risk types	
87625	 	 $                     86.04 	Hpv types 16 & 18 only	
87631	 	 $                    314.57 	Resp virus 3-11 targets	
87632	 	 $                    523.33 	Resp virus 6-11 targets	
87633	 	 $                 1,021.95 	Resp virus 12-25 targets	
87640	 	 $                     86.04 	Staph a dna amp probe	
87641	 	 $                     86.04 	Mr-staph dna amp probe	
87650	 	 $                     49.18 	Strep a dna dir probe	
87650	QW	 $                     49.18 	Strep a dna dir probe	
87651	 	 $                     86.04 	Strep a dna amp probe	
87651	QW	 $                     86.04 	Strep a dna amp probe	
87652	 	 $                    102.38 	Strep a dna quant	
87653	 	 $                     86.04 	Strep b dna amp probe	
87660	 	 $                     49.18 	Trichomonas vagin dir probe	
87661	 	 $                     86.04 	Trichomonas vaginalis amplif	
87797	 	 $                     49.18 	Detect agent nos dna dir	
87798	 	 $                     86.04 	Detect agent nos dna amp	
87799	 	 $                    105.03 	Detect agent nos dna quant	
87800	 	 $                     98.35 	Detect agnt mult dna direc	
87801	 	 $                    172.12 	Detect agnt mult dna ampli	
87802	 	 $                     29.39 	Strep b assay w/optic	
87803	 	 $                     29.39 	Clostridium toxin a w/optic	
87804	 	 $                     29.39 	Influenza assay w/optic	
87804	QW	 $                     29.39 	Influenza assay w/optic	
87806	 	 $                     59.04 	Hiv antigen w/hiv antibodies	
87806	QW	 $                     59.04 	Hiv antigen w/hiv antibodies	
87807	 	 $                     29.39 	Rsv assay w/optic	
87807	QW	 $                     29.39 	Rsv assay w/optic	
87808	 	 $                     29.39 	Trichomonas assay w/optic	
87808	QW	 $                     29.39 	Trichomonas assay w/optic	
87809	 	 $                     29.39 	Adenovirus assay w/optic	
87809	QW	 $                     29.39 	Adenovirus assay w/optic	
87810	 	 $                     29.39 	Chylmd trach assay w/optic	
87850	 	 $                     29.39 	N. gonorrhoeae assay w/optic	
87880	 	 $                     29.39 	Strep a assay w/optic	
87880	QW	 $                     29.39 	Strep a assay w/optic	
87899	 	 $                     29.39 	Agent nos assay w/optic	
87899	QW	 $                     29.39 	Agent nos assay w/optic	
87900	 	 $                    319.61 	Phenotype infect agent drug	
87901	 	 $                    631.24 	Genotype dna hiv reverse t	
87902	 	 $                    631.24 	Genotype dna/rna hep c	
87903	 	 $                 1,198.15 	Phenotype dna hiv w/culture	
87904	 	 $                     63.92 	Phenotype dna hiv w/clt add	
87905	 	 $                     12.85 	Sialidase enzyme assay	
87905	QW	 $                     12.85 	Sialidase enzyme assay	
87906	 	 $                    315.63 	Genotype dna/rna hiv	
87910	 	 $                    631.24 	Genotype cytomegalovirus	
87912	 	 $                    631.24 	Genotype dna hepatitis b	
88130	 	 $                     36.92 	Sex chromatin identification	
88140	 	 $                       7.11 	Sex chromatin identification	
88142	 	 $                     49.68 	Cytopath c/v thin layer	
88143	 	 $                     49.68 	Cytopath c/v thin layer redo	
88147	 	 $                     27.90 	Cytopath c/v automated	
88148	 	 $                     37.26 	Cytopath c/v auto rescreen	
88150	 	 $                     25.90 	Cytopath c/v manual	
88152	 	 $                     25.90 	Cytopath c/v auto redo	
88153	 	 $                     25.90 	Cytopath c/v redo	
88154	 	 $                     25.90 	Cytopath c/v select	
88155	 	 $                     14.69 	Cytopath c/v index add-on	
88164	 	 $                     25.90 	Cytopath tbs c/v manual	
88165	 	 $                     25.90 	Cytopath tbs c/v redo	
88166	 	 $                     25.90 	Cytopath tbs c/v auto redo	
88167	 	 $                     25.90 	Cytopath tbs c/v select	
88174	 	 $                     52.40 	Cytopath c/v auto in fluid	
88175	 	 $                     64.96 	Cytopath c/v auto fluid redo	
88230	 	 $                     90.41 	Tissue culture lymphocyte	
88233	 	 $                    180.79 	Tissue culture skin/biopsy	
88235	 	 $                    180.79 	Tissue culture placenta	
88237	 	 $                    309.71 	Tissue culture bone marrow	
88239	 	 $                    361.71 	Tissue culture tumor	
88240	 	 $                     24.77 	Cell cryopreserve/storage	
88241	 	 $                     24.77 	Frozen cell preparation	
88245	 	 $                    365.00 	Chromosome analysis 20-25	
88248	 	 $                    424.62 	Chromosome analysis 50-100	
88249	 	 $                    424.62 	Chromosome analysis 100	
88261	 	 $                    433.37 	Chromosome analysis 5	
88262	 	 $                    305.62 	Chromosome analysis 15-20	
88263	 	 $                    368.51 	Chromosome analysis 45	
88264	 	 $                    305.62 	Chromosome analysis 20-25	
88267	 	 $                    440.80 	Chromosome analys placenta	
88269	 	 $                    407.83 	Chromosome analys amniotic	
88271	 	 $                     52.51 	Cytogenetics dna probe	
88272	 	 $                     65.65 	Cytogenetics 3-5	
88273	 	 $                     78.79 	Cytogenetics 10-30	
88274	 	 $                     85.36 	Cytogenetics 25-99	
88275	 	 $                     98.46 	Cytogenetics 100-300	
88280	 	 $                     61.54 	Chromosome karyotype study	
88283	 	 $                    168.21 	Chromosome banding study	
88285	 	 $                     46.58 	Chromosome count additional	
88289	 	 $                     84.44 	Chromosome study additional	
88371	 	 $                     54.45 	Protein western blot tissue	
88372	 	 $                     48.44 	Protein analysis w/probe	
88720	 	 $                     12.29 	Bilirubin total transcut	
88738	 	 $                     12.29 	Hgb quant transcutaneous	
88740	 	 $                     12.29 	Transcutaneous carboxyhb	
88741	 	 $                     12.29 	Transcutaneous methb	
89050	 	 $                     10.42 	Body fluid cell count	
89051	 	 $                     13.50 	Body fluid cell count	
89055	 	 $                     10.48 	Leukocyte assessment fecal	
89060	 	 $                     17.55 	Exam synovial fluid crystals	
89125	 	 $                     10.58 	Specimen fat stain	
89160	 	 $                       8.73 	Exam feces for meat fibers	
89190	 	 $                       8.73 	Nasal smear for eosinophils	
89300	 	 $                     21.89 	Semen analysis w/huhner	
89300	QW	 $                     21.89 	Semen analysis w/huhner	
89310	 	 $                     15.59 	Semen analysis w/count	
89320	 	 $                     29.54 	Semen anal vol/count/mot	
89321	 	 $                     29.54 	Semen anal sperm detection	
89321	QW	 $                     29.54 	Semen anal sperm detection	
89322	 	 $                     38.00 	Semen anal strict criteria	
89325	 	 $                     19.12 	Sperm antibody test	
89329	 	 $                     51.41 	Sperm evaluation test	
89330	 	 $                     24.26 	Evaluation cervical mucus	
89331	 	 $                     48.04 	Retrograde ejaculation anal	
0006M	 	 $                          -   	Onc hep gene risk classifier	
0007M	 	 $                          -   	Onc gastro 51 gene nomogram	
0008M	 	 $                 6,154.96 	Onc breast risk score	
0009M	 	 $                          -   	Fetal aneuploidy trisom risk	
0010M	 	 $                          -   	Onc prostate prob score	
ATP02	 	 $                     12.78 	Auto.Test Panel Pricing Code, 1-2 Tests	
ATP03	 	 $                     16.29 	Auto.Test Panel Pricing Code, 3 Tests	
ATP04	 	 $                     17.19 	Auto.Test Panel Pricing Code, 4 Tests	
ATP05	 	 $                     19.19 	Auto.Test Panel Pricing Code, 5 Tests	
ATP06	 	 $                     19.22 	Auto.Test Panel Pricing Code, 6 Tests	
ATP07	 	 $                     20.03 	Auto.Test Panel Pricing Code, 7 Tests	
ATP08	 	 $                     20.74 	Auto.Test Panel Pricing Code, 8 Tests	
ATP09	 	 $                     21.29 	Auto.Test Panel Pricing Code, 9 Tests	
ATP10	 	 $                     21.29 	Auto.Test Panel Pricing Code, 10 Tests	
ATP11	 	 $                     21.67 	Auto.Test Panel Pricing Code, 11 Tests	
ATP12	 	 $                     22.14 	Auto.Test Panel Pricing Code, 12 Tests	
ATP16	 	 $                     25.90 	Auto Test Panel Pricing Code  13-16 Test	
ATP18	 	 $                     26.10 	Auto Test Panel Pricing Code, 17-18 Test	
ATP19	 	 $                     27.14 	Auto Test Panel Pricing Code, 19 Tests	
ATP20	 	 $                     27.99 	Auto Test Panel Pricing Code, 20 Tests	
ATP21	 	 $                     28.89 	Auto Test Panel Pricing Code, 21 Tests	
ATP22	 	 $                     29.74 	Auto.Test Panel Pricing Code, 22+ Tests	
ATP23	 	 $                     29.74 	Auto.Test Panel Pricing Code, 23+ Tests	
G0027	 	 $                     15.95 	Semen analysis	
G0103	 	 $                     45.11 	PSA screening	
G0123	 	 $                     49.68 	Screen cerv/vag thin layer	
G0143	 	 $                     49.68 	Scr c/v cyto,thinlayer,rescr	
G0144	 	 $                     52.40 	Scr c/v cyto,thinlayer,rescr	
G0145	 	 $                     64.96 	Scr c/v cyto,thinlayer,rescr	
G0147	 	 $                     27.90 	Scr c/v cyto, automated sys	
G0148	 	 $                     37.26 	Scr c/v cyto, autosys, rescr	
G0306	 	 $                     17.33 	CBC/diffwbc w/o platelet	
G0307	 	 $                     12.22 	CBC without platelet	
G0328	 	 $                     39.01 	Fecal blood scrn immunoassay	
G0328	QW	 $                     39.01 	Fecal blood scrn immunoassay	
G0432	 	 $                     24.46 	EIA HIV-1/HIV-2 screen	
G0433	 	 $                     24.46 	ELISA HIV-1/HIV-2 screen	
G0433	QW	 $                     24.46 	ELISA HIV-1/HIV-2 screen	
G0435	 	 $                     29.39 	Oral HIV-1/HIV-2 screen	
G0471	 	 $                       9.00 	Ven blood coll SNF/HHA	
G0472	 	 $                     34.99 	Hep c screen high risk/other	
G0472	QW	 $                     34.99 	Hep c screen high risk/other	
G0477	 	 $                     26.75 	Drug test presump optical	
G0478	 	 $                     35.66 	Drug test presump opt inst	
G0479	 	 $                    142.65 	Drug test presump not opt	
G0480	 	 $                    143.89 	Drug test def 1-7 classes	
G0481	 	 $                    221.38 	Drug test def 8-14 classes	
G0482	 	 $                    298.85 	Drug test def 15-21 classes	
G0483	 	 $                    387.41 	Drug test def 22+ classes	
G9143	 	 $                    295.99 	Warfarin respon genetic test	
P2038	 	 $                     12.33 	Blood mucoprotein	
P3000	 	 $                     25.90 	Screen pap by tech w md supv	
P9612	 	 $                       5.40 	Catheterize for urine spec	
P9615	 	 $                       5.40 	Urine specimen collect mult	
Q0111	 	 $                     10.48 	Wet mounts/ w preparations	
Q0112	 	 $                     10.48 	Potassium hydroxide preps	
Q0113	 	 $                     13.27 	Pinworm examinations	
Q0114	 	 $                     17.55 	Fern test	
Q0115	 	 $                     24.26 	Post-coital mucous exam