Any billed CPT® code identified as a procedure” in CPT® shall have an “separate appropriate modifier appended to the code for the payer to allow separate payment (i.e., modifier -59). No code listed in CPT® identified as an code is payable unless an appropriate “add-on” primary code is billed with the code in the same episode of care. “add-on” The National Physician Fee Schedule Relative file, as modified, are the only fields recognized in the Colorado Workers’ Compensation Medical Fee Schedule: (1) HCPCS (Healthcare Common Procedure Coding System) any –including CPT® codes; (2) 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) Facility RVU; (6) PC/TC (Professional Component/Technical Component) Indicators: (a) Physician Services Only PC/TC distinction does not apply to “0” – – these service codes; (b) Diagnostic Tests for Radiology Services - diagnostic test codes for “1” – radiology service with or without modifiers 26 or TC; (c) Professional Component Only Codes stand-alone professional “2” – – service codes only; (d) - Technical Component Only Codes - stand-alone technical service “3” codes only; (e) Global Test Only - modifiers 26 and TC cannot be used with “4” – these codes because the values equal to the sum of the total RVUs; (f) - Incident To Codes - do not apply to workers’ compensation; “5” (g) - Laboratory Physician Interpretation Codes clinical laboratory “6” – codes for which separate payments for interpretations by laboratory physicians may be made; (h) - Physical Therapy Services codes are not recognized by “7” – DoWC; (i) - Physician Interpretation Codes laboratory codes for which “8” –clinical 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;
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). 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 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 CPT® codes; (2) 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) 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 Tests for Radiology Services - diagnostic test codes for radiology service with or without modifiers 26 or TC; (c) “2” – Professional Component Only Codes – stand-alone professional service codes only; (d) “3” - Technical Component Only Codes - stand-alone technical service codes only; (e) “4” – Global Test Only - modifiers 26 and TC cannot be used with these codes because the values equal to the sum of the total RVUs; (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; (h) “7” - Physical Therapy Services – 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;
Rule_18_2016.docx