DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 CCR 1101-3
WORKERS’ COMPENSATION RULES OF PROCEDURE
Rule 18
18-1
MEDICAL FEE SCHEDULE
STATEMENT OF PURPOSE
Pursuant to § 8-42-101(3)(a)(I) C.R.S. and Section 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 herein the 2006 edition of the Relative Values for Physicians (RVP©),
developed by Relative Value Studies, Inc., published by Ingenix St. Anthony Publishing, and
version 23.0 of DRGs: Diagnosis Related Groups, Definitions Manual, (DRGs Definitions Manual)
developed and published by 3M Health Information Systems using DRGs effective after October
1, 2005. 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 Fee Schedule Administrator, 633 17th Street, Suite 400, Denver,
Colorado 80202-3660. These materials may be examined at any state publications depository
library. All guidelines and instructions are adopted as set forth in the RVP© or DRGs: Definitions
Manual, unless otherwise specified in this rule.
This rule applies to all services rendered on or after January 1, 2007. All other bills shall be
reimbursed in accordance with the fee schedule in effect at the time service was rendered.
18-2
18-3
STANDARD TERMINOLOGY FOR THIS RULE
(A)
CPT - CPT 2006 Current Procedural Terminology, copyrighted and distributed by the
American Medical Association (AMA).
(B)
DoWC – Colorado Division of Workers’ Compensation created codes
(C)
DRGs Definitions Manual – version 23.0 incorporated by reference in Rule 18-1.
(D)
RVP© – the 2006 edition incorporated by reference in Rule 18-1.
(E)
For other terms, see Rule 16-2, Utilization Standards.
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 copies of all materials incorporated by reference in Rule 18. Copies of the RVP© may
be purchased from Ingenix St. Anthony Publishing, the DRGs Definitions Manual may be
purchased from 3M Health Information Systems, and 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 Unofficial copies of all rules, including Rule 18, are
available on the Colorado Department of Labor and Employment web site at
www.coworkforce.com/DWC/ .
18-4
CONVERSION FACTORS (CF)
The following CFs shall be used to determine the maximum allowed fee. The maximum fee is
determined by multiplying the following section CFs by the established relative value unit(s)
(RVU) found in the corresponding RVP© sections:
RVP© SECTION
18-5
CF
Anesthesia
$47.96/RVU
Surgery
$90.97/RVU
Surgery X Procedures
(see Rule 18-5(D)(1)( d))
$37.69/RVU
Radiology
$17.26/RVU
Pathology
$12.99/RVU
Medicine
$ 7.56/RVU
Physical Medicine
Physical Medicine and Rehabilitation,
Medical Nutrition Therapy and
Acupuncture
$ 5.41/RVU
Evaluation & Management (E&M)
$ 8.22/RVU
INSTRUCTIONS AND/OR MODIFICATIONS TO THE RVP©
(A)
Maximum allowance for all providers under Rule 16-5 is 100% of the RVP© value or as
defined in this Rule 18.
(B)
Interim relative value procedures (marked by an “I” in the left-hand margin of the RVP©)
are accepted as a basis of payment for services; however deleted CPT® codes (marked
by an “M” in the RVP©) are not, unless otherwise advised by this rule. The CPT® 2006
may be referenced for further clarification of descriptions and billing, but if conflicts arise
between the RVP© and the CPT® 2006, the RVP© should control.
(C)
Temporary codes listed in the RVP© may be used for billing with agreement of the payer
as to reimbursement. Payment shall be in compliance with Rule 16-6(B).
(D)
Surgery/Anesthesia
(1)
Anesthesia Section:
(a)
All anesthesia base values shall be established by the use of the codes
as set forth in the RVP©, Anesthesia Section. Anesthesia services are
only reimbursable if the anesthesia is administered by a physician or
Certified Registered Nurse Anesthetist (CRNA) who remains in constant
attendance during the procedure for the sole purpose of rendering
anesthesia.
When anesthesia is administered by a CRNA:
(1)
Not under the medical direction of an anesthesiologist,
reimbursement shall be 90% of the maximum anesthesia value,
(2)
Under the medical direction of an anesthesiologist,
reimbursement shall be 50% of the maximum anesthesia value.
The other 50% is payable to the anesthesiologist providing the
medical direction to the CRNA,
(3)
Medical direction for administering the anesthesia includes
performing the following activities:

Performs a pre-anesthesia examination and evaluation,

Prescribes the anesthesia plan,

Personally participates in the most demanding
procedures in the anesthesia plan including induction
and emergence,

Ensures that any procedure in the anesthesia plan that
s/he does not perform are performed by a qualified
anesthetist,

Monitors the course of anesthesia administration at
frequent intervals,

Remains physically present and available for immediate
diagnosis and treatment of emergencies, and

Provides indicated post-anesthesia care.
(b)
Anesthesia add-on codes are reimbursed using the anesthesia CF and
unit values found in the RVP©, Anesthesia section’s Guidelines IX,
“Qualifying Circumstances.” (Not under the Medicine section.)
(c)
The following modifiers are to be used when billing for anesthesia
services:
AA – anesthesia services performed personally by the anesthesiologist
QX – CRNA service; with medical direction by a physician
QZ – CRNA service; without medical direction by a physician
QY – Medical direction of one CRNA by an anesthesiologist
(d)
Surgery X Procedures
(1)
The Surgery X procedures are limited to those listed below and
found in the table under the RVP©, Anesthesia section’s
Guidelines XI, “Anesthesia Services Where Time Units Are Not
Allowed”:

Providing local anesthetic or other medications
through a regional IV

Daily drug management

Endotracheal intubation

Venipuncture, including cutdowns

Arterial punctures

Epidural or subarachnoid spine injections

Somatic and Sympathetic Nerve Injections

Paravertebral facet joint injections and rhizotomies
In addition, lumbar plexus spine anesthetic injection, posterior
approach with daily administration = 7 RVUs.
(2)
The maximum reimbursement for these procedures shall be
based upon the anesthesia value listed in the table in the RVP©,
Anesthesia section’s Guideline XI multiplied by $37.69 CF. No
additional unit values are added for time when calculating the
maximum values for reimbursement.
(3)
When performing more than one surgery X procedure in a single
surgical setting, multiple surgery guidelines shall apply (100% of
the listed value for the primary procedure and 50% of the listed
value for additional procedures). Use modifier -51 to indicate
multiple Surgery X procedures performed on the same day
during a single operative setting. The 50% reduction does not
apply to procedures that are identified in the RVP© as “Add-on”
procedures.
(4)
Other procedures from Table XI not described above may be
found in another section of the RVP© (e.g., surgery). Any
procedures found in the table under the RVP©, Anesthesia
section’s Guidelines XI, “Anesthesia Services Where Time Units
Are Not Allowed” but not contained in this list (Rule 18-
5(D)(1)(d)(1)) are reimbursed in accordance with the assigned
units from their respective sections multiplied by their respective
CF.
(2)
Surgical Section:
(a)
The use of assistant surgeons shall be limited according to the American
College Of Surgeons' 2002 Study: Physicians as Assistants at Surgery
(April 2002), available from the American College of Surgeons, Chicago,
IL, or from their web page at
http://www.facs.org/ahp/pubs/2002physasstsurg.pdf, (accessed June 29,
2006). 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 Fee Schedule Administrator,
633 17th Street, Suite 400, Denver, Colorado, 80202-3660.
Where the publication restricts use of such assistants to "almost never"
or a procedure is not referenced in the publication, prior authorization for
payment shall be obtained from the payer.
(b)
Incidental procedures are commonly performed as an integral part of a
total service and do not warrant a separate benefit.
(c)
No payment shall be made for more than one assistant surgeon or
minimum assistant surgeon without prior authorization unless a trauma
team was activated due to the emergency nature of the injury(ies).
(d)
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 1611(B)(3).
(e)
Non-physician, minimum assistant surgeons used as surgical assistants
shall be reimbursed at 10 % of the listed value.
(f)
Global Period
(1)
The following services performed during a global period would
warrant separate billing if documentation demonstrates
significant identifiable services were involved, such as:

E&M services unrelated to the primary surgical
procedure,

Services necessary to stabilize the patient for the
primary surgical procedure,

Services not usually part of the surgical procedure,
including an E&M vISIT by an authorized treating
physician (ATP) for disability management,
(2)
(g)

Unusual circumstances, complications, exacerbations, or
recurrences, or

Unrelated diseases or injuries.
Separate identifiable services shall use an appropriate RVP©
modifier in conjunction with the billed service.
Intradiscal Electrothermal Annuloplasty (IDEA) Prior authorization is required. A physician well-trained in the procedure
must perform it. Please refer to the applicable Rule 17 medical
treatment guideline for the required surgical indications for this
procedure.
First level, uni- or
$1,690.26
bilateral including fluoroscopic guidance
one or more additional levels
$ 657.33
CT or MRI may be billed separately in addition to the IDEA procedure.
(h)
Lumbar Artificial Disc
Lumbar disc arthroplasty is reimbursed using the following RVUs
multiplied by the surgery CF:
(E)
one interspace
67.5 RVUs
Per additional interspace
25 RVUs
Radiology Section:
(1)
(2)
General
(a)
The cost of dyes and contrast shall be reimbursed at 80 % of billed
charges.
(b)
Copying charges for X-Rays and MRIs shall be $15.00/film regardless of
the size of the film.
(c)
The payer may use available billing information such as provider
credential(s) and clinical record(s) to determine if an appropriate RVP©
modifier should have been used on the bill. To modify a billed code,
refer to Rule 16-11(B)(3).
Thermography
(a)
The physician supervising and interpreting the thermographic evaluation
shall be board certified by the examining board of one of the following
national organizations and follow their recognized protocols:
American Academy of Thermology;
American Chiropractic College of Infrared Imaging.
(b)
Indications for thermographic evaluation must be one of the following:
Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy
(CRPS/RSD);
Sympathetically Maintained Pain (SMP);
Autonomic neuropathy;
Chronic Neuropathic Pain (involving small caliber sensory fiber
neuropathy).
(c)
Protocol for stress testing is outlined in the Medical Treatment Guidelines
found in Rule 17.
(d)
Thermography Billing Codes:
DoWC 79993 Upper body w/ Autonomic Stress Testing $856.80
DoWC 79995 Lower body w/Autonomic Stress Testing
$856.80
DoWC 79997 Whole Body w/Autonomic Stress Testing $1,285.20
When whole body thermography is performed, only "whole body" billing
codes can be used. Do not use separate upper and lower body billing
codes and fees.
(e)
(F)
Prior authorization for payment 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 Rule 18-5(E)(2).
Pathology Section:
The payer may use available billing information such as provider credential(s) and clinical
record(s) to determine if an appropriate modifier should have been used on the bill. To
modify a billed code refer to Rule 16-11(B)(3).
(G)
Medicine Section:
(1)
Medicine home therapy services in the RVP© are not adopted. For appropriate
codes see Rule 18-6(N), Home Therapy.
(2)
Anesthesia add-on values are reimbursed in accordance with the anesthesia
section of Rule 18.
(3)
Biofeedback
Prior authorization for payment shall be required from the payer after 12 visits. A
licensed physician or psychologist shall prescribe all services and include the
number of sessions. Session notes shall be periodically reviewed by the
prescribing physician to determine the continued need for the service. All
services shall be provided or supervised by an appropriate recognized provider
as listed under Rule 16-5. Supervision shall be as defined in an applicable Rule
17 medical treatment guidelineS. Persons providing biofeedback shall be
certified by the Biofeedback Certification Institution of America, or be a licensed
physician or psychologist, as listed under Rule 16-5(A)(1)(a) and (b) with
evidence of equivalent biofeedback training.
(4)
Appendix J of the 2006 CPT lists the maximum number of nerves per type of
electrodiagnostic study.
(5)
Manipulation -- Chiropractic (DC), Medical (MD) and Osteopathic (DO):
(6)
(a)
Prior authorization from the payer shall be obtained before billing for
more than four body regions in one visit. Manipulative therapy is limited
to no more than 34 visits or the maximum allowed in the relevant Rule 17
medical treatment guidelines. The provider's medical records shall
reflect medical necessity and prior authorization for payment 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.
Psychiatric/Psychological CNS Tests and Assessment Services:
(a)
A licensed clinical psychologist is reimbursed a maximum of 90 % of the
medical fee listed in the RVP©. Other non-physician providers
performing psychological/psychiatric services shall be paid at 75 % of the
fee allowed for physicians.
(b)
Most initial evaluations for delayed recovery can be completed in two (2)
hours. Prior authorization for payment is required any time the following
limitations are exceeded:
Evaluation Procedures
limit: 4 hours
Testing Procedures
limit: 6 hours
Psychotherapy services
limit: 50 mins per visit
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 from the payer.
(7)
Hyperbaric Oxygen Therapy Services
The maximum unit value shall be 24 units, instead of 14 units as listed in the
RVP©.
(H)
Physical Medicine and Rehabilitation:
Restorative services are an integral part of the healing process for a variety of injured
workers.
(1)
Prior authorization is required for medical nutrition therapy. See Rule 186(O)(10).
(2)
For recommendations on the use of the physical medicine and rehabilitation
procedures, modalities, and testing, see Rule 17, Medical Treatment Guidelines
Exhibits.
(3)
Special Note to All Physical Medicine and Rehabilitation Providers:
Prior authorization shall be obtained from the payer for any physical medicine
treatment exceeding the recommendations of the Medical Treatment Guidelines
as set forth in Rule 17.
The injured worker shall be re-evaluated by the prescribing physician within thirty
(30) calendar days from the initiation of the prescribed treatment and at least
once every month while that treatment continues. Prior authorization for
payment shall be required for treatment of a condition not covered under the
medical treatment guidelines and exceeding sixty (60) days from the initiation of
treatment.
(4)
Interdisciplinary Rehabilitation Programs – (Requires Prior Authorization)
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, rehabilitation programs may
include, but are not limited to: chronic pain, spinal cord, or brain injury programs.
Billing Restrictions: The billing provider shall detail to the payer the services,
frequency of services, duration of the program and their proposed fees for the
entire program, inclusive for all professionals. The billing provider and payer
shall attempt to mutually agree upon billing code(s) and fee(s) for each
interdisciplinary rehabilitation program.
(5)
For orthotic and prosthetic management, apply the 2005 RVP© RVUs to the
renumbered 2006 RVP© instead of the “RNE” value.
(6)
Procedures (therapeutic exercises, neuromuscular re-education, aquatic therapy,
gait training, massage, acupuncture and any unlisted physical medicine
procedures)
Unless the provider’s medical records reflect medical necessity and the provider
obtains prior authorization for payment from the payer, the maximum amount of
time allowed is one hour of procedures per day, per discipline.
(7)
Modalities
RVP© 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 TENS unit for the patient's independent
use shall be billed using the timed e-stim RVP© CODE.
(8)
Evaluation Services for Therapists: Physical Therapy (PT), Occupational
Therapy (OT) and Athletic Trainers (cf. §12-36-106 C.R.S.)
(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.
These codes shall not be billed for 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.
(9)
(b)
Payers are only required to pay for evaluation services directly
performed by a PT, OT or athletic trainer, as defined in §12-36-106
C.R.S. All evaluation notes or reports must be written and signed by the
PT or OT. Physicians shall bill the appropriate E&M code from the E&M
section of the RVP©.
(c)
A patient may be seen by more than one health care professional on the
same day. An evaluation service with appropriate documentation may
be charged for each professional per patient per day.
(d)
Reimbursement to PTs, OTs, speech language pathologists and
audiologists for coordination of care with professionals shall be based
upon RVP© telephone case management codes. Coordination of care
reimbursement is limited to telephone calls made to professionals
outside of the therapist’s/pathologist’s/audiologist’s employment
facility(ies) and/or to the injured worker or their family and the prescribing
physician.
(e)
All interdisciplinary team conferences shall be billed under the case
management services section in the RVP© using medical conference
codes.
Special Tests
The following respective tests are considered special tests:

Job Site Evaluation

Computer- Enhanced Evaluation
Functional Capacity Evaluation
Work Tolerance Screening
(a)
(b)
(10)

Assistive technology assessment

Speech
Billing Restrictions:
(1)
Job Site Evaluations requires prior authorization if exceeding 2
hours. Computer-Enhanced Evaluations, Functional Capacity
Evaluations and Work Tolerance Screenings requires prior
authorization for payment for more than 4 hours.
(2)
The provider shall specify the time required to perform the test in
15-minute increments.
(3)
The value for the analysis and the written report is included in
the code’s value.
(4)
No E&M services or PT, OT, or acupuncture evaluations shall be
charged separately for these tests.
(5)
Data from computerized equipment shall always include the
supporting analysis developed by the physical medicine
professional before it is payable as a special test.
Provider Restrictions: all special tests must be fully supervised by a
physician, a PT, an OT, a speech language pathologist/therapist or
audiologist. Final reports must be written and signed by the physician,
the PT, the OT, the speech language pathologist/therapist or the
audiologist.
Speech Therapy/Evaluation and Treatment
Reimbursement shall be according to the unit values as listed in the RVP©
multiplied by their section’s respective CF.
(11)
Supplies
Physical medicine supplies are reimbursed in accordance with Rule 18-6(H).
(12)
Unattended Treatment
When a patient uses a facility or its equipment but is performing unattended
procedures, in either an individual or group setting, bill:
DoWC 97152
(13)
fixed fee per day
1.5 RVU
Non-Medical Facility
Fees, such as gyms, pools, etc., and training or supervision by non-medical
providers require prior authorization from the payer and a written negotiated fee.
(14)
Unlisted Service Physical Medicine
All unlisted services or procedures require a report.
(15)
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
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.
(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.
(I)
(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.
(1)
Prior authorization is required.
(2)
Provider Restrictions: All procedures must be performed by or
under the onsite supervision of a physician, PT, OT, speech
language pathologist or audiologist.
Evaluation and Management Section (E&M)
(1)
Medical record documentation shall encompass the RVP© “E&M Guideline”
criteria to justify the billed E&M service. If 50 % of the time spent with an injured
worker during an E&M visit is disability counseling, then time can determine the
level of E&M service.
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. 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 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.
(3)
Number of Office Visits
All providers, as defined in Rule 16-5 (A-C), are limited to one office visit per
patient, per day, per workers’ compensation claim unless prior authorization is
obtained from the payer. The E&M Guideline criteria as specified in the RVP©
E&M Section shall be used in all office visits to determine the appropriate level.
(4)
Case Management
(a)
(b)
Telephone case management services may be billed if the services are
performed on a separate day from an E&M office visit and when the
medical records/documentation specifies all the following:
(1)
the amount of time and date;
(2)
the person or person(s) talked to; and
(3)
the discussion and/or decision made during the call to coordinate
care for the injured worker.
An interdisciplinary team conference, consisting of medical professionals
caring for the injured worker, shall select a team member to perform the
following duties:
(1)
Prepare the billing statement in accordance with Rule 16,
Utilization Standards,

One conference charge per facility, per patient, per day.

(2)
18-6
Reimbursement for each interdisciplinary team
conference shall be billed in 15-minute increments.
Fifteen-minute conferences shall be reimbursed by
reducing the maximum allowance to 50% of the total 30
minute value found in the RVP©.
Prepare and submit a written report for each conference that
includes at least the following information:

Patient's identifying information;

Diagnosis;

Medical professionals attending the conference;

A brief statement of conference recommendations and
actions (no additional allowance shall be made for this
statement); and

Length of time of meeting.
DIVISION ESTABLISHED CODES AND VALUES
(A)
Conferences Held at the Request of a Party
Telephonic or face-to-face conferences shall be related to the injured worker's treatment.
All parties shall receive actual notification from the requesting party in advance and within
24 hours of scheduling.
DoWC 99901 Maximum of
billed at $56.25 per 15-minute increments.
(B)
$225.00 per hour;
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:
(2)
DoWC 99910
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
this Rule 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.
Reasonable cost shall not exceed $14.00 for the first 10 or fewer pages, $0.50 per page
for pages 11-40, and $0.33 per page thereafter. Actual postage or shipping costs and
applicable sales tax, if any, may also be charged. The per-page fee for records copied
from microfilm shall be $1.50 per page.
Copying Fee Billing Code:
(D)
DoWC 99911
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 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:
(2)
Deposition:
Payment for a physician's testimony at a deposition shall not exceed 35 RVU per
hour multiplied by the medicine CF ($7.56) billed in half-hour increments.
Calculation of the physician's time shall be "portal to portal."
The physician may request a full hour deposit in advance in order to schedule the
deposition.
By prior agreement with the deposing party, the physician may charge for
preparation time or for reviewing and signing the deposition.
The physician shall refund to the deposing party, any portion of an advance
payment in excess of time actually spent preparing and/or testifying when the
physician is notified of the cancellation of the deposition at least three (3)
business days prior to the scheduled deposition.
However, if the provider is not notified at least three (3) 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 he or she has reasonably spent in
preparation and has scheduled for the deposition.
Deposition
(3)
units per hr.
Billed in half-hour increments
Testimony:
Calculation of the physician's time shall be "portal to portal."
For testifying at a hearing, the physician may request a four (4) hour deposit in
advance in order to schedule the testimony.
By prior agreement, the physician may charge for preparation time for testimony.
The physician shall refund any portion of an advance payment in excess of time
actually spent preparing and/or testifying when the physician is notified of the
cancellation of the hearing at least five (5) business days prior to the date of the
hearing.
However, if the provider is not notified of a cancellation at least five (5) business
days prior to the date of the hearing, or the hearing is shorter than the time
scheduled, the provider shall be paid the number of hours he or she has
reasonably spent in preparation and has scheduled for the hearing.
Testimony Billing Code:
DoWC 99085
Maximum Rate of $400.00 per hour
(E)
Mileage Expenses
The payer shall reimburse an injured worker for reasonable and necessary mileage
expenses for travel to and from medical appointments and reasonable mileage to obtain
prescribed medications. The reimbursement rate shall be 37 cents per mile. The injured
worker shall submit a statement to the payer showing the date(s) of travel and number of
miles traveled, with receipts for any other reasonable and necessary travel expenses
incurred.
Mileage Expense Billing Code: DoWC 99912
(F)
Permanent Impairment Rating
(1)
The payer is only required to pay for one combined whole-person permanent
impairment rating per claim, except as otherwise provided in these 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 authorized treating
physician, if Level II accredited, or by a Level II accredited physician selected by
the authorized treating provider.
(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 and the fee for completing the Physician’s Report of Workers’
Compensation Injury (Closing Report), WC164 (See Rule 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
RVP©.
(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,
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.
(b)
USE THE APPROPRIATE RVP© CODE:
(1)
Fee for the Level II Accredited Authorized Treating Physician
Providing Primary Care:
Reimbursed for 1.5 hours with a
maximum not to exceed $320.58.
(2)
Fee for the Referral, Level II Accredited Authorized Physician:
Reimbursed for 2.5 hours with a
maximum not to exceed $616.50.
(3)
Fee for a Multiple Impairment Evaluation Requiring More Than
One 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
Completion of routine reports or records are incorporated in all fees for service
and include:
Diagnostic Testing
Procedure Reports
Progress notes
Office notes
Operative reports
Supply invoices, if requested by the payer
Requests for second copies of routine reports are reimbursable under the
copying fee section of Rule 18.
(2)
Completion of the Physician’s Report of Workers’ Compensation Injury (WC164)
(a)
Initial Report
The completed WC164 initial report is submitted to the payer after the
first visit with the injured worker. 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 when an injured worker is at maximum medical improvement
with or without a permanent impairment. A physician may bill for the
completion of the WC164 if neither impairment rating code (see Rule 186(F)(4)) has been billed. 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:
(c)
(1)
All necessary permanent impairment rating reports when the
authorized treating physician is Level II Accredited, or
(2)
The name of the Level II Accredited physician designated to
perform the permanent impairment rating when a rating is
necessary and the authorized treating physician is not
determining the permanent impairment rating.
Payer Requested WC164 Report
If the payer requests the 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 Form
If the provider wants to use the WC164 report as a progress report or for
any purpose other than those designated here in Rule 18-6(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:
(3)
DoWC 99960
$42.00
Initial Report
DoWC 99961
$42.00
Progress Report (Payer Requested or
Provider Initiated)
DoWC 99962
$42.00
Closing Report
DoWC 99963
$42.00
Initial and Closing Reports are
completed on the same form for the
same date of service
Special Reports
The term special reports includes reports falling outside the requirements set
forth in Rule 16, Utilization Standards, Rule 17, Medical Treatment Guidelines
and Rule 18 and includes any form, questionnaire or letter with variable content.
Reimbursement for preparation of special reports or records shall require prior
agreement with the requesting party. In special circumstances (e.g., when
reviewing and/or editing is necessary) and when prior agreement is made with
the requesting party, institutions, clinics or physicians’ offices may charge
additional sums. Use the appropriate RVP© code.
Special Report Preparation:
not to exceed $225.00 per hour.
Billed in half hour increments.
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.
(H)
(I)
Supplies, Durable Medical Equipment (DME), Orthotics and Prosthesis
(1)
Unless otherwise indicated, payment for supplies shall reflect the provider’s
actual cost plus a 20% markup. Cost includes shipping and handling charges.
(2)
“Supply et al.” is defined in Rule 16-2. Reimbursement shall be the provider’s
cost plus 20%. The provider shall furnish an invoice or their supplier’s published
rate, either with their bill for services or by previous agreement, to substantiate
their cost. The billing provider is responsible for identifying and itemizing all
“Supply et al.” items.
(3)
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 RULE 18-5(H)(5).
Inpatient Hospital Facility Fees
(1)
Provider Restrictions
All non-emergency, inpatient admissions require prior authorization for payment.
(2)
Bills for Services
(a)
Inpatient hospital facility fees shall be billed on the UB-92 and require
summary level billing by revenue code. The provider must submit
itemized bills along with the UB-92.
(b)
The maximum inpatient facility fee is determined by applying the Center
for Medicare and Medicaid Services (CMS) “Diagnosis Related Group”
(DRG) classification system. Exhibit 1 to Rule 18 shows the relative
weights per DRG that are used in calculating the maximum allowance.
The hospital shall indicate the DRG code number in the remarks section
(form locator 78) of the UB-92 billing form and maintain documentation
on file showing how the DRG was determined. The hospital shall
determine the DRG using the DRGs Definitions Manual. The attending
physician shall not be required to certify this documentation unless a
dispute arises between the hospital and the payer regarding DRG
assignment. The payer may deny payment for services until the
appropriate DRG code is supplied.
(3)
(c)
Exhibit 1 to Rule 18 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
Rule 18-6(I)(3)(d) is allowed.
(d)
Any inpatient admission requiring the use of both an acute care hospital
and its Medicare certified rehabilitation facility is considered as one
admission and DRG. This does not apply to long term care and licensed
rehabilitation facilities.
Inpatient Facility Reimbursement:
(a)
(b)
The following types of inpatient facilities are reimbursed at 100% of billed
inpatient charges:
(1)
Children’s hospital
(2)
Veterans’ Administration hospital
(3)
State psychiatric hospital
The following types of inpatient facilities are reimbursed at 80% of billed
inpatient charges:
(1)
Medicare certified Critical Access Hospital (CAH) (listed in
Exhibit 3 of Rule 18)
(2)
Medicare certified long-term care hospital
(3)
Colorado Department of Public Health and Environment
(CDPHE) licensed rehabilitation facility, and,
(4)
CDPHE licensed psychiatric facilities that are privately owned.
(c)
All other inpatient facilities are reimbursed as follows:
Retrieve the relative weights for the assigned DRG from the DRG table
in Exhibit 1 to Rule 18 and locate the hospital’s base rate in Exhibit 2 to
Rule 18.
The “Maximum Fee Allowance” is determined by calculating:
(d)
(1)
(DRG Relative Wt x Specific hospital base rate x 200%) +
(reimbursement for all “Supply et al.”)
(2)
“Supply et al.” is defined in Rule 16-2. Reimbursement shall be
consistent with Rule 18-6(H). The billing provider is responsible
for identifying and itemizing all “Supply et al.” items.
Outliers are admissions with extraordinary cost warranting additional
reimbursement beyond the maximum allowance under (3) (c) of Rule 186(I). To calculate the additional reimbursement, if any:
(1)
Determine the “Hospital’s Cost”:
total billed charges (excluding any “Supply et al.” billed charges)
multiplied by the hospital’s cost-to-charge ratio.
(2)
Each hospital’s cost-to-charge ratio is given in Exhibit 2 of Rule
18.
(3)
The “Difference” = “Hospital’s Cost” – “Maximum Fee Allowance”
excluding any “Supply et al.” allowance (see (c) above)
(4)
If the “Difference” is greater than $25,800.00, additional
reimbursement is warranted. The additional reimbursement is
determined by the following equation:
“Difference” x .80 = additional fee allowance
(e)
Inpatient combined with ERD or Trauma Center reimbursement
(1) If an injured worker is admitted to the hospital, the ERD
reimbursement is included in the inpatient reimbursement under 18-6
(I)(3),
(2) Except, Trauma Center activation fees (see 18-6(M)(3)(g)) are paid
in addition to inpatient fees (18-6(I)(3)(c-d).
(f)
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 DRG maximum value. The
per diem value is calculated based upon the transferring hospital’s DRG
relative weight multiplied by the hospital’s specific base rate (Exhibit 2 to
Rule 18) divided by the DRG geometric mean length of stay. 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 DRG maximum value.
(J)
Scheduled Outpatient Surgery Facility Fees
(1)
(2)
(3)
Provider Restrictions
(a)
All non-emergency outpatient surgeries require prior authorization from
the payer.
(b)
A separate facility fee is only payable if the facility is licensed by the
Colorado Department of Public Health and Environment (CDPHE) as:
(1)
a hospital; or
(2)
an Ambulatory Surgery Center (ASC).
Bills for Services
(a)
Outpatient facility fees shall be billed on the UB-92 and require summary
level billing by revenue code. The provider must submit itemized bills
along with the UB-92.
(b)
All professional charges are subject to the RVP© and Dental Fee
Schedules as incorporated by Rule 18.
(c)
ASCs and hospitals shall bill using the surgical RVP© code(s) as
indicated by the surgeon’s operative note up to a maximum of four
surgery codes per surgical episode.
Outpatient Surgery Facility Reimbursement:
(a)
The following types of outpatient facilities are reimbursed at 100% of
billed outpatient charges:
(1)
Children’s hospital
(2)
Veterans’ Administration hospital
(3)
State psychiatric hospital
(b)
CAHs, listed in Exhibit 3 of Rule 18, are to be reimbursed at 80% of
billed charges.
(c)
All other outpatient surgery facilities are reimbursed based on Exhibit 4
of this Rule 18. Exhibit 4 lists Medicare’s Outpatient Hospital Ambulatory
Prospective Payment Codes (APC) with the Division’s values for each
APC code.
The surgical procedure codes are classified by APC code in Medicare’s
April 2006 Addendum B. This Addendum B should be used to determine
the APC code payable under the Division’s Exhibit 4. However, not
every surgical code listed under Addendum B warrants a separate facility
fee. A separate facility fee may be warranted if there is a significant
health risk to the injured worker if the procedure is not performed in a
facility where credentialed emergency equipment and personnel are
maintained, including but not limited to, any procedure requiring the
administration of regional or general anesthesia. Minor procedures,
including but not limited to, laceration repairs and trigger point injections,
do not routinely warrant a separate facility fee as a scheduled outpatient
surgery.
The APC values listed in Exhibit 4 include reimbursement for the
following even if they are billed as line item charges:

nursing,

technician and related services,

use by the recipient of the facility including the
operating room and recovery room,

equipment directly related to the provision of surgical
procedures,

fluoroscopy and x-rays during the surgical episode,

supplies, drugs, biologics, surgical dressings, splints,
cases and appliances that do not meet the “Supply
et al.” threshold,

administration, record keeping, housekeeping items
and services, and

materials and trained observer for anesthesia.
The April 2006 Addendum B can be accessed at Medicare’s Hospital
Outpatient PPS website.
Total maximum facility value for an outpatient surgical episode of care
includes the sum of:
(1)
The highest valued APC code per Exhibit 4 plus 50% of any
lesser-valued APC code values.
Multiple procedures and bilateral procedures are to be indicated
by the use of modifiers –51 and –50, respectively. The 50%
reduction applies to all lower valued procedures, even if they are
identified in the RVP© as modifier -51 exempt.
The surgery discogram procedure(s) (APC 388) value is for each
level and includes conscious sedation and the technical
component of the radiological procedure.
Facility fee reimbursement is limited to a maximum of four
surgical procedures per surgical episode; and
(2)
“Supply et al.” is defined in Rule 16-2. Reimbursement shall be
consistent with Rule 18-6(H). The billing provider is responsible
for identifying and itemizing all “Supply et al.” items; and
(3)
Diagnostic testing and preoperative labs are reimbursed by
applying the appropriate CF to the unit values for the specific
CPT® code as listed in the RVP.
RVP© radiological procedure codes (not the injection codes)
with an appropriate modifier are to be used for all arthrograms
and myelograms; and
(K)
(4)
Observation room maximum allowance shall not exceed a rate of
$50.00 an hour and is limited to a maximum of 6 hours without
prior authorization. Documentation should support the medical
necessity for observation.
(5)
Additional reimbursement is payable for the following services
not included in the values found in Exhibit 4 of Rule 18:

ambulance services

blood, blood plasma, platelets
(d)
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.
(e)
All surgical procedures performed in one operating room, regardless of
the number of surgeons, are considered one outpatient surgical episode
of care for purposes of facility fee reimbursement.
(f)
In compliance with rule 16-6(A), the sum of Rule 18-6(J)(3)(c)(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 18-6(J)(3)(c) is not appropriate.
Outpatient Diagnostic Testing and Clinic Facility Fees
(1)
Bills for Services
All providers shall indicate whether they are billing for the total, professional only
or technical only component of a diagnostic test by listing the appropriate RVP©
modifier on the UB-92 or CMS 1500.
(2)
Reimbursement
(a)
(b)
The following types of outpatient diagnostic testing and clinic facilitIes are
reimbursed at 100% of billed charges:
(1)
Children’s hospitals,
(2)
Veterans’ Administration hospitals
(3)
State psychiatric hospitals
Rural health facilities listed in Exhibit 5 are reimbursed at 80% of billed
charges for clinic visits, diagnostic testing, and supplies and drugs that
do not meet the “Supply et al.” threshold.
“Supply et al.” is defined in Rule 16-2 and reimbursement shall be
consistent with Rule 18-6(H). The billing provider is responsible for
identifying and itemizing all “Supply et al.” items.
(c)
(L)
All other facilities:
(1)
No separate allowance for clinic visit fees. Supplies are
reimbursed in accordance with Rule 18-6(H).
(2)
No separate facility fee allowance for diagnostic testing. Facility
fees for diagnostic testing are considered part of the procedure’s
technical component value. Outpatient diagnostic testing is
reimbursed using the RVP© code unit value. Dyes and
contrasts may be reimbursed at 80% of billed charges.
(3)
“Supply et al.” is defined in Rule 16-2 and reimbursement shall
be consistent with Rule 18-6(H). The billing provider is
responsible for identifying and itemizing all “Supply et al.” items.
Outpatient Urgent Care Facility Fees
(1)
Provider Restrictions:
(a)
Prior agreement or authorization is recommended for all facilities billing a
separate Urgent Care fee. Facilities must provide documentation of the
required urgent care facility criteria if requested by the payer.
(b)
Urgent care facility fees are only payable if the facility qualifies as an
Urgent Care facility. Facilities licensed by the CDPHE as a Community
Clinic (CC) or a Community Clinic and Emergency Center (CCEC) under
6 CCR 1011-1, Chapter IX, should still provide evidence of these
qualifications to be reimbursed as an Urgent Care facility. The facility
shall meet all of the following criteria to be eligible for a separate Urgent
Care facility fee:
(1)
Separate facility dedicated to providing initial walk-in urgent care;
(2)
Access without appointment during all operating hours;
(c)
(2)
(3)
(3)
State licensed physician on-site at all times exclusively to
evaluate walk-in patients;
(4)
Support staff dedicated to urgent walk-in visits with certifications
in Basic Life Support (BLS);
(5)
Advanced Cardiac Life Support (ACLS) certified life support
capabilities to stabilize emergencies including, but not limited to,
EKG, defibrillator, oxygen and respiratory support equipment (full
crash cart), etc.;
(6)
Ambulance access;
(7)
Professional staff on-site at the facility certified in ACLS;
(8)
Extended hours including evening and some weekend hours;
(9)
Basic X-ray availability on-site during all operating hours;
(10)
Clinical Laboratory Improvement Amendments (CLIA) certified
laboratory on-site for basic diagnostic labs or ability to obtain
basic laboratory results within 1 hour;
(11)
Capabilities include, but are not limited to, suturing, minor
procedures, splinting, IV medications and hydration;
(12)
Written procedures exist for the facility’s stabilization and
transport processes.
No separate facility fees are allowed for follow-up care. Subsequent
care for an initial diagnosis does not qualify for a separate facility fee. To
receive another facility fee any subsequent diagnosis shall be a new
acute care situation entirely different from the initial diagnosis.
Bills for Services
(a)
Urgent care facility fees may be billed on a CMS 1500
(b)
Urgent care facility fees shall be billed using HCPCS Level II code:
S9088 – “Services provided in an Urgent care facility.”
Urgent Care Reimbursement
The total maximum value for an urgent care episode of care includes the sum of:
(a)
An Urgent Care Facility fee maximum allowance of $75.00; and
(b)
“Supply et al.” is defined in Rule 16-2 and reimbursement shall be
consistent with Rule 18-6(H). The billing provider is responsible for
identifying and itemizing all “Supply et al.” items.
Supplies and drugs that do not meet the “Supply et al.” threshold and
treatment rooms are included in the Urgent Care maximum fees; and
(4)
(M)
(c)
All diagnostic testing, laboratory services and therapeutic services
(including, but not limited to, radiology, pathology, respiratory therapy,
physical therapy or occupational therapy) shall be reimbursed by
multiplying the appropriate CF by the unit value for the specific CPT®
code as listed in the RVP© and Rule 18; and
(d)
The Observation Room allowance shall not exceed a rate of $50.00 per
hour and is limited to a maximum of 3 hours without prior authorization.
(e)
In compliance with Rule 16-6 (A), the sum of all Urgent Care fees
charged, less any amounts charged for professional fees or dispensed
prescriptions per Rule 18-6(L)(4) found on the same bill, is to be
compared to the maximum reimbursement allowed by the calculated
value of Rule 18-6(L)(3)(a-d). The lesser of the two amounts shall be the
maximum facility allowance for the episode of urgent care. A line by line
comparison is not appropriate.
Any prescription for a drug supply to be used longer than a 24 hour period, filled
at any Urgent Care facility, shall fall under the requirements and be reimbursed
as a pharmacy fee. See Rule 18-6(O).
Outpatient Emergency Room Department (ERD) Facility Fees
(1)
Provider Restrictions
To be reimbursed under this section (M), all outpatient ERDs within Colorado
must be physically located within a hospital licensed by the CDPHE as a general
hospital, or if free-standing ERD, must have equivalent operations as a licensed
ERD. To be paid as an ERD, out-of-state facilities shall meet that state’s
licensure requirements.
(2)
(3)
Bills For Services
(a)
ERD facility fees shall be billed on the UB-92 and require summary level
billing by revenue code. The provider must submit itemized bills along
with the UB-92.
(b)
Documentation should support the “Level of Care” being billed.
ERD Reimbursement
(a)
The following types of facilities are reimbursed at 100% of billed ERD
charges:
(1)
Children’s hospitals
(2)
Veterans’ Administration hospitals
(3)
State Psychiatric hospitals
(b)
Medicare certified Critical Access Hospitals (CAH) (listed in Exhibit 3 of
Rule 18) are reimbursed at 80% of billed charges.
(c)
The ERD “Level of Care” is identified based upon one of five levels of
care. The level of care is defined by the point system developed by the
hospital in compliance with Medicare regulations and determined by the
total number of points accumulated by assigning points to interventions
completed by the ERD staff during an ERD visit. Upon request the
provider shall supply a copy of their point system to the payer.
(d)
Total maximum value for an ERD episode of care includes the sum of
the following:
(1)
ERD reimbursement amount for “Level of Care” points:
ERD
LEVEL
Reimbursement
1
$
120.00
2
$
160.00
3
$
250.00
4
$
500.00
5
$
1,500.00
and
(e)
(2)
All diagnostic testing, laboratory services and therapeutic
services not included in the hospital’s point system (including,
but not limited to, radiology, pathology, any respiratory therapy,
PT or OT) shall be reimbursed by the appropriate CF multiplied
by the unit value for the specific code as listed in the RVP© and
Rule 18; and
(3)
The observation room allowance shall not exceed a rate of
$50.00 per hour and is limited to a maximum of 3 hours without
prior authorization. The documentation should support the
medical necessity for observation; and
(4)
ERD level of care maximum fees include supplies and drugs that
do not meet the “Supply et al.” threshold and treatment rooms.
“Supply et al.” is defined in Rule 16-2 and reimbursement shall
be consistent with Rule 18-6(H). The billing provider is
responsible for identifying and itemizing all “Supply et al.” items
For the purposes of Rule 16-6 (A), the sum of all outpatient ERD fees
charged, less any amounts charged for professional fees found on the
same bill, is to be compared to the maximum reimbursement allowed by
the calculated value of Rule 18-6(M)(3)(d). The lesser of the two
amounts shall be the maximum facility allowance for the ERD episode of
care. A line by line comparison is not appropriate.
(N)
(f)
If an injured worker is admitted to the hospital through that hospital’s
ERD, the ERD reimbursement is included in the inpatient reimbursement
under 18-6(I)(3).
(g)
Trauma Center Fees are not paid for alerts. Activation fees are as
follows:
Level I
$3,000.00
Level II
$2,500.00
Level III
$1,000.00
Level IV
$00.00
(1)
These fees are in addition to ERD and inpatient fees.
(2)
Activation Fees mean a Trauma Team has been activated, not
just alerted.
Home Therapy
Prior authorization is required for all home therapy. The payer and the home health entity
should agree in writing on the type of care, 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 diem rates for home infusion therapy shall include the initial patient
evaluation, education, coordination of care, products, equipment, IV
administration sets, supplies, supply management, and delivery services.
Nursing fees should be billed as indicated in Rule 18-6(N)(2).
(a)
(b)
Parenteral Nutrition:
0 -1 liter
$140.00/day
1.1 - 2.0 liter
$200.00/day
2.1 - 3.0 liter
$260.00/day
Antibiotic Therapy:
$105.00/day + Average Wholesale Price (AWP)
(c)
Chemotherapy:
$ 85.00/day + AWP
(d)
Enteral nutrition:
Category I
$ 43.00/day
Category II
$ 41.00/day
Category III
$ 52.00/day
(e)
Pain Management:
$ 95.00/day + AWP
(f)
Fluid Replacement:
$ 70.00/day + AWP
(g)
Multiple Therapies:
Only highest cost therapy + AWP for any remaining therapy
Medication/Drug Restrictions - the payment for drugs may be based upon the
AWP of the drug as determined through the use of industry publications such as
the monthly Price Alert, First Databank, Inc.
(2)
Nursing Services
DoWC 99970
Skilled Nursing (LPN & RN)
$95.79 per hour
There is a limit of 2 hours without prior authorization.
DoWC 99972
Certified Nurse Assistant (CNA):
$31.67 per hour for the first hour;
$9.46 for each additional half hour. Service must be at least 15 minutes
to bill an additional half hour charge.
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 the physical medicine and rehabilitation services section of Rule 18.
(4)
Travel Allowances
Travel is typically included in the fees listed. Any extensive travel may
need to be billed separately. Travel allowances should be agreed upon
with the payer and should not exceed $28.00 per visit, portal to portal.
The $28.00 allowance includes mileage.
DoWC code:
99971
(O)
Pharmacy Fees
(1)
AWP + $4.00
(2)
All bills shall reflect the National Drug Code (NDC)
(3)
All prescriptions shall be filled with bio-equivalent generic drugs unless the
physician indicates "Dispense As Written" (DAW) on the prescription
(4)
The above formula applies to both brand name and generic drugs
(5)
The provider shall dispense no more than a 60-day supply per prescription
(6)
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
(7)
AWP for brand name and generic pharmaceuticals may be determined through
the use of such monthly publications as Price Alert, First Databank, Inc.
(8)
Compounding Pharmacies
Reimbursement for compounding pharmacies shall be based on the cost of the
materials plus 20%, $50.00 per hour for the pharmacist’s documented time, and
actual cost of any mailing & handling.
Bill Code:
(9)
DoWC 99913
Materials, mailing, handling
DoWC 99914
Pharmacist
Injured Worker Reimbursement
The payer is responsible for timely payment of pharmaceutical costs (see Rule
16-11(A)(3)). In the event the injured worker has directly paid pharmaceutical
costs, the payer shall reimburse the injured worker for actual costs incurred for
authorized pharmacy services. If the actual costs exceed the maximum fee
allowed by this rule, the payer may seek a refund from the dispensing provider
for the difference between the amount charged to the injured worker and the
maximum fee. Each request for a refund shall indicate the prescription number
and the date of service involved.
(10)
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
for specific vitamins supported by Rule 17.
(11)
Prescription Writing
Physicians shall indicate on the prescription form that the medication is related to
a workers’ compensation claim.
(12)
Provider Reimbursement
Provider offices that prescribe and dispense medications from their office have a
maximum allowance of AWP plus $4.00.
All medications administered in the course of the provider’s care shall be
reimbursed at actual cost incurred.
(13)
Required Billing Forms
(a)
(P)
All parties shall use one of the following forms:
(1)
CMS 1500 (formerly HCFA 1500) – the dispensing provider shall
bill by using the RVP© supply code and shall include the metric
quantity and NDC number of the drug being dispensed; or
(2)
WC -M4 form or equivalent – each item on the form shall be
completed, or
(3)
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.
(b)
Items prescribed for the work-related injury that do not have an NDC
code shall be billed as a supply, using the RVP© supply code.
(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 patient or his/her
authorized representative has received the prescription.
Complementary Alternative Medicine (CAM) (Requires prior authorization)
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. Providers of CAM may be both
licensed and non-licensed health practitioners with training in one or more forms of
therapy. Refer to Rule 17, Medical Treatment Guidelines for the specific types of CAM
modalities.
(Q)
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 providers must be Registered Acupuncturists (LAc) or certified by an existing
licensing board as provided in Rule 16, Utilization Standards, and must provide
evidence of training, registration and/or certification upon request of the payer.
(2)
(3)
Billing Restrictions
(a).
For treatments of more than fourteen (14) sessions, the provider must
obtain prior authorization from the payer.
(b)
Unless the provider’s medical records reflect medical necessity and the
provider obtains prior authorization for payment from the payer, the
maximum amount of time allowed for acupuncture and procedures is one
hour of procedures, per day, per discipline.
Billing Codes:
(a)
Reimburse acupuncture, including or not including electrical stimulation,
as listed in the RVP©.
(b)
Non-Physician evaluation services
(1)
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.
(2)
LAc new patient visit:
DoWC 97041
(3)
$86.56
LAc established patient visit:
DoWC 97044
18-7
Maximum value
Maximum value
$58.43
(c)
Herbs require prior authorization and fee agreements as in this Rule 186(O)(10);
(d)
See the appropriate physical medicine and rehabilitation section of the
RVP© for other billing codes and limitations (see also Rule 18-5.H).
(e)
Acupuncture supplies are reimbursed in accordance with Rule 18-6(H).
DENTAL FEE SCHEDULE
The dental schedule is adopted using the American Dental Association’s Current Dental
Terminology, Fourth Edition (CDT-4). However, surgical treatment for dental trauma and
subsequent, related procedures shall be billed using codes from the RVP©. Reimbursement
shall be in accordance with the surgery/anesthesia section of the RVP©, its corresponding CFs,
the Division's Rule 16, Utilization Standards, and Rule 17, Medical Treatment Guidelines. See
Exhibit 6 for the listing and maximum allowance for dental codes.
Exhibit 1
DRGs with Relative Weights, Geometric and Arithmetic Means
DRG
V23
MDC
TYPE
1
01
SURG
2
01
SURG
3
01
4
5
6
01
01
01
SURG
*
SURG
SURG
SURG
7
01
SURG
8
01
SURG
9
01
MED
10
01
MED
11
01
MED
12
01
MED
13
01
MED
14
01
MED
15
01
MED
16
01
MED
17
01
MED
18
01
MED
DRG TITLE
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
CRANIOTOMY AGE >17
W CC
CRANIOTOMY AGE >17
W/O CC
CRANIOTOMY AGE 0-17
3.4347
7.6
10.1
1.9587
3.5
4.6
1.9860
12.7
12.7
NO LONGER VALID
NO LONGER VALID
CARPAL TUNNEL
RELEASE
PERIPH & CRANIAL
NERVE & OTHER NERV
SYST PROC W CC
PERIPH & CRANIAL
NERVE & OTHER NERV
SYST PROC W/O CC
SPINAL DISORDERS &
INJURIES
NERVOUS SYSTEM
NEOPLASMS W CC
NERVOUS SYSTEM
NEOPLASMS W/O CC
DEGENERATIVE
NERVOUS SYSTEM
DISORDERS
MULTIPLE SCLEROSIS &
CEREBELLAR ATAXIA
INTRACRANIAL
HEMORRHAGE OR
CEREBRAL INFARCTION
NONSPECIFIC CVA &
PRECEREBRAL
OCCLUSION W/O
INFARCT
NONSPECIFIC
CEREBROVASCULAR
DISORDERS W CC
NONSPECIFIC
CEREBROVASCULAR
DISORDERS W/O CC
CRANIAL & PERIPHERAL
NERVE DISORDERS W
CC
0.0000
0.0000
0.7878
0.0
0.0
2.2
0.0
0.0
3.0
2.6978
6.7
9.7
1.5635
2.0
3.0
1.4045
4.5
6.4
1.2222
4.6
6.2
0.8736
2.9
3.8
0.8998
4.3
5.5
0.8575
4.0
5.0
1.2456
4.5
5.8
0.9421
3.7
4.6
1.3351
5.0
6.5
0.7229
2.5
3.2
0.9903
4.1
5.3
DRG
V23
MDC
TYPE
19
01
MED
20
01
MED
21
22
01
01
MED
MED
23
01
MED
24
01
MED
25
01
MED
26
01
MED
27
01
MED
28
01
MED
29
01
MED
30
01
MED
*
31
01
MED
32
01
MED
33
01
34
01
MED
*
MED
35
01
MED
36
37
38
02
02
02
SURG
SURG
SURG
39
02
SURG
40
02
SURG
DRG TITLE
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
CRANIAL & PERIPHERAL
NERVE DISORDERS W/O
CC
NERVOUS SYSTEM
INFECTION EXCEPT
VIRAL MENINGITIS
VIRAL MENINGITIS
HYPERTENSIVE
ENCEPHALOPATHY
NONTRAUMATIC
STUPOR & COMA
SEIZURE & HEADACHE
AGE >17 W CC
SEIZURE & HEADACHE
AGE >17 W/O CC
SEIZURE & HEADACHE
AGE 0-17
TRAUMATIC STUPOR &
COMA, COMA >1 HR
TRAUMATIC STUPOR &
COMA, COMA <1 HR
AGE >17 W CC
TRAUMATIC STUPOR &
COMA, COMA <1 HR
AGE >17 W/O CC
TRAUMATIC STUPOR &
COMA, COMA <1 HR
AGE 0-17
CONCUSSION AGE >17
W CC
CONCUSSION AGE >17
W/O CC
CONCUSSION AGE 0-17
0.7077
2.7
3.5
2.7865
8.0
10.4
1.4451
1.1304
4.9
4.0
6.3
5.2
0.7712
3.0
3.9
0.9970
3.6
4.8
0.6180
2.5
3.1
1.8191
3.4
6.3
1.3531
3.2
5.2
1.3353
4.4
5.9
0.7212
2.6
3.4
0.3359
2.0
2.0
0.9567
3.0
4.0
0.6194
1.9
2.4
0.2109
1.6
1.6
OTHER DISORDERS OF
NERVOUS SYSTEM W
CC
OTHER DISORDERS OF
NERVOUS SYSTEM W/O
CC
RETINAL PROCEDURES
ORBITAL PROCEDURES
PRIMARY IRIS
PROCEDURES
LENS PROCEDURES
WITH OR WITHOUT
VITRECTOMY
EXTRAOCULAR
PROCEDURES EXCEPT
ORBIT AGE >17
1.0062
3.7
4.8
0.6241
2.4
3.0
0.7288
1.1858
0.6975
1.3
2.7
2.5
1.6
4.2
3.5
0.7108
1.7
2.4
0.9627
3.0
4.1
DRG
V23
MDC
TYPE
DRG TITLE
41
02
SURG
*
42
02
SURG
43
44
02
02
MED
MED
45
02
MED
46
02
MED
47
02
MED
48
02
49
03
MED
*
SURG
50
51
03
03
SURG
SURG
52
03
SURG
53
03
SURG
54
03
55
03
SURG
*
SURG
56
57
03
03
SURG
SURG
58
03
SURG
*
59
03
SURG
60
03
SURG
*
61
03
SURG
EXTRAOCULAR
PROCEDURES EXCEPT
ORBIT AGE 0-17
INTRAOCULAR
PROCEDURES EXCEPT
RETINA, IRIS & LENS
HYPHEMA
ACUTE MAJOR EYE
INFECTIONS
NEUROLOGICAL EYE
DISORDERS
OTHER DISORDERS OF
THE EYE AGE >17 W CC
OTHER DISORDERS OF
THE EYE AGE >17 W/O
CC
OTHER DISORDERS OF
THE EYE AGE 0-17
MAJOR HEAD & NECK
PROCEDURES
SIALOADENECTOMY
SALIVARY GLAND
PROCEDURES EXCEPT
SIALOADENECTOMY
CLEFT LIP & PALATE
REPAIR
SINUS & MASTOID
PROCEDURES AGE >17
SINUS & MASTOID
PROCEDURES AGE 0-17
MISCELLANEOUS EAR,
NOSE, MOUTH &
THROAT PROCEDURES
RHINOPLASTY
T&A PROC, EXCEPT
TONSILLECTOMY &/OR
ADENOIDECTOMY
ONLY, AGE >17
T&A PROC, EXCEPT
TONSILLECTOMY &/OR
ADENOIDECTOMY
ONLY, AGE 0-17
TONSILLECTOMY &/OR
ADENOIDECTOMY
ONLY, AGE >17
TONSILLECTOMY &/OR
ADENOIDECTOMY
ONLY, AGE 0-17
MYRINGOTOMY W TUBE
INSERTION AGE >17
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.3419
1.6
1.6
0.7852
2.0
2.8
0.6141
0.6874
2.4
3.9
3.1
4.8
0.7474
2.5
3.1
0.7524
3.2
4.2
0.5203
2.3
2.9
0.3012
2.9
2.9
1.6361
3.1
4.4
0.8690
0.8809
1.5
1.9
1.8
2.8
0.8348
1.5
1.9
1.3269
2.4
3.9
0.4882
3.2
3.2
0.9597
2.0
3.1
0.8711
1.0428
1.8
2.3
2.6
3.6
0.2772
1.5
1.5
0.8082
1.8
2.6
0.2110
1.5
1.5
1.2867
3.3
5.4
DRG
V23
MDC
TYPE
DRG TITLE
62
03
63
03
SURG
*
SURG
64
03
MED
65
66
67
68
03
03
03
03
MED
MED
MED
MED
69
03
MED
70
03
MED
71
72
03
03
MED
MED
73
03
MED
74
03
MED
*
75
04
SURG
76
04
SURG
77
04
SURG
78
79
04
04
MED
MED
80
04
MED
81
04
MED
*
82
04
MED
83
04
MED
MYRINGOTOMY W TUBE
INSERTION AGE 0-17
OTHER EAR, NOSE,
MOUTH & THROAT O.R.
PROCEDURES
EAR, NOSE, MOUTH &
THROAT MALIGNANCY
DYSEQUILIBRIUM
EPISTAXIS
EPIGLOTTITIS
OTITIS MEDIA & URI AGE
>17 W CC
OTITIS MEDIA & URI AGE
>17 W/O CC
OTITIS MEDIA & URI AGE
0-17
LARYNGOTRACHEITIS
NASAL TRAUMA &
DEFORMITY
OTHER EAR, NOSE,
MOUTH & THROAT
DIAGNOSES AGE >17
OTHER EAR, NOSE,
MOUTH & THROAT
DIAGNOSES AGE 0-17
MAJOR CHEST
PROCEDURES
OTHER RESP SYSTEM
O.R. PROCEDURES W
CC
OTHER RESP SYSTEM
O.R. PROCEDURES W/O
CC
PULMONARY EMBOLISM
RESPIRATORY
INFECTIONS &
INFLAMMATIONS AGE
>17 W CC
RESPIRATORY
INFECTIONS &
INFLAMMATIONS AGE
>17 W/O CC
RESPIRATORY
INFECTIONS &
INFLAMMATIONS AGE 017
RESPIRATORY
NEOPLASMS
MAJOR CHEST TRAUMA
W CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.2989
1.3
1.3
1.3983
3.0
4.5
1.1663
4.1
6.1
0.5991
0.5958
0.7725
0.6611
2.3
2.4
2.9
3.2
2.8
3.1
3.7
4.0
0.4850
2.5
3.0
0.4210
2.1
2.3
0.7524
0.7449
3.2
2.6
4.0
3.4
0.8527
3.3
4.4
0.3398
2.1
2.1
3.0732
7.6
9.9
2.8830
8.4
11.1
1.1857
3.3
4.7
1.2427
1.6238
5.4
6.7
6.4
8.5
0.8947
4.4
5.5
1.5383
6.1
6.1
1.3936
5.1
6.8
0.9828
4.2
5.3
DRG
V23
MDC
TYPE
84
04
MED
85
04
MED
86
04
MED
87
04
MED
88
04
MED
89
04
MED
90
04
MED
91
04
MED
92
04
MED
93
04
MED
94
95
04
04
MED
MED
96
04
MED
97
04
MED
98
04
99
04
MED
*
MED
100
04
MED
101
04
MED
102
04
MED
103
PRE
SURG
104
05
SURG
DRG TITLE
MAJOR CHEST TRAUMA
W/O CC
PLEURAL EFFUSION W
CC
PLEURAL EFFUSION
W/O CC
PULMONARY EDEMA &
RESPIRATORY FAILURE
CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
SIMPLE PNEUMONIA &
PLEURISY AGE >17 W
CC
SIMPLE PNEUMONIA &
PLEURISY AGE >17 W/O
CC
SIMPLE PNEUMONIA &
PLEURISY AGE 0-17
INTERSTITIAL LUNG
DISEASE W CC
INTERSTITIAL LUNG
DISEASE W/O CC
PNEUMOTHORAX W CC
PNEUMOTHORAX W/O
CC
BRONCHITIS & ASTHMA
AGE >17 W CC
BRONCHITIS & ASTHMA
AGE >17 W/O CC
BRONCHITIS & ASTHMA
AGE 0-17
RESPIRATORY SIGNS &
SYMPTOMS W CC
RESPIRATORY SIGNS &
SYMPTOMS W/O CC
OTHER RESPIRATORY
SYSTEM DIAGNOSES W
CC
OTHER RESPIRATORY
SYSTEM DIAGNOSES
W/O CC
HEART TRANSPLANT
OR IMPLANT OF HEART
ASSIST SYSTEM
CARDIAC VALVE & OTH
MAJOR
CARDIOTHORACIC
PROC W CARD CATH
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.5799
2.6
3.2
1.2405
4.8
6.3
0.6974
2.8
3.6
1.3654
4.9
6.4
0.8778
4.0
4.9
1.0320
4.7
5.7
0.6104
3.2
3.8
0.8124
3.4
4.4
1.1853
4.8
6.1
0.7150
3.1
3.9
1.1354
0.6035
4.6
2.9
6.2
3.6
0.7303
3.6
4.4
0.5364
2.8
3.4
0.5560
3.7
3.7
0.7094
2.4
3.1
0.5382
1.7
2.1
0.8733
3.3
4.3
0.5402
2.0
2.5
18.5617
23.7
37.7
8.2201
12.7
14.9
DRG
V23
MDC
TYPE
DRG TITLE
105
05
SURG
106
05
SURG
107
108
05
05
SURG
SURG
109
110
05
05
SURG
SURG
111
05
SURG
112
113
05
05
SURG
SURG
114
05
SURG
115
116
117
05
05
05
SURG
SURG
SURG
118
05
SURG
119
05
SURG
120
05
SURG
121
05
MED
122
05
MED
123
05
MED
124
05
MED
CARDIAC VALVE & OTH
MAJOR
CARDIOTHORACIC
PROC W/O CARD CATH
CORONARY BYPASS W
PTCA
NO LONGER VALID
OTHER
CARDIOTHORACIC
PROCEDURES
NO LONGER VALID
MAJOR
CARDIOVASCULAR
PROCEDURES W CC
MAJOR
CARDIOVASCULAR
PROCEDURES W/O CC
NO LONGER VALID
AMPUTATION FOR CIRC
SYSTEM DISORDERS
EXCEPT UPPER LIMB &
TOE
UPPER LIMB & TOE
AMPUTATION FOR CIRC
SYSTEM DISORDERS
NO LONGER VALID
NO LONGER VALID
CARDIAC PACEMAKER
REVISION EXCEPT
DEVICE REPLACEMENT
CARDIAC PACEMAKER
DEVICE REPLACEMENT
VEIN LIGATION &
STRIPPING
OTHER CIRCULATORY
SYSTEM O.R.
PROCEDURES
CIRCULATORY
DISORDERS W AMI &
MAJOR COMP,
DISCHARGED ALIVE
CIRCULATORY
DISORDERS W AMI W/O
MAJOR COMP,
DISCHARGED ALIVE
CIRCULATORY
DISORDERS W AMI,
EXPIRED
CIRCULATORY
DISORDERS EXCEPT
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
6.0192
8.4
10.2
7.0346
9.5
11.2
0.0000
5.8789
13.5
8.6
13.5
11.0
0.0000
3.8417
12.1
5.7
12.1
8.4
2.4840
2.6
3.4
0.0000
3.1682
0.0
10.8
0.0
13.7
1.7354
6.7
8.9
0.0000
0.0000
1.3223
15.8
9.3
2.6
15.8
9.3
4.2
1.6380
2.1
3.0
1.3456
3.3
5.5
2.3853
5.9
9.2
1.6136
5.3
6.6
0.9847
2.8
3.5
1.5407
2.9
4.8
1.4425
3.3
4.4
DRG
V23
MDC
TYPE
125
05
MED
126
05
MED
127
05
MED
128
05
MED
129
05
MED
130
05
MED
131
05
MED
132
05
MED
133
05
MED
134
135
05
05
MED
MED
136
05
MED
137
05
MED
*
138
05
MED
139
05
MED
140
141
05
05
MED
MED
142
05
MED
143
144
05
05
MED
MED
DRG TITLE
AMI, W CARD CATH &
COMPLEX DIAG
CIRCULATORY
DISORDERS EXCEPT
AMI, W CARD CATH W/O
COMPLEX DIAG
ACUTE & SUBACUTE
ENDOCARDITIS
HEART FAILURE &
SHOCK
DEEP VEIN
THROMBOPHLEBITIS
CARDIAC ARREST,
UNEXPLAINED
PERIPHERAL VASCULAR
DISORDERS W CC
PERIPHERAL VASCULAR
DISORDERS W/O CC
ATHEROSCLEROSIS W
CC
ATHEROSCLEROSIS
W/O CC
HYPERTENSION
CARDIAC CONGENITAL
& VALVULAR
DISORDERS AGE >17 W
CC
CARDIAC CONGENITAL
& VALVULAR
DISORDERS AGE >17
W/O CC
CARDIAC CONGENITAL
& VALVULAR
DISORDERS AGE 0-17
CARDIAC ARRHYTHMIA
& CONDUCTION
DISORDERS W CC
CARDIAC ARRHYTHMIA
& CONDUCTION
DISORDERS W/O CC
ANGINA PECTORIS
SYNCOPE & COLLAPSE
W CC
SYNCOPE & COLLAPSE
W/O CC
CHEST PAIN
OTHER CIRCULATORY
SYSTEM DIAGNOSES W
CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.0948
2.1
2.7
2.7440
9.4
12.0
1.0345
4.1
5.2
0.6949
4.4
5.2
1.0404
1.7
2.6
0.9425
4.4
5.5
0.5566
3.2
3.9
0.6273
2.2
2.8
0.5337
1.8
2.2
0.6068
0.8917
2.4
3.2
3.1
4.3
0.6214
2.2
2.8
0.8288
3.3
3.3
0.8287
3.0
3.9
0.5227
2.0
2.4
0.5116
0.7521
2.0
2.7
2.4
3.5
0.5852
2.0
2.5
0.5659
1.2761
1.7
4.1
2.1
5.8
DRG
V23
MDC
TYPE
145
05
MED
146
06
SURG
147
06
SURG
148
06
SURG
149
06
SURG
150
06
SURG
151
06
SURG
152
06
SURG
153
06
SURG
154
06
SURG
155
06
SURG
156
06
SURG
*
157
06
SURG
158
06
SURG
159
06
SURG
160
06
SURG
DRG TITLE
OTHER CIRCULATORY
SYSTEM DIAGNOSES
W/O CC
RECTAL RESECTION W
CC
RECTAL RESECTION
W/O CC
MAJOR SMALL & LARGE
BOWEL PROCEDURES
W CC
MAJOR SMALL & LARGE
BOWEL PROCEDURES
W/O CC
PERITONEAL
ADHESIOLYSIS W CC
PERITONEAL
ADHESIOLYSIS W/O CC
MINOR SMALL & LARGE
BOWEL PROCEDURES
W CC
MINOR SMALL & LARGE
BOWEL PROCEDURES
W/O CC
STOMACH,
ESOPHAGEAL &
DUODENAL
PROCEDURES AGE >17
W CC
STOMACH,
ESOPHAGEAL &
DUODENAL
PROCEDURES AGE >17
W/O CC
STOMACH,
ESOPHAGEAL &
DUODENAL
PROCEDURES AGE 0-17
ANAL & STOMAL
PROCEDURES W CC
ANAL & STOMAL
PROCEDURES W/O CC
HERNIA PROCEDURES
EXCEPT INGUINAL &
FEMORAL AGE >17 W
CC
HERNIA PROCEDURES
EXCEPT INGUINAL &
FEMORAL AGE >17 W/O
CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.5835
2.1
2.6
2.6621
8.6
10.0
1.4781
5.2
5.8
3.4479
10.0
12.3
1.4324
5.4
6.0
2.8061
8.9
11.0
1.2641
4.0
5.1
1.8783
6.7
8.0
1.0821
4.5
5.0
4.0399
9.9
13.3
1.2889
3.1
4.1
0.8535
6.0
6.0
1.3356
4.1
5.8
0.6657
2.1
2.6
1.4081
3.8
5.1
0.8431
2.2
2.7
DRG
V23
MDC
TYPE
DRG TITLE
161
06
SURG
162
06
SURG
163
06
SURG
164
06
SURG
165
06
SURG
166
06
SURG
167
06
SURG
168
03
SURG
169
03
SURG
170
06
SURG
171
06
SURG
172
06
MED
173
06
MED
174
06
MED
175
06
MED
176
06
MED
177
06
MED
178
06
MED
179
06
MED
180
06
MED
181
06
MED
INGUINAL & FEMORAL
HERNIA PROCEDURES
AGE >17 W CC
INGUINAL & FEMORAL
HERNIA PROCEDURES
AGE >17 W/O CC
HERNIA PROCEDURES
AGE 0-17
APPENDECTOMY W
COMPLICATED
PRINCIPAL DIAG W CC
APPENDECTOMY W
COMPLICATED
PRINCIPAL DIAG W/O CC
APPENDECTOMY W/O
COMPLICATED
PRINCIPAL DIAG W CC
APPENDECTOMY W/O
COMPLICATED
PRINCIPAL DIAG W/O CC
MOUTH PROCEDURES
W CC
MOUTH PROCEDURES
W/O CC
OTHER DIGESTIVE
SYSTEM O.R.
PROCEDURES W CC
OTHER DIGESTIVE
SYSTEM O.R.
PROCEDURES W/O CC
DIGESTIVE
MALIGNANCY W CC
DIGESTIVE
MALIGNANCY W/O CC
G.I. HEMORRHAGE W
CC
G.I. HEMORRHAGE W/O
CC
COMPLICATED PEPTIC
ULCER
UNCOMPLICATED
PEPTIC ULCER W CC
UNCOMPLICATED
PEPTIC ULCER W/O CC
INFLAMMATORY BOWEL
DISEASE
G.I. OBSTRUCTION W
CC
G.I. OBSTRUCTION W/O
CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.1931
3.1
4.4
0.6785
1.7
2.1
0.6723
2.2
2.9
2.2476
6.6
8.0
1.1868
3.6
4.2
1.4521
3.3
4.5
0.8929
1.9
2.2
1.2662
3.3
4.9
0.7297
1.8
2.3
2.9612
7.8
11.0
1.1905
3.1
4.1
1.4125
5.1
7.0
0.7443
2.7
3.6
1.0060
3.8
4.7
0.5646
2.4
2.9
1.1246
4.1
5.2
0.9166
3.6
4.4
0.7013
2.6
3.1
1.0911
4.5
5.9
0.9784
4.2
5.4
0.5614
2.8
3.3
DRG
V23
MDC
TYPE
182
06
MED
183
06
MED
184
06
MED
185
03
MED
186
03
MED
*
187
03
MED
188
06
MED
189
06
MED
190
06
MED
191
07
SURG
192
07
SURG
193
07
SURG
194
07
SURG
195
07
SURG
196
07
SURG
DRG TITLE
ESOPHAGITIS,
GASTROENT & MISC
DIGEST DISORDERS
AGE >17 W CC
ESOPHAGITIS,
GASTROENT & MISC
DIGEST DISORDERS
AGE >17 W/O CC
ESOPHAGITIS,
GASTROENT & MISC
DIGEST DISORDERS
AGE 0-17
DENTAL & ORAL DIS
EXCEPT EXTRACTIONS
& RESTORATIONS, AGE
>17
DENTAL & ORAL DIS
EXCEPT EXTRACTIONS
& RESTORATIONS, AGE
0-17
DENTAL EXTRACTIONS
& RESTORATIONS
OTHER DIGESTIVE
SYSTEM DIAGNOSES
AGE >17 W CC
OTHER DIGESTIVE
SYSTEM DIAGNOSES
AGE >17 W/O CC
OTHER DIGESTIVE
SYSTEM DIAGNOSES
AGE 0-17
PANCREAS, LIVER &
SHUNT PROCEDURES W
CC
PANCREAS, LIVER &
SHUNT PROCEDURES
W/O CC
BILIARY TRACT PROC
EXCEPT ONLY
CHOLECYST W OR W/O
C.D.E. W CC
BILIARY TRACT PROC
EXCEPT ONLY
CHOLECYST W OR W/O
C.D.E. W/O CC
CHOLECYSTECTOMY W
C.D.E. W CC
CHOLECYSTECTOMY W
C.D.E. W/O CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.8413
3.4
4.4
0.5848
2.3
2.9
0.5663
2.5
3.3
0.8702
3.2
4.5
0.3253
2.9
2.9
0.8363
3.1
4.2
1.1290
4.2
5.6
0.6064
2.4
3.1
0.6179
3.1
4.4
3.9680
9.0
12.9
1.6793
4.3
5.7
3.2818
9.9
12.1
1.5748
5.6
6.7
3.0530
8.8
10.6
1.6031
4.9
5.7
DRG
V23
MDC
TYPE
DRG TITLE
197
07
SURG
198
07
SURG
199
07
SURG
200
07
SURG
201
07
SURG
202
07
MED
203
07
MED
204
07
MED
205
07
MED
206
07
MED
207
07
MED
208
07
MED
209
210
08
08
SURG
SURG
211
08
SURG
212
08
SURG
CHOLECYSTECTOMY
EXCEPT BY
LAPAROSCOPE W/O
C.D.E. W CC
CHOLECYSTECTOMY
EXCEPT BY
LAPAROSCOPE W/O
C.D.E. W/O CC
HEPATOBILIARY
DIAGNOSTIC
PROCEDURE FOR
MALIGNANCY
HEPATOBILIARY
DIAGNOSTIC
PROCEDURE FOR NONMALIGNANCY
OTHER HEPATOBILIARY
OR PANCREAS O.R.
PROCEDURES
CIRRHOSIS &
ALCOHOLIC HEPATITIS
MALIGNANCY OF
HEPATOBILIARY
SYSTEM OR PANCREAS
DISORDERS OF
PANCREAS EXCEPT
MALIGNANCY
DISORDERS OF LIVER
EXCEPT
MALIG,CIRR,ALC HEPA
W CC
DISORDERS OF LIVER
EXCEPT
MALIG,CIRR,ALC HEPA
W/O CC
DISORDERS OF THE
BILIARY TRACT W CC
DISORDERS OF THE
BILIARY TRACT W/O CC
NO LONGER VALID
HIP & FEMUR
PROCEDURES EXCEPT
MAJOR JOINT AGE >17
W CC
HIP & FEMUR
PROCEDURES EXCEPT
MAJOR JOINT AGE >17
W/O CC
HIP & FEMUR
PROCEDURES EXCEPT
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
2.5425
7.5
9.2
1.1604
3.7
4.3
2.4073
6.8
9.5
2.7868
6.5
9.8
3.7339
9.9
13.7
1.3318
4.7
6.2
1.3552
4.9
6.5
1.1249
4.2
5.6
1.2059
4.4
6.0
0.7292
3.0
3.9
1.1746
4.1
5.3
0.6895
2.3
2.9
0.0000
1.9059
17.1
6.1
17.1
6.9
1.2690
4.4
4.7
1.2877
2.4
2.9
DRG
V23
MDC
TYPE
DRG TITLE
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
2.0428
7.2
9.7
0.0000
0.0000
1.9131
0.0
0.0
3.3
0.0
0.0
5.8
3.0596
9.3
13.2
1.6648
4.4
5.6
1.0443
2.6
3.1
0.5913
5.3
5.3
0.0000
0.0000
1.1164
0.0
0.0
2.3
0.0
0.0
3.2
0.8185
1.6
1.9
1.2251
1.5884
3.7
4.5
5.2
6.5
0.8311
2.1
2.6
1.1459
2.8
4.1
MAJOR JOINT AGE 0-17
213
08
SURG
214
215
216
08
08
08
SURG
SURG
SURG
217
08
SURG
218
08
SURG
219
08
SURG
220
08
SURG
*
221
222
223
08
08
08
SURG
SURG
SURG
224
08
SURG
225
226
08
08
SURG
SURG
227
08
SURG
228
08
SURG
AMPUTATION FOR
MUSCULOSKELETAL
SYSTEM & CONN
TISSUE DISORDERS
NO LONGER VALID
NO LONGER VALID
BIOPSIES OF
MUSCULOSKELETAL
SYSTEM & CONNECTIVE
TISSUE
WND DEBRID & SKN
GRFT EXCEPT
HAND,FOR
MUSCSKELET & CONN
TISS DIS
LOWER EXTREM &
HUMER PROC EXCEPT
HIP,FOOT,FEMUR AGE
>17 W CC
LOWER EXTREM &
HUMER PROC EXCEPT
HIP,FOOT,FEMUR AGE
>17 W/O CC
LOWER EXTREM &
HUMER PROC EXCEPT
HIP,FOOT,FEMUR AGE
0-17
NO LONGER VALID
NO LONGER VALID
MAJOR
SHOULDER/ELBOW
PROC, OR OTHER
UPPER EXTREMITY
PROC W CC
SHOULDER,ELBOW OR
FOREARM PROC,EXC
MAJOR JOINT PROC,
W/O CC
FOOT PROCEDURES
SOFT TISSUE
PROCEDURES W CC
SOFT TISSUE
PROCEDURES W/O CC
MAJOR THUMB OR
JOINT PROC,OR OTH
HAND OR WRIST PROC
W CC
DRG
V23
MDC
TYPE
DRG TITLE
229
08
SURG
230
08
SURG
231
232
233
08
08
08
SURG
SURG
SURG
234
08
SURG
235
236
08
08
MED
MED
237
08
MED
238
239
08
08
MED
MED
240
08
MED
241
08
MED
242
243
08
08
MED
MED
244
08
MED
245
08
MED
246
08
MED
247
08
MED
248
08
MED
HAND OR WRIST PROC,
EXCEPT MAJOR JOINT
PROC, W/O CC
LOCAL EXCISION &
REMOVAL OF INT FIX
DEVICES OF HIP &
FEMUR
NO LONGER VALID
ARTHROSCOPY
OTHER
MUSCULOSKELET SYS
& CONN TISS O.R. PROC
W CC
OTHER
MUSCULOSKELET SYS
& CONN TISS O.R. PROC
W/O CC
FRACTURES OF FEMUR
FRACTURES OF HIP &
PELVIS
SPRAINS, STRAINS, &
DISLOCATIONS OF HIP,
PELVIS & THIGH
OSTEOMYELITIS
PATHOLOGICAL
FRACTURES &
MUSCULOSKELETAL &
CONN TISS
MALIGNANCY
CONNECTIVE TISSUE
DISORDERS W CC
CONNECTIVE TISSUE
DISORDERS W/O CC
SEPTIC ARTHRITIS
MEDICAL BACK
PROBLEMS
BONE DISEASES &
SPECIFIC
ARTHROPATHIES W CC
BONE DISEASES &
SPECIFIC
ARTHROPATHIES W/O
CC
NON-SPECIFIC
ARTHROPATHIES
SIGNS & SYMPTOMS OF
MUSCULOSKELETAL
SYSTEM & CONN
TISSUE
TENDONITIS, MYOSITIS
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.6976
1.9
2.5
1.3174
3.7
5.6
0.0000
0.9702
1.9184
0.0
1.8
4.6
0.0
2.8
6.8
1.2219
2.0
2.8
0.7768
0.7407
3.8
3.8
4.8
4.6
0.6090
3.0
3.7
1.4401
1.0767
6.7
5.0
8.7
6.2
1.4051
5.0
6.7
0.6629
3.0
3.7
1.1504
0.7658
5.1
3.6
6.7
4.5
0.7200
3.6
4.5
0.4583
2.5
3.1
0.5932
2.8
3.6
0.5795
2.6
3.3
0.8554
3.8
4.8
DRG
V23
MDC
TYPE
249
08
MED
250
08
MED
251
08
MED
252
08
MED
*
253
08
MED
254
08
MED
255
08
MED
*
256
08
MED
257
09
SURG
258
09
SURG
259
09
SURG
260
09
SURG
261
09
SURG
262
09
SURG
263
09
SURG
DRG TITLE
& BURSITIS
AFTERCARE,
MUSCULOSKELETAL
SYSTEM & CONNECTIVE
TISSUE
FX, SPRN, STRN & DISL
OF FOREARM, HAND,
FOOT AGE >17 W CC
FX, SPRN, STRN & DISL
OF FOREARM, HAND,
FOOT AGE >17 W/O CC
FX, SPRN, STRN & DISL
OF FOREARM, HAND,
FOOT AGE 0-17
FX, SPRN, STRN & DISL
OF UPARM,LOWLEG EX
FOOT AGE >17 W CC
FX, SPRN, STRN & DISL
OF UPARM,LOWLEG EX
FOOT AGE >17 W/O CC
FX, SPRN, STRN & DISL
OF UPARM,LOWLEG EX
FOOT AGE 0-17
OTHER
MUSCULOSKELETAL
SYSTEM & CONNECTIVE
TISSUE DIAGNOSES
TOTAL MASTECTOMY
FOR MALIGNANCY W CC
TOTAL MASTECTOMY
FOR MALIGNANCY W/O
CC
SUBTOTAL
MASTECTOMY FOR
MALIGNANCY W CC
SUBTOTAL
MASTECTOMY FOR
MALIGNANCY W/O CC
BREAST PROC FOR
NON-MALIGNANCY
EXCEPT BIOPSY &
LOCAL EXCISION
BREAST BIOPSY &
LOCAL EXCISION FOR
NON-MALIGNANCY
SKIN GRAFT &/OR
DEBRID FOR SKN
ULCER OR CELLULITIS
W CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.7095
2.7
3.9
0.6974
3.2
3.9
0.4749
2.3
2.8
0.2567
1.8
1.8
0.7747
3.8
4.6
0.4588
2.6
3.1
0.2990
2.9
2.9
0.8509
3.9
5.1
0.8967
2.0
2.6
0.7138
1.5
1.7
0.9671
1.8
2.8
0.7032
1.2
1.4
0.9732
1.6
2.2
0.9766
3.3
4.8
2.1130
8.6
11.4
DRG
V23
MDC
TYPE
DRG TITLE
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
264
09
SURG
SKIN GRAFT &/OR
DEBRID FOR SKN
ULCER OR CELLULITIS
W/O CC
SKIN GRAFT &/OR
DEBRID EXCEPT FOR
SKIN ULCER OR
CELLULITIS W CC
SKIN GRAFT &/OR
DEBRID EXCEPT FOR
SKIN ULCER OR
CELLULITIS W/O CC
PERIANAL & PILONIDAL
PROCEDURES
SKIN, SUBCUTANEOUS
TISSUE & BREAST
PLASTIC PROCEDURES
OTHER SKIN, SUBCUT
TISS & BREAST PROC W
CC
OTHER SKIN, SUBCUT
TISS & BREAST PROC
W/O CC
SKIN ULCERS
MAJOR SKIN
DISORDERS W CC
MAJOR SKIN
DISORDERS W/O CC
MALIGNANT BREAST
DISORDERS W CC
MALIGNANT BREAST
DISORDERS W/O CC
NON-MALIGNANT
BREAST DISORDERS
CELLULITIS AGE >17 W
CC
CELLULITIS AGE >17
W/O CC
CELLULITIS AGE 0-17
1.0635
5.0
6.5
265
09
SURG
1.6593
4.4
6.8
266
09
SURG
0.8637
2.3
3.2
267
09
SURG
0.8962
2.8
4.2
268
09
SURG
1.1326
2.4
3.5
269
09
SURG
1.8352
6.2
8.6
270
09
SURG
0.8313
2.7
3.9
271
272
09
09
MED
MED
1.0195
0.9860
5.6
4.5
7.1
5.9
273
09
MED
0.5539
2.9
3.7
274
09
MED
1.1294
4.7
6.3
275
09
MED
0.5340
2.4
3.3
276
09
MED
0.6892
3.5
4.5
277
09
MED
0.8676
4.6
5.6
278
09
MED
0.5391
3.4
4.1
279
09
280
09
MED
*
MED
0.7822
4.2
4.2
TRAUMA TO THE SKIN,
SUBCUT TISS & BREAST
AGE >17 W CC
TRAUMA TO THE SKIN,
SUBCUT TISS & BREAST
AGE >17 W/O CC
TRAUMA TO THE SKIN,
SUBCUT TISS & BREAST
AGE 0-17
MINOR SKIN
0.7313
3.2
4.1
281
09
MED
0.4913
2.3
2.9
282
09
MED
*
0.2600
2.2
2.2
283
09
MED
0.7423
3.5
4.6
DRG
V23
MDC
TYPE
284
09
MED
285
10
SURG
286
10
SURG
287
10
SURG
288
10
SURG
289
10
SURG
290
291
10
10
SURG
SURG
292
10
SURG
293
10
SURG
294
295
296
10
10
10
MED
MED
MED
297
10
MED
298
10
MED
299
10
MED
300
10
MED
301
10
MED
302
303
11
11
SURG
SURG
304
11
SURG
DRG TITLE
DISORDERS W CC
MINOR SKIN
DISORDERS W/O CC
AMPUTAT OF LOWER
LIMB FOR
ENDOCRINE,NUTRIT,&
METABOL DISORDERS
ADRENAL & PITUITARY
PROCEDURES
SKIN GRAFTS & WOUND
DEBRID FOR ENDOC,
NUTRIT & METAB
DISORDERS
O.R. PROCEDURES FOR
OBESITY
PARATHYROID
PROCEDURES
THYROID PROCEDURES
THYROGLOSSAL
PROCEDURES
OTHER ENDOCRINE,
NUTRIT & METAB O.R.
PROC W CC
OTHER ENDOCRINE,
NUTRIT & METAB O.R.
PROC W/O CC
DIABETES AGE >35
DIABETES AGE 0-35
NUTRITIONAL & MISC
METABOLIC DISORDERS
AGE >17 W CC
NUTRITIONAL & MISC
METABOLIC DISORDERS
AGE >17 W/O CC
NUTRITIONAL & MISC
METABOLIC DISORDERS
AGE 0-17
INBORN ERRORS OF
METABOLISM
ENDOCRINE
DISORDERS W CC
ENDOCRINE
DISORDERS W/O CC
KIDNEY TRANSPLANT
KIDNEY,URETER &
MAJOR BLADDER
PROCEDURES FOR
NEOPLASM
KIDNEY,URETER &
MAJOR BLADDER PROC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.4563
2.4
3.0
2.1831
8.2
10.5
1.9390
4.0
5.5
1.9470
7.8
10.4
2.0384
3.2
4.1
0.9315
1.7
2.6
0.8891
1.0877
1.6
1.6
2.1
2.8
2.6395
7.3
10.3
1.3472
3.2
4.5
0.7652
0.7267
0.8187
3.3
2.8
3.7
4.3
3.7
4.8
0.4879
2.5
3.1
0.5486
2.5
3.9
1.0329
3.7
5.2
1.0922
4.6
6.0
0.6118
2.7
3.4
3.1679
2.2183
7.0
5.8
8.2
7.4
2.3761
6.1
8.6
DRG
V23
MDC
TYPE
305
11
SURG
306
307
11
11
SURG
SURG
308
11
SURG
309
11
SURG
310
11
SURG
311
11
SURG
312
11
SURG
313
11
SURG
314
11
315
11
SURG
*
SURG
316
317
11
11
MED
MED
318
11
MED
319
11
MED
320
11
MED
321
11
MED
322
11
MED
323
11
MED
324
11
MED
DRG TITLE
FOR NON-NEOPL W CC
KIDNEY,URETER &
MAJOR BLADDER PROC
FOR NON-NEOPL W/O
CC
PROSTATECTOMY W CC
PROSTATECTOMY W/O
CC
MINOR BLADDER
PROCEDURES W CC
MINOR BLADDER
PROCEDURES W/O CC
TRANSURETHRAL
PROCEDURES W CC
TRANSURETHRAL
PROCEDURES W/O CC
URETHRAL
PROCEDURES, AGE >17
W CC
URETHRAL
PROCEDURES, AGE >17
W/O CC
URETHRAL
PROCEDURES, AGE 0-17
OTHER KIDNEY &
URINARY TRACT O.R.
PROCEDURES
RENAL FAILURE
ADMIT FOR RENAL
DIALYSIS
KIDNEY & URINARY
TRACT NEOPLASMS W
CC
KIDNEY & URINARY
TRACT NEOPLASMS
W/O CC
KIDNEY & URINARY
TRACT INFECTIONS
AGE >17 W CC
KIDNEY & URINARY
TRACT INFECTIONS
AGE >17 W/O CC
KIDNEY & URINARY
TRACT INFECTIONS
AGE 0-17
URINARY STONES W
CC, &/OR ESW
LITHOTRIPSY
URINARY STONES W/O
CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.1595
2.6
3.2
1.2700
0.6202
3.6
1.7
5.5
2.1
1.6349
3.9
6.1
0.9085
1.6
2.0
1.1898
3.0
4.5
0.6432
1.5
1.9
1.1159
3.2
4.8
0.6783
1.7
2.2
0.5012
2.3
2.3
2.0823
3.6
6.8
1.2692
0.7942
4.9
2.4
6.4
3.5
1.1539
4.2
5.8
0.6385
2.1
2.8
0.8658
4.2
5.2
0.5652
3.0
3.6
0.5498
2.9
3.4
0.8214
2.3
3.1
0.5050
1.6
1.9
DRG
V23
MDC
TYPE
325
11
MED
326
11
MED
327
11
MED
*
328
11
MED
329
11
MED
330
11
331
11
MED
*
MED
332
11
MED
333
11
MED
334
12
SURG
335
12
SURG
336
12
SURG
337
12
SURG
338
12
SURG
339
12
SURG
340
12
SURG
*
341
342
343
12
12
12
344
12
SURG
SURG
SURG
*
SURG
DRG TITLE
KIDNEY & URINARY
TRACT SIGNS &
SYMPTOMS AGE >17 W
CC
KIDNEY & URINARY
TRACT SIGNS &
SYMPTOMS AGE >17
W/O CC
KIDNEY & URINARY
TRACT SIGNS &
SYMPTOMS AGE 0-17
URETHRAL STRICTURE
AGE >17 W CC
URETHRAL STRICTURE
AGE >17 W/O CC
URETHRAL STRICTURE
AGE 0-17
OTHER KIDNEY &
URINARY TRACT
DIAGNOSES AGE >17 W
CC
OTHER KIDNEY &
URINARY TRACT
DIAGNOSES AGE >17
W/O CC
OTHER KIDNEY &
URINARY TRACT
DIAGNOSES AGE 0-17
MAJOR MALE PELVIC
PROCEDURES W CC
MAJOR MALE PELVIC
PROCEDURES W/O CC
TRANSURETHRAL
PROSTATECTOMY W CC
TRANSURETHRAL
PROSTATECTOMY W/O
CC
TESTES PROCEDURES,
FOR MALIGNANCY
TESTES PROCEDURES,
NON-MALIGNANCY AGE
>17
TESTES PROCEDURES,
NON-MALIGNANCY AGE
0-17
PENIS PROCEDURES
CIRCUMCISION AGE >17
CIRCUMCISION AGE 017
OTHER MALE
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.6436
2.9
3.7
0.4391
2.1
2.6
0.3748
3.1
3.1
0.7079
2.6
3.5
0.4701
1.5
1.8
0.3227
1.6
1.6
1.0619
4.1
5.5
0.6160
2.4
3.1
0.9669
3.5
5.3
1.4368
3.5
4.3
1.1004
2.4
2.7
0.8425
2.5
3.3
0.5747
1.7
1.9
1.3772
3.9
6.2
1.1866
3.2
5.1
0.2868
2.4
2.4
1.2622
0.8737
0.1559
1.9
2.5
1.7
3.2
3.4
1.7
1.2475
1.7
2.7
DRG
V23
MDC
TYPE
345
12
SURG
346
12
MED
347
12
MED
348
12
MED
349
12
MED
350
12
MED
351
12
352
12
MED
*
MED
353
13
SURG
354
13
SURG
355
13
SURG
356
13
SURG
357
13
SURG
358
13
SURG
DRG TITLE
REPRODUCTIVE
SYSTEM O.R.
PROCEDURES FOR
MALIGNANCY
OTHER MALE
REPRODUCTIVE
SYSTEM O.R. PROC
EXCEPT FOR
MALIGNANCY
MALIGNANCY, MALE
REPRODUCTIVE
SYSTEM, W CC
MALIGNANCY, MALE
REPRODUCTIVE
SYSTEM, W/O CC
BENIGN PROSTATIC
HYPERTROPHY W CC
BENIGN PROSTATIC
HYPERTROPHY W/O CC
INFLAMMATION OF THE
MALE REPRODUCTIVE
SYSTEM
STERILIZATION, MALE
OTHER MALE
REPRODUCTIVE
SYSTEM DIAGNOSES
PELVIC EVISCERATION,
RADICAL
HYSTERECTOMY &
RADICAL VULVECTOMY
UTERINE,ADNEXA PROC
FOR NONOVARIAN/ADNEXAL
MALIG W CC
UTERINE,ADNEXA PROC
FOR NONOVARIAN/ADNEXAL
MALIG W/O CC
FEMALE
REPRODUCTIVE
SYSTEM
RECONSTRUCTIVE
PROCEDURES
UTERINE & ADNEXA
PROC FOR OVARIAN OR
ADNEXAL MALIGNANCY
UTERINE & ADNEXA
PROC FOR NONMALIGNANCY W CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.1472
3.1
4.8
1.0441
4.2
5.7
0.6104
2.2
3.1
0.7188
3.2
4.1
0.4210
1.9
2.4
0.7289
3.5
4.5
0.2392
1.3
1.3
0.7360
2.9
4.0
1.8504
4.7
6.3
1.5135
4.6
5.7
0.8824
2.8
3.1
0.7428
1.7
1.9
2.2237
6.5
8.1
1.1448
3.2
4.0
DRG
V23
MDC
TYPE
DRG TITLE
359
13
SURG
360
13
SURG
361
13
SURG
362
13
363
13
SURG
*
SURG
364
13
SURG
365
13
SURG
366
13
MED
367
13
MED
368
13
MED
369
13
MED
370
14
SURG
371
14
SURG
372
14
MED
373
14
MED
374
14
SURG
375
14
SURG
*
376
14
MED
UTERINE & ADNEXA
PROC FOR NONMALIGNANCY W/O CC
VAGINA, CERVIX &
VULVA PROCEDURES
LAPAROSCOPY &
INCISIONAL TUBAL
INTERRUPTION
ENDOSCOPIC TUBAL
INTERRUPTION
D&C, CONIZATION &
RADIO-IMPLANT, FOR
MALIGNANCY
D&C, CONIZATION
EXCEPT FOR
MALIGNANCY
OTHER FEMALE
REPRODUCTIVE
SYSTEM O.R.
PROCEDURES
MALIGNANCY, FEMALE
REPRODUCTIVE
SYSTEM W CC
MALIGNANCY, FEMALE
REPRODUCTIVE
SYSTEM W/O CC
INFECTIONS, FEMALE
REPRODUCTIVE
SYSTEM
MENSTRUAL & OTHER
FEMALE
REPRODUCTIVE
SYSTEM DISORDERS
CESAREAN SECTION W
CC
CESAREAN SECTION
W/O CC
VAGINAL DELIVERY W
COMPLICATING
DIAGNOSES
VAGINAL DELIVERY W/O
COMPLICATING
DIAGNOSES
VAGINAL DELIVERY W
STERILIZATION &/OR
D&C
VAGINAL DELIVERY W
O.R. PROC EXCEPT
STERIL &/OR D&C
POSTPARTUM & POST
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.7948
2.2
2.4
0.8582
2.0
2.6
1.0847
2.2
3.0
0.3057
1.4
1.4
0.9728
2.7
3.8
0.8709
3.0
4.2
2.0408
5.3
7.7
1.2348
4.8
6.6
0.5728
2.3
3.0
1.1684
5.2
6.7
0.6310
2.4
3.3
0.8974
4.1
5.2
0.6066
3.1
3.4
0.5027
2.5
3.2
0.3556
2.0
2.2
0.6712
2.5
2.8
0.5837
4.4
4.4
0.5242
2.6
3.4
DRG
V23
MDC
TYPE
377
14
SURG
378
379
14
14
MED
MED
380
381
14
14
MED
SURG
382
383
14
14
MED
MED
384
14
MED
385
15
MED
*
386
15
MED
*
387
15
388
15
389
15
390
15
MED
*
MED
*
MED
*
MED
*
391
15
392
393
16
16
394
16
MED
*
SURG
SURG
*
SURG
395
16
MED
396
16
MED
DRG TITLE
ABORTION DIAGNOSES
W/O O.R. PROCEDURE
POSTPARTUM & POST
ABORTION DIAGNOSES
W O.R. PROCEDURE
ECTOPIC PREGNANCY
THREATENED
ABORTION
ABORTION W/O D&C
ABORTION W D&C,
ASPIRATION
CURETTAGE OR
HYSTEROTOMY
FALSE LABOR
OTHER ANTEPARTUM
DIAGNOSES W MEDICAL
COMPLICATIONS
OTHER ANTEPARTUM
DIAGNOSES W/O
MEDICAL
COMPLICATIONS
NEONATES, DIED OR
TRANSFERRED TO
ANOTHER ACUTE CARE
FACILITY
EXTREME IMMATURITY
OR RESPIRATORY
DISTRESS SYNDROME,
NEONATE
PREMATURITY W
MAJOR PROBLEMS
PREMATURITY W/O
MAJOR PROBLEMS
FULL TERM NEONATE W
MAJOR PROBLEMS
NEONATE W OTHER
SIGNIFICANT
PROBLEMS
NORMAL NEWBORN
SPLENECTOMY AGE >17
SPLENECTOMY AGE 017
OTHER O.R.
PROCEDURES OF THE
BLOOD AND BLOOD
FORMING ORGANS
RED BLOOD CELL
DISORDERS AGE >17
RED BLOOD CELL
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.6996
2.9
4.5
0.7472
0.3578
1.9
2.0
2.3
2.8
0.3925
0.6034
1.6
1.6
2.1
2.2
0.2070
0.5053
1.3
2.6
1.4
3.7
0.3225
1.8
2.6
1.3930
1.8
1.8
4.5935
17.9
17.9
3.1372
13.3
13.3
1.8929
8.6
8.6
3.2226
4.7
4.7
1.1406
3.4
3.4
0.1544
3.1
3.1
3.0459
1.3645
6.5
9.1
9.2
9.1
1.9109
4.5
7.4
0.8328
3.2
4.3
0.8323
2.6
4.3
DRG
V23
MDC
TYPE
397
16
*
MED
398
16
MED
399
16
MED
400
401
17
17
SURG
SURG
402
17
SURG
403
17
MED
404
17
MED
405
17
MED
*
406
17
SURG
407
17
SURG
408
17
SURG
409
410
17
17
MED
MED
411
17
MED
412
17
MED
413
17
MED
DRG TITLE
DISORDERS AGE 0-17
COAGULATION
DISORDERS
RETICULOENDOTHELIAL
& IMMUNITY
DISORDERS W CC
RETICULOENDOTHELIAL
& IMMUNITY
DISORDERS W/O CC
NO LONGER VALID
LYMPHOMA & NONACUTE LEUKEMIA W
OTHER O.R. PROC W CC
LYMPHOMA & NONACUTE LEUKEMIA W
OTHER O.R. PROC W/O
CC
LYMPHOMA & NONACUTE LEUKEMIA W CC
LYMPHOMA & NONACUTE LEUKEMIA W/O
CC
ACUTE LEUKEMIA W/O
MAJOR O.R.
PROCEDURE AGE 0-17
MYELOPROLIF DISORD
OR POORLY DIFF
NEOPL W MAJ
O.R.PROC W CC
MYELOPROLIF DISORD
OR POORLY DIFF
NEOPL W MAJ
O.R.PROC W/O CC
MYELOPROLIF DISORD
OR POORLY DIFF
NEOPL W OTHER
O.R.PROC
RADIOTHERAPY
CHEMOTHERAPY W/O
ACUTE LEUKEMIA AS
SECONDARY
DIAGNOSIS
HISTORY OF
MALIGNANCY W/O
ENDOSCOPY
HISTORY OF
MALIGNANCY W
ENDOSCOPY
OTHER MYELOPROLIF
DIS OR POORLY DIFF
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.2986
3.7
5.1
1.2082
4.4
5.7
0.6674
2.7
3.3
0.0000
2.9678
0.0
8.0
0.0
11.3
1.1810
2.8
4.1
1.8432
5.8
8.1
0.9265
3.0
4.2
1.9346
4.9
4.9
2.7897
7.0
9.9
1.2289
3.0
3.8
2.2460
4.8
8.2
1.2074
1.1069
4.3
3.0
5.8
3.8
0.3635
2.5
3.3
0.8451
1.8
2.8
1.3048
5.0
6.8
DRG
V23
MDC
TYPE
414
17
MED
415
18
SURG
416
417
418
18
18
18
MED
MED
MED
419
18
MED
420
18
MED
421
422
18
18
MED
MED
423
18
MED
424
19
SURG
425
19
MED
426
19
MED
427
19
MED
428
19
MED
429
19
MED
430
431
19
19
MED
MED
432
19
MED
433
20
MED
434
435
20
20
MED
MED
DRG TITLE
NEOPL DIAG W CC
OTHER MYELOPROLIF
DIS OR POORLY DIFF
NEOPL DIAG W/O CC
O.R. PROCEDURE FOR
INFECTIOUS &
PARASITIC DISEASES
SEPTICEMIA AGE >17
SEPTICEMIA AGE 0-17
POSTOPERATIVE &
POST-TRAUMATIC
INFECTIONS
FEVER OF UNKNOWN
ORIGIN AGE >17 W CC
FEVER OF UNKNOWN
ORIGIN AGE >17 W/O CC
VIRAL ILLNESS AGE >17
VIRAL ILLNESS & FEVER
OF UNKNOWN ORIGIN
AGE 0-17
OTHER INFECTIOUS &
PARASITIC DISEASES
DIAGNOSES
O.R. PROCEDURE W
PRINCIPAL DIAGNOSES
OF MENTAL ILLNESS
ACUTE ADJUSTMENT
REACTION &
PSYCHOSOCIAL
DYSFUNCTION
DEPRESSIVE
NEUROSES
NEUROSES EXCEPT
DEPRESSIVE
DISORDERS OF
PERSONALITY &
IMPULSE CONTROL
ORGANIC
DISTURBANCES &
MENTAL RETARDATION
PSYCHOSES
CHILDHOOD MENTAL
DISORDERS
OTHER MENTAL
DISORDER DIAGNOSES
ALCOHOL/DRUG ABUSE
OR DEPENDENCE, LEFT
AMA
NO LONGER VALID
NO LONGER VALID
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.7788
3.0
4.0
3.9890
11.0
14.8
1.6774
1.1689
1.0716
5.6
3.2
4.8
7.5
4.1
6.2
0.8453
3.4
4.4
0.6077
2.7
3.4
0.7664
0.6171
3.1
2.6
4.1
3.7
1.9196
6.0
8.4
2.2773
7.3
12.4
0.6191
2.6
3.5
0.4656
3.0
4.1
0.5135
3.2
4.7
0.6981
4.6
7.3
0.7919
4.3
5.6
0.6483
0.5178
5.8
4.0
7.9
5.9
0.6282
2.9
4.3
0.2776
2.2
3.0
0.0000
0.0000
0.0
0.0
0.0
0.0
DRG
V23
MDC
TYPE
436
437
438
439
20
20
20
21
MED
MED
440
21
SURG
441
21
SURG
442
21
SURG
443
21
SURG
444
21
MED
445
21
MED
446
21
447
21
MED
*
MED
448
21
449
21
MED
*
MED
450
21
MED
451
21
MED
*
452
21
MED
453
21
MED
454
21
MED
455
21
MED
456
457
458
459
460
22
22
22
22
22
MED
SURG
SURG
MED
SURG
DRG TITLE
NO LONGER VALID
NO LONGER VALID
NO LONGER VALID
SKIN GRAFTS FOR
INJURIES
WOUND
DEBRIDEMENTS FOR
INJURIES
HAND PROCEDURES
FOR INJURIES
OTHER O.R.
PROCEDURES FOR
INJURIES W CC
OTHER O.R.
PROCEDURES FOR
INJURIES W/O CC
TRAUMATIC INJURY
AGE >17 W CC
TRAUMATIC INJURY
AGE >17 W/O CC
TRAUMATIC INJURY
AGE 0-17
ALLERGIC REACTIONS
AGE >17
ALLERGIC REACTIONS
AGE 0-17
POISONING & TOXIC
EFFECTS OF DRUGS
AGE >17 W CC
POISONING & TOXIC
EFFECTS OF DRUGS
AGE >17 W/O CC
POISONING & TOXIC
EFFECTS OF DRUGS
AGE 0-17
COMPLICATIONS OF
TREATMENT W CC
COMPLICATIONS OF
TREATMENT W/O CC
OTHER INJURY,
POISONING & TOXIC
EFFECT DIAG W CC
OTHER INJURY,
POISONING & TOXIC
EFFECT DIAG W/O CC
NO LONGER VALID
NO LONGER VALID
NO LONGER VALID
NO LONGER VALID
NO LONGER VALID
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
0.0000
0.0000
0.0000
1.9398
0.0
0.0
0.0
5.4
0.0
0.0
0.0
8.9
1.9457
5.9
9.2
0.9382
2.3
3.4
2.5660
6.0
8.9
0.9943
2.6
3.4
0.7556
3.2
4.1
0.5033
2.2
2.8
0.2999
2.4
2.4
0.5569
1.9
2.6
0.0987
2.9
2.9
0.8529
2.6
3.7
0.4282
1.6
2.0
0.2663
2.1
2.1
1.0462
3.5
4.9
0.5285
2.2
2.8
0.8141
2.9
4.1
0.4725
1.7
2.2
0.0000
0.0000
0.0000
0.0000
0.0000
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
DRG
V23
MDC
TYPE
DRG TITLE
461
23
SURG
462
463
23
23
MED
MED
464
23
MED
465
23
MED
466
23
MED
467
23
MED
O.R. PROC W
DIAGNOSES OF OTHER
CONTACT W HEALTH
SERVICES
REHABILITATION
SIGNS & SYMPTOMS W
CC
SIGNS & SYMPTOMS
W/O CC
AFTERCARE W HISTORY
OF MALIGNANCY AS
SECONDARY
DIAGNOSIS
AFTERCARE W/O
HISTORY OF
MALIGNANCY AS
SECONDARY
DIAGNOSIS
OTHER FACTORS
INFLUENCING HEALTH
STATUS
EXTENSIVE O.R.
PROCEDURE
UNRELATED TO
PRINCIPAL DIAGNOSIS
PRINCIPAL DIAGNOSIS
INVALID AS DISCHARGE
DIAGNOSIS
UNGROUPABLE
BILATERAL OR
MULTIPLE MAJOR JOINT
PROCS OF LOWER
EXTREMITY
NO LONGER VALID
ACUTE LEUKEMIA W/O
MAJOR O.R.
PROCEDURE AGE >17
NO LONGER VALID
RESPIRATORY SYSTEM
DIAGNOSIS WITH
VENTILATOR SUPPORT
PROSTATIC O.R.
PROCEDURE
UNRELATED TO
PRINCIPAL DIAGNOSIS
NON-EXTENSIVE O.R.
PROCEDURE
UNRELATED TO
PRINCIPAL DIAGNOSIS
NO LONGER VALID
468
469
**
470
471
08
**
SURG
472
473
22
17
SURG
MED
474
475
04
04
SURG
MED
476
SURG
477
SURG
478
05
SURG
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.3974
3.0
5.1
0.8700
0.6960
8.9
3.1
10.8
3.9
0.5055
2.4
2.9
0.6224
2.4
3.8
0.7806
2.8
5.3
0.4803
2.0
2.7
4.0031
9.7
13.2
0.0000
0.0
0.0
0.0000
3.1391
0.0
4.5
0.0
5.1
0.0000
3.4231
0.0
7.4
0.0
12.7
0.0000
3.6091
0.0
8.1
0.0
11.3
2.1822
7.4
10.5
2.0607
5.8
8.7
0.0000
0.0
0.0
DRG
V23
MDC
TYPE
DRG TITLE
479
05
SURG
480
PRE
SURG
481
PRE
SURG
482
PRE
SURG
483
484
PRE
24
SURG
SURG
485
24
SURG
486
24
SURG
487
24
MED
488
25
SURG
489
25
MED
490
25
MED
491
08
SURG
492
17
MED
493
07
SURG
494
07
SURG
495
496
PRE
08
SURG
SURG
497
08
SURG
OTHER VASCULAR
PROCEDURES W/O CC
LIVER TRANSPLANT
AND/OR INTESTINAL
TRANSPLANT
BONE MARROW
TRANSPLANT
TRACHEOSTOMY FOR
FACE,MOUTH & NECK
DIAGNOSES
NO LONGER VALID
CRANIOTOMY FOR
MULTIPLE SIGNIFICANT
TRAUMA
LIMB REATTACHMENT,
HIP AND FEMUR PROC
FOR MULTIPLE
SIGNIFICANT TRA
OTHER O.R.
PROCEDURES FOR
MULTIPLE SIGNIFICANT
TRAUMA
OTHER MULTIPLE
SIGNIFICANT TRAUMA
HIV W EXTENSIVE O.R.
PROCEDURE
HIV W MAJOR RELATED
CONDITION
HIV W OR W/O OTHER
RELATED CONDITION
MAJOR JOINT & LIMB
REATTACHMENT
PROCEDURES OF
UPPER EXTREMITY
CHEMOTHERAPY W
ACUTE LEUKEMIA OR W
USE OF HI DOSE
CHEMOAGENT
LAPAROSCOPIC
CHOLECYSTECTOMY
W/O C.D.E. W CC
LAPAROSCOPIC
CHOLECYSTECTOMY
W/O C.D.E. W/O CC
LUNG TRANSPLANT
COMBINED
ANTERIOR/POSTERIOR
SPINAL FUSION
SPINAL FUSION EXCEPT
CERVICAL W CC
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.4434
2.1
2.8
8.9693
13.7
18.0
6.2321
18.2
21.7
3.3387
9.6
12.1
0.0000
5.1438
0.0
9.3
0.0
12.8
3.4952
8.4
10.2
4.7323
8.5
12.5
1.9459
5.3
7.3
4.4353
11.8
16.4
1.8058
5.9
8.4
1.0639
3.8
5.4
1.6780
2.6
3.1
3.5926
8.8
13.7
1.8333
4.5
6.1
1.0285
2.1
2.7
8.5736
6.0932
14.0
6.4
17.3
8.8
3.6224
5.0
5.9
DRG
V23
MDC
TYPE
DRG TITLE
498
08
SURG
499
08
SURG
500
08
SURG
501
08
SURG
502
08
SURG
503
08
SURG
504
22
SURG
505
22
MED
506
22
SURG
507
22
SURG
508
22
MED
509
22
MED
510
22
MED
511
22
MED
512
PRE
SURG
513
PRE
SURG
514
05
SURG
SPINAL FUSION EXCEPT
CERVICAL W/O CC
BACK & NECK
PROCEDURES EXCEPT
SPINAL FUSION W CC
BACK & NECK
PROCEDURES EXCEPT
SPINAL FUSION W/O CC
KNEE PROCEDURES W
PDX OF INFECTION W
CC
KNEE PROCEDURES W
PDX OF INFECTION W/O
CC
KNEE PROCEDURES
W/O PDX OF INFECTION
EXTEN. BURNS OR FULL
THICKNESS BURN W/MV
96+HRS W/SKIN GFT
EXTEN. BURNS OR FULL
THICKNESS BURN W/MV
96+HRS W/O SKIN GFT
FULL THICKNESS BURN
W SKIN GRAFT OR
INHAL INJ W CC OR SIG
TRAUMA
FULL THICKNESS BURN
W SKIN GRFT OR INHAL
INJ W/O CC OR SIG
TRAUMA
FULL THICKNESS BURN
W/O SKIN GRFT OR
INHAL INJ W CC OR SIG
TRAUMA
FULL THICKNESS BURN
W/O SKIN GRFT OR INH
INJ W/O CC OR SIG
TRAUMA
NON-EXTENSIVE BURNS
W CC OR SIGNIFICANT
TRAUMA
NON-EXTENSIVE BURNS
W/O CC OR
SIGNIFICANT TRAUMA
SIMULTANEOUS
PANCREAS/KIDNEY
TRANSPLANT
PANCREAS
TRANSPLANT
NO LONGER VALID
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
2.7791
3.4
3.8
1.3831
3.1
4.3
0.9046
1.8
2.2
2.6462
8.5
10.4
1.4462
4.9
5.9
1.2038
2.9
3.8
11.8018
21.7
27.3
2.2953
2.4
4.6
4.0939
11.2
15.9
1.7369
5.8
8.5
1.2767
5.1
7.4
0.8217
3.6
5.2
1.1817
4.4
6.4
0.7424
2.6
4.1
5.3660
10.7
12.8
5.9669
8.9
9.9
0.0000
0.0
0.0
DRG
V23
MDC
TYPE
DRG TITLE
515
05
SURG
516
517
518
05
05
05
SURG
SURG
SURG
519
08
SURG
520
08
SURG
521
20
MED
522
20
MED
523
20
MED
524
525
01
05
MED
SURG
526
527
528
05
05
01
SURG
SURG
SURG
529
01
SURG
530
01
SURG
531
01
SURG
532
01
SURG
533
01
SURG
534
01
SURG
535
05
SURG
536
05
SURG
CARDIAC
DEFIBRILLATOR
IMPLANT W/O CARDIAC
CATH
NO LONGER VALID
NO LONGER VALID
PERC CARDIO PROC
W/O CORONARY
ARTERY STENT OR AMI
CERVICAL SPINAL
FUSION W CC
CERVICAL SPINAL
FUSION W/O CC
ALCOHOL/DRUG ABUSE
OR DEPENDENCE W CC
ALC/DRUG ABUSE OR
DEPEND W
REHABILITATION
THERAPY W/O CC
ALC/DRUG ABUSE OR
DEPEND W/O
REHABILITATION
THERAPY W/O CC
TRANSIENT ISCHEMIA
OTHER HEART ASSIST
SYSTEM IMPLANT
NO LONGER VALID
NO LONGER VALID
INTRACRANIAL
VASCULAR PROC W
PDX HEMORRHAGE
VENTRICULAR SHUNT
PROCEDURES W CC
VENTRICULAR SHUNT
PROCEDURES W/O CC
SPINAL PROCEDURES
W CC
SPINAL PROCEDURES
W/O CC
EXTRACRANIAL
PROCEDURES W CC
EXTRACRANIAL
PROCEDURES W/O CC
CARDIAC DEFIB
IMPLANT W CARDIAC
CATH W AMI/HF/SHOCK
CARDIAC DEFIB
IMPLANT W CARDIAC
CATH W/O
AMI/HF/SHOCK
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
5.5205
2.6
4.3
0.0000
0.0000
1.6544
0.0
0.0
1.8
0.0
0.0
2.5
2.4695
3.0
4.8
1.6788
1.6
2.0
0.6939
4.2
5.6
0.4794
7.7
9.6
0.3793
3.2
3.9
0.7288
11.4282
2.6
7.2
3.2
13.6
0.0000
0.0000
7.0505
0.0
0.0
13.8
0.0
0.0
17.2
2.3160
5.3
8.3
1.2041
2.4
3.1
3.1279
6.5
9.6
1.4195
2.8
3.7
1.5767
2.4
3.8
1.0201
1.5
1.8
7.9738
7.9
10.3
6.9144
5.9
7.6
DRG
V23
MDC
TYPE
DRG TITLE
537
08
SURG
538
08
SURG
539
17
SURG
540
17
SURG
541
PRE
SURG
542
PRE
SURG
543
01
SURG
544
08
SURG
545
08
SURG
546
08
SURG
547
05
SURG
548
05
SURG
549
05
SURG
550
05
SURG
551
05
SURG
LOCAL EXCIS & REMOV
OF INT FIX DEV EXCEPT
HIP & FEMUR W CC
LOCAL EXCIS & REMOV
OF INT FIX DEV EXCEPT
HIP & FEMUR W/O CC
LYMPHOMA & LEUKEMIA
W MAJOR OR
PROCEDURE W CC
LYMPHOMA & LEUKEMIA
W MAJOR OR
PROCEDURE W/O CC
ECMO OR TRACH W MV
96+HRS OR PDX EXC
FACE, MOUTH & NECK
W MAJ O.R.
TRACH W MV 96+HRS
OR PDX EXC FACE,
MOUTH & NECK W/O
MAJ O.R.
CRANIOTOMY
W/IMPLANT OF CHEMO
AGENT OR ACUTE
COMPLX CNS PDX
MAJOR JOINT
REPLACEMENT OR
REATTACHMENT OF
LOWER EXTREMITY
REVISION OF HIP OR
KNEE REPLACEMENT
SPINAL FUSION EXC
CERV WITH
CURVATURE OF THE
SPINE OR MALIG
CORONARY BYPASS W
CARDIAC CATH W
MAJOR CV DX
CORONARY BYPASS W
CARDIAC CATH W/O
MAJOR CV DX
CORONARY BYPASS
W/O CARDIAC CATH W
MAJOR CV DX
CORONARY BYPASS
W/O CARDIAC CATH
W/O MAJOR CV DX
PERMANENT CARDIAC
PACEMAKER IMPL W
MAJ CV DX OR AICD
LEAD OR GNRTR
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
1.8360
4.8
6.9
0.9833
2.1
2.8
3.2782
7.0
10.8
1.1940
2.6
3.6
19.8038
38.1
45.7
12.8719
29.1
35.1
4.4184
8.5
12.3
1.9643
4.1
4.5
2.4827
4.5
5.2
5.0739
7.1
8.8
6.1948
10.8
12.3
4.7198
8.2
9.0
5.0980
8.7
10.3
3.6151
6.2
6.9
3.1007
4.4
6.4
DRG
V23
MDC
TYPE
552
05
SURG
DRG TITLE
WEIGHTS
GEOMETRIC
MEAN LOS
ARITHMETIC
MEAN LOS
OTHER PERMANENT
2.0996
2.5
3.5
CARDIAC PACEMAKER
IMPLANT W/O MAJOR
CV DX
553
05
SURG OTHER VASCULAR
3.0957
6.6
9.7
PROCEDURES W CC W
MAJOR CV DX
554
05
SURG OTHER VASCULAR
2.0721
4.0
5.9
PROCEDURES W CC
W/O MAJOR CV DX
555
05
SURG PERCUTANEOUS
2.4315
3.4
4.7
CARDIOVASCULAR
PROC W MAJOR CV DX
556
05
SURG PERCUTANEOUS
1.9132
1.6
2.1
CARDIOVASC PROC W
NON-DRUG-ELUTING
STENT W/O MAJ CV DX
557
05
SURG PERCUTANEOUS
2.8717
3.0
4.1
CARDIOVASCULAR
PROC W DRUG-ELUTING
STENT W MAJOR CV DX
558
05
SURG PERCUTANEOUS
2.2108
1.5
1.9
CARDIOVASCULAR
PROC W DRUG-ELUTING
STENT W/O MAJ CV DX
559
01
MED
ACUTE ISCHEMIC
2.2473
5.8
7.2
STROKE WITH USE OF
THROMBOLYTIC AGENT
MEDICARE DATA HAVE BEEN SUPPLEMENTED BY DATA FROM 19 STATES FOR LOW
VOLUME DRGS.
DRGS 469 AND 470 CONTAIN CASES WHICH COULD NOT BE ASSIGNED TO VALID DRGS.
NOTE: GEOMETRIC MEAN IS USED ONLY TO DETERMINE PAYMENT FOR TRANSFER
CASES.
NOTE: ARITHMETIC MEAN IS PRESENTED FOR INFORMATIONAL PURPOSES ONLY.
NOTE: RELATIVE WEIGHTS ARE BASED ON MEDICARE PATIENT DATA AND MAY NOT
BE APPROPRIATE FOR OTHER PATIENTS.
Exhibit 2
Base Rates and Cost-to-Charge Ratios
Hospital Name
Medicare
Provider #
60117
2006 Base Rate
$4,948.63
Total Cost to
Charge Ratio
0.505
60036
$5,500.22
0.569
Boulder Community
60027
$5,342.84
0.413
Colo.Plains Med Ctr
60044
$5,580.68
0.312
Community - GJ
60054
$5,025.38
0.653
Delta County
60071
$5,316.46
0.57
Denver Health &
Hospital
Exempla Good
Samaritian
Keefe
60011
$8,533.16
0.456
60116
$5,066.06
0.356
60043
$13,235.62
0.6
Longmont
60003
$5,514.03
0.423
Lutheran
60009
$5,429.46
0.278
McKee
60030
$5,463.59
0.478
Med Ctr Aurora
60100
$5,899.95
0.273
Memorial
60022
$5,619.71
0.328
Mercy-Durango
60013
$5,125.03
0.456
Montrose
National Jewish
North Suburban
60006
60107
60065
$5,244.71
$8,673.81
$6,249.28
0.435
0.369
0.279
Northern Colorado
Medical Center
Parker Adventist
60001
$6,152.80
0.667
60114
$5,426.69
0.643
Parkview
60020
$5,512.20
0.275
Penrose
60031
$5,022.62
0.297
Pioneer
60041
$9,300.56
1.116
Platte Valley
60004
$6,054.12
0.392
Porter - J. Avista
Porter -Littleton
Portercare
Poudre Valley
60103
60113
60064
60010
$5,941.13
$5,417.11
$5,438.47
$5,385.49
0.378
0.356
0.317
0.472
Animas Surgical
Hospital
Arkansas Valley
Hospital Name
2006 Base Rate
Pres/St. Luke
Medicare
Provider #
60014
$6,730.74
Total Cost to
Charge Ratio
0.315
Rose
60032
$6,215.04
0.264
San Luis Valley Reg.
Med.
Sky Ridge
60008
$5,494.20
0.507
60112
$4,961.99
0.287
Southwest
60018
$5,269.39
0.516
St Anthony's - Summit
Cty - Frisco CO
St. Anthony Central
60118
$4,948.63
0.505
60015
$6,217.08
0.255
St. Anthony North
60104
$5,733.10
0.271
St. Joseph
60028
$5,979.30
0.255
St. Mary Corwin
60012
$5,563.11
0.306
St. Mary's Hosp.
St. Thomas More
Sterling Medical Center
Swedish
University
60023
60016
60076
60034
60024
$5,769.40
$5,185.28
$5,260.04
$5,583.25
$8,457.90
0.536
0.409
0.535
0.273
0.312
Vail Valley Med Ctr
Valley View
Yampa Valley
60096
60075
60049
$5,824.58
$6,389.89
$5,904.70
0.69
0.709
0.749
Exhibit 3
Critical Access Hospitals
Name
Location in Colorado
Aspen Valley Hospital
Aspen
Conejos County Hospital
La Jara
East Morgan County Hospital Brush
Estes Park Medical Center
Estes Park
Family Health West Hospital
Fruita
Grand River Medical Center
Rifle
Gunnison Valley Hospital
Gunnison
Haxtun Hospital District
Haxtun
Heart of the Rockies
Regional Medical Center
Salida
Kit Carson County Memeorial Burlington
Hospital
Kremmling Memorial Hospital Kremmling
Lincoln Community Hospital
Hugo
Melissa Memorial Hospital
Holyoke
The Memorial Hospital
Craig
Mt. San Rafael Hospital
Trinidad
Prowers Medical Center
Lamar
Rangeley District Hospital
Rangely
Rio Grande Hospital
Del Norte
Sedgwick County Memorial
Hospital
Julesburg
Southeast Colorado Hospital
Springfield
Spanish Peaks Regional
Helath Center
Walsenburg
Name
Location in Colorado
St. Vincent General Hospital
Leadville
Weisbrod Memorial County
Hospital
Eads
Wray Community District
Hospital
Wray
Yuma District Hospital
Yuma
Exhibit 4
Outpatient Surgery Facility Groupers and Fees
06 APC
Grouper
Description of Grouper
Dollar
Value
7
Level II Incision & Drainage
$1,418.84
8
Level III Incision and Drainage
$1,418.84
13
Level II Debridement & Destruction
$126.20
15
Level III Debridement & Destruction
$196.56
16
Level IV Debridement & Destruction
$322.77
20
Level II Excision/ Biopsy
$826.14
21
Level III Excision/ Biopsy
$1,696.64
22
Level IV Excision/ Biopsy
$2,207.52
24
Level I Skin Repair
$184.64
25
Level II Skin Repair
$947.13
27
Level IV Skin Repair
$1,918.68
40
Percutaneous Implantation of Neurostimulator Electrodes,
Excluding Cranial Nerve
$2,480.57
41
Level I Arthroscopy
$3,193.95
42
Level II Arthroscopy
$4,966.67
45
Bone/Joint Manipulation Under Anesthesia
$1,619.37
46
Open/Percutaneous Treatment Fracture or Dislocation
$4,001.40
47
Arthroplasty without Prosthesis
$3,538.56
48
Level I Arthroplasty with Prosthesis
$3,538.56
49
Level I Musculoskeletal Procedures Except Hand and Foot
$2,302.64
50
Level II Musculoskeletal Procedures Except Hand and Foot and
Allograft and Autograft for Spine Surgery
$2,803.59
51
Level III Musculoskeletal Procedures Except Hand and Foot
$4,086.91
52
Level IV Musculoskeletal Procedures Except Hand and Foot
$4,966.12
06 APC
Grouper
Description of Grouper
Dollar
Value
53
Level I Hand Musculoskeletal Procedures
$1,767.55
54
Level II Hand Musculoskeletal Procedures
$2,834.69
55
Level I Foot Musculoskeletal Procedures
$2,204.62
56
Level II Foot Musculoskeletal Procedures
$3,029.38
57
Bunion Procedures
$3,077.42
61
Laminectomy or Incision for Implantation of Neurostimulator
Electrodes, Excluding Cranial Nerve
$2,779.35
72
Level II Endoscopy Upper Airway
$158.44
73
Level III Endoscopy Upper Airway
$471.53
75
Level V Endoscopy Upper Airway
$2,386.03
76
Level I Endoscopy Lower Airway
$1,075.52
131
Level II Laparoscopy
$4,872.35
141
Level I Upper GI Procedures
154
Hernia/Hydrocele Procedures
156
Level II Urinary and Anal Procedures
161
Level II Cystourethroscopy and other Genitourinary Procedures
$2,123.02
169
Lithotripsy
$5,085.56
203
Level IV Nerve Injections
$1,244.86
204
Level I Nerve Injections
$372.69
206
Level II Nerve Injections
$999.01
207
Level III Nerve Injections
$1,073.70
208
Laminotomies, Laminectomies
$4,851.56
210
Spinal Fusions
$5,579.28
212
Nervous System Injections
220
Level I Nerve Procedures
$1,971.21
221
Level II Nerve Procedures
$3,271.75
$920.03
$3,199.70
$282.44
$335.81
06 APC
Grouper
Description of Grouper
Dollar
Value
222
Implantation of Neurological Device
$3,665.78
223
Implantation or Revision of Pain Management Catheter
$1,699.85
225
Implantation of Neurostimulator Electrodes, Cranial Nerve
$7.464.12
226
Implantation of Drug Infusion Reservoir
$1,295.80
227
Implantation of Drug Infusion Device
$4,059.78
234
Level III Anterior Segment Eye Procedures
$2,522.76
236
Level II Posterior Segment Eye Procedures
$2,433.25
237
Level III Posterior Segment Eye Procedures
$2,433.25
239
Level II Repair and Plastic Eye Procedures
$763.74
240
Level III Repair and Plastic Eye Procedures
$2,059.54
241
Level IV Repair and Plastic Eye Procedures
$2,682.18
242
Level V Repair and Plastic Eye Procedures
$3,446.84
244
Corneal Transplant
$2,433.24
246
Cataract Procedures with IOL Insert
$2,658.96
249
Level II Cataract Procedures without IOL Insert
$3,243.66
252
Level II ENT Procedures
254
Level IV ENT Procedures
$2,660.44
256
Level V ENT Procedures
$4,208.75
340
Minor Ancillary Procedures
388
Discography, per level
$1,200.00
415
Level II Endoscopy Lower Airway
$2,506.25
425
Level II Arthroplasty with Prosthesis
$6,232.90
672
Level IV Posterior Segment Eye Procedures
$3,934.98
681
Knee Arthroplasty
$8,061.62
682
Level V Debridement & Destruction
$999.00
$72.13
$833.23
06 APC
Grouper
Description of Grouper
Dollar
Value
685
Level III Needle Biopsy/Aspiration Except Bone Marrow
$689.53
686
Level III Skin Repair
$1,743.03
687
Revision/Removal of Neurostimulator Electrodes
$2,284.78
688
Revision/Removal of Neurostimulator Pulse Generator Receiver
$4,922.60
Exhibit 5
Rural Health Facilities
BENT COUNTY NURSING SERVICE WOMEN’S HEALTH
CLINIC
701 PARK AVE
LAS ANIMAS, CO 81054 - BENT COUNTY
Telephone: (719)456-0517, Fax: (719)456-0518
BRUSH FAMILY CLINIC
2400 W EDISON
BRUSH, CO 80723 - MORGAN COUNTY
Telephone: (970)842-2833, Fax: (970)842-6241
BUENA VISTA FAMILY PRACTICE CLINIC
836 U.S. HWY 24 SO
BUENA VISTA, CO 81211 - CHAFFEE COUNTY
Telephone: (719)395-9048, Fax: (719)395-9064
BUTTON FAMILY PRACTICE
1335 PHAY AVENUE SUITE D
CANNON CITY, CO 81212 – FREMONT COUNTY
Telephone: (719) 269-8820, Fax: (719) 204-0230
CENTENNIAL FAMILY HEALTH CLENTER
319 MAIN STREET
ORDWAY, CO 81063 – CROWLEY COUNTY
Telephone: (719) 267-3503, Fax: (719) 267-4153
COLORADO PLAINS CLINIC – WIGGINS
226 MAIN STREET
WIGGINS, CO 80654 – MORGAN COUNTY
Telephone: (970) 483-7283
CONEJOS MEDICAL CLINIC
19021 STATE HWY 285
LA JARA, CO 81140 - CONEJOS COUNTY
Telephone: (719)274-5121, Fax: (719)274-6003
CREED FAMILY PRACTICE OF RIO GRANDE HOSPITAL
802 RIO GRANDE AVENUE
CREED, CO 81130 – MINERAL COUNTY
Telephone: (719) 658-0929, FAX: (719) 657-2851
CUSTER COUNTY MEDICAL CLINIC
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
555 COLORADO AVENUE
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
FAMILY PRACTICE OF HOLYOKE
520 SOUTH INTEROCEAN
HOLYOKE, CO 80734 - PHILLIPS COUNTY
Telephone: (970)854-2500, Fax: (970)854-3440
FLEMING FAMILY HEALTH CENTER
104 W LARIMER ST
FLEMING, CO 80728 - LOGAN COUNTY
Telephone: (970)774-6123, Fax: (970)774-6158
FLORENCE MEDICAL CENTER
501 W 5TH ST
FLORENCE, CO 81226 - FREMONT COUNTY
Telephone: (719)784-4816, Fax: (719)784-6014
GRAND RIVER PRIMARY CARE
501 AIRPORT ROAD
RIFLE, CO 81650 - GARFIELD COUNTY
Telephone: (970)625-1100, Fax: (970)625-0725
GRAND RIVER PRIMARY CARE - BATTLEMENT MESA
73 SIPPERELLE DRIVE, SUITE K
PARACHUTE, CO 81635 - GARFIELD COUNTY
Telephone: (970)285-7046, Fax: (970)285-6064
HAVENS FAMILY CLINIC
109 LATIGO LN STE C
CANON CITY, CO 81212 - FREMONT COUNTY
Telephone: (719)276-3211, Fax: (719)276-3011
KIT CARSON CLINIC
102 EAST 2ND AVENUE
KIT CARSON, CO 80825 - CHEYENNE COUNTY
Telephone: (719)962-3501, Fax: (719)962-3403
LA CLINICA INC
24850 N ST HWY 69
GARDNER, CO 81040 - HUERFANO COUNTY
Telephone: (719)746-2244
LAKE CITY AREA MEDICAL CENTER
700 N HENSON STREET
LAKE CITY, CO 81235 - HINSDALE COUNTY
Telephone: (970)944-2331, Fax: (970)944-2320
MEEKER FAMILY HEALTH CENTER
345 CLEVELAND
MEEKER, CO 81641 - RIO BLANCO COUNTY
Telephone: (970)878-4014, Fax: (970)878-3285
MOUNTAIN MEDICAL CENTER OF BUENA VISTA, P.C
36 OAK ST
BUENA VISTA, CO 81211 - CHAFFEE COUNTY
Telephone: (719)395-8632, Fax: (719)395-4971
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 CLINIC
521 5TH ST
WALDEN, CO 80480 - JACKSON COUNTY
Telephone: (970)723-4255, Fax: (970)723-4268
OLATHE MEDICAL CLINIC
308 MAIN ST
OLATHE, CO 81425 - MONTROSE COUNTY
Telephone: (970)323-6141, Fax: (970)323-6117
PARKE HEALTH CLINIC
182 16TH ST
BURLINGTON, CO 80807 - KIT CARSON COUNTY
Telephone: (719)346-9481, Fax: (719)346-9485
PEDIATRIC ASSOCIATES, THE
947 SOUTH 5TH STREET
MONTROSE, CO 81401 – MONTROSE COUNTY
Telephone: (970) 249-2421, Fax: (970) 249-8897
PEDIATRIC ASSOCIATION OF CANON CITY
1335 PHAY AVENUE
CANON CITY, CO 81212 - FREMONT COUNTY
Telephone: (719)269-1727, Fax: (719)269-1730
PRAIRIE VIEW RURAL HEALTH CLINIC
560 N 6 W STREET
CHEYENNE WELLS, CO 80810 - CHEYENNE COUNTY
Telephone: (719)767-5669, Fax: (719)767-8042
RIO GRANDE HOSPITAL CLINIC
1280 GRAND AVENUE
DEL NORTE CO 81132 – RIO GRANDE COUNTY
Telephone: (719)657-2418, Fax: (719) 658-3001
RIVER VALLEY PEDIATRICS
1335 PHAY AVENUE
CANON CITY, CO 81212 – FREMONT COUNTY
Telephone: (719)276-2222
ROCKY FORD FAMILY HEALTH CENTER
1014 ELM AVENUE
ROCKY FORD, CO 81067 - OTERO COUNTY
Telephone: (719)254-7421, Fax: (719)254-6966
SANTA FE TRAIL MEDICAL CENTER
111 WAVERLY AVE
TRINIDAD, CO 81082 - LAS ANIMAS COUNTY
Telephone: (719)846-0123, Fax: (719)846-0121
SOUTHEAST COLORADO PHYSICIAN'S CLINIC
210 E TENTH AVE
SPRINGFIELD, CO 81073 - BACA COUNTY
Telephone: (719)523-6628, Fax: (719)523-4513
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
TELLURIDE MEDICAL CENTER
500 W PACIFIC
TELLURIDE, CO 81435 - SAN MIGUEL COUNTY
Telephone: (970)728-3840, Fax: (970)728-3404
TRINIDAD FAMILY MEDICAL CENTER
1502 E MAIN ST
TRINIDAD, CO 81082 - LAS ANIMAS COUNTY
Telephone: (719)846-3305, Fax: (719)846-4922
TRINIDAD MEDICAL ASSOCIATES
400 BENEDICTA #E
TRINIDAD, CO 81082 - LAS ANIMAS COUNTY
Telephone: (719)845-0627, Fax: (719)845-0663
UNITED MEDICAL CENTER OF BERTHOUD
549 MOUNTAIN AVENUE
BERTHOUD, CO 80513 - LARIMER COUNTY
Telephone: (970)532-4644, Fax: (970)532-0608
VALLEY MEDICAL CLINIC
116 E NINTH STREET
JULESBURG, CO 80737 - SEDGWICK COUNTY
Telephone: (970)474-3376, Fax: (970)474-2461
WASHINGTON COUNTY CLINIC
482 ADAMS AVENUE
AKRON, CO 80720 - WASHINGTON COUNTY
Telephone: (970)345-2262, Fax: (970)345-2265
WILEY MEDICAL CLINIC
302 MAIN STREET
WILEY, CO 81092 - PROWERS COUNTY
Telephone: (719)829-4627, Fax: (719)829-4269
YUMA RURAL HEALTH CLINIC
910 S MAIN ST
YUMA, CO 80759 - YUMA COUNTY
Telephone: (970)848-4700, Fax: (970)848-0809
Exhibit 6
Dental Fee Schedule
Code
D0120
D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0274
D0277
D0290
D0310
D0320
D0321
D0322
D0330
D0340
D0350
D0415
D0416
D0421
D0425
D0431
Description in Rule 18
Clinical Oral Evaluations
Periodic oral evaluation
Limited oral evaluation - problem focused
Comprehensive oral evaluation - new or established patient
Detailed and extensive oral evaluation - problem focused, by
report
Re-evaluation - limited, problem focused (established patient; not
post-operative visit)
Comprehensive periodontal evaluation - new or established
patient
Radiographs/Diagnostic Imaging (including interpretation)
Intraoral - complete series (including bitewings)
Intraoral - periapical first film
Intraoral - periapical each additional film
Intraoral - occlusal film
Extraoral - first film
Extraoral - each additional film
Bitewing - single film
Bitewing - two films
Bitewing - four films
Vertical Bitewings-7-8 Films
Posterior - anterior or lateral skull and facial bone survey film
Sialography
Temporomandibular joint arthrogram, including injection
Other temporomandibular joint films
Tomographic Survey
Panoramic Film
Cephalometric film
Oral/Facial Photographic Images (Incl. Intra and extra-oral
images)
Tests and Examinations
Collection of microorganisms for culture and sensitivity
Viral culture A diagnostic test to identify viral organisms, most
often herpes virus.
Genetic test for susceptibility to oral diseases
Caries susceptibility tests
Adjunctive pre-diagnostic test that aids in detection of mucosal
abnormalities including premalignant and malignant lesions, not
to include cytology or biopsy procedures
VALUE
$41.30
$56.19
$77.89
$100.32
$49.57
BR
$123.60
$21.25
$17.70
$35.41
$48.39
$47.21
$25.96
$39.14
$57.68
$84.97
$162.85
$415.42
$711.63
BR
$571.20
$88.52
$120.38
$53.11
$47.22
BR
BR
$30.68
BR
D0460 Pulp vitality tests
D0470 Diagnostic casts
$53.11
$88.52
Oral Pathology Laboratory
D0472 Accession Tissue-Gross Exam, Prep & Trans report
D0473 Accession Tissue-Gross & Micro exam, prep & trans report
$80.25
$155.78
D0474 Accession tissue-Gross & micro exam, Assess surgical margins,
prep & trans report
D0475 Decalcification procedure
D0476 Special stains for microorganisms
D0477 Special stains, not for microorganisms
D0478 Immunohistochemical stains
D0479 Tissue in-situ hybridization, including interpretation
D0480 Process & interpret of exfoliate cytologica smears-Prep & report
D0481 Electron microscopy – diagnostic
D0482 Direct immunofluorescence
D0483 Indirect immunofluorescence
D0484 Consultation on slides prepared elsewhere
D0485 Consultation, including preparation of slides from biopsy material
supplied by referring source
D0502 Other oral pathology procedures
D0999 Unspecified diagnostic procedure
Dental Prophylaxis
D1110 Prophylaxis - adult
D1120 Prophylaxis - child
Topical Fluoride Treatment
D1201 Topical application of fluoride (including prophylaxis)- child
D1203 Topical application of fluoride (prophylaxis not included)- child
D1204 Topical application of fluoride (prophylaxis not included) - adult
D1205 Topical application of fluoride (including prophylaxis) - adult
Other Preventive Services
D1310 Nutritional counseling for the control of dental disease
D1320 Tobacco counseling for the control and prevention of oral
dis-ease
D1330 Oral hygiene instruction
D1351 Sealant - per tooth
Space Maintenance (Passive Appliances)
D1510 Space maintainer - fixed (unilateral)
D1515 Space maintainer - fixed (bilateral)
D1520 Space maintainer - removable (unilateral)
D1525 Space maintainer - removable (bilateral)
D1550 Re-cementation of space maintainer
Amalgam Restorations (Including Polishing)
D2140 Amalgam - one surface, primary or permanent
D2150 Amalgam - two surface, primary or permanent
D2160 Amalgam - three surfaces, primary or permanent
D2161 Amalgam - four or more surfaces, primary or permanent
Resin-Based Composite Restorations -Direct
D2330 Resin – based composite -one surface, anterior
D2331 Resin – based composite - two surfaces, anterior
D2332 Resin – based composite - three surfaces, anterior
D2335 Resin - four or more surfaces or involving incisal angle, anterior
D2390 Resin-based composite crown, anterior
D2391 Resin-based composite - one surface, posterior
D2392 Resin-based composite - two surfaces, posterior
D2393 Resin-based composite - three surfaces, posterior
$187.64
BR
BR
BR
BR
BR
$113.30
BR
BR
BR
BR
BR
BR
BR
$76.71
$53.11
$71.99
$35.41
$35.41
$88.52
$44.84
$47.22
$60.19
$41.70
$265.53
$341.06
$362.31
$496.84
$63.73
$100.31
$129.82
$167.58
$194.72
$118.02
$162.85
$205.35
$241.93
$308.01
$160.49
$186046
$256.10
D2394 Resin-based composite - four or more surfaces, posterior
Gold Foil Restorations
D2410 Gold foil - one surface
D2420 Gold foil - two surfaces
D2430 Gold foil - three surfaces
Inlay/Onlay Restorations
D2510 Inlay - metallic - one surface
D2520 Inlay - metallic - two surfaces
D2530 Inlay - metallic - three or more surfaces
D2542 On-lay-metallic-2 surfaces
D2543 On-lay - metallic - three surfaces
D2544 On-lay - metallic - four or more surfaces
D2610 Inlay - porcelain/ceramic - one surface
D2620 Inlay - porcelain/ceramic - two surfaces
D2630 Inlay - porcelain/ceramic -three or more surfaces
D2642 On-lay - porcelain/ceramic - two surfaces
D2643 On-lay - porcelain/ceramic - three surfaces
D2644 On-lay - porcelain/ceramic - four or more surfaces
D2650 Inlay – resin-based composite/resin - one surface (indirect tech)
D2651 Inlay – resin-based composite/resin - two surfaces (indirect tech)
D2652 Inlay – resin-based composite/resin - three or more surfaces
(indirect tech)
D2662 On-lay – resin-based composite/resin - two surfaces (indirect
tech)
D2663 On-lay – resin-based composite/resin - three surfaces (indirect
tech)
D2664 On-lay – resin-based composite/resin - four or more surfaces
(indirect tech)
Crowns - Single Restorations Only
D2710 Crown – resin-based composite (indirect)
D2712 Crown – 3/4 resin-based composite (indirect)
D2720 Crown - resin with high noble metal
D2721 Crown - resin with predominantly base metal
D2722 Crown - resin with noble metal
D2740 Crown - porcelain/ceramic substrate
D2750 Crown - porcelain fused to high noble metal
D2751 Crown - porcelain fused to predominantly base metal
D2752 Crown - porcelain fused to noble metal
D2780 Crown-3/4 cast high noble metal
D2781 Crown-3/4 cast predominantly base metal
D2782 Crown-3/4 cast noble metal
D2783 Crown-3/4 Porcelain/ceramic (without facial veneers)
D2790 Crown - full cast high noble metal
D2791 Crown - full cast predominantly base metal
D2792 Crown - full cast noble metal
D2794 Crown - titanium
D2799 Provisional crown
Other Restorative Services
D2910 Recement inlay, onlay, or partial coverage restoration
D2915 Recement cast or prefabricated post and core
D2920 Recement crown
$324.54
$256.10
$427.21
$739.94
$708.08
$722.25
$886.29
$868.59
$835.55
$954.29
$797.78
$737.58
$841.44
$921.69
$921.69
$997.23
$774.18
$774.18
$656.16
$570.00
$670.32
$717.53
$404.86
BR
$997.23
$933.49
$954.74
$921.69
$929.96
$743.50
$796.60
$967.73
$911.07
$940.58
$996.04
$835.55
$922.87
$939.40
BR
$404.79
$99.14
BR
$88.52
D2930
D2931
D2932
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
D2971
D2975
Prefabricated stainless steel crown - primary tooth
Prefabricated stainless steel crown - permanent tooth
Prefabricated resin crown
Prefabricated stainless steel crown with resin window
Prefabricated esthetic coated stainless steel crown – primary
tooth
Sedative filling
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Cast post & core in addition to crown
Each add cast post-same tooth
Prefabricated post and core in addition to crown
Post removal (not in conjunction with endodontic therapy)
Each additional prefabricated post-same tooth
Labial veneer (resin laminate) - chairside
Labial veneer (resin laminate) - laboratory
Labial veneer (porcelain laminate) - laboratory
Additional procedures to construct new crown under existing
partial denture framework To be reported in addition to a crown
code.
Coping A thin covering of the remaining portion of a tooth,
usually fabricated of metal and devoid of anatomic contour. This
is to be used as a definitive restoration.
D2980 Crown repair, by report
D2999 Unspecified restorative procedure, by report
Pulp Capping
D3110 Pulp cap - direct (excluding final restoration)
D3120 Pulp cap - indirect (excluding final restoration)
Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of
pulp coronal to the dentinocemental junction and application of
medicament
D3221 Pulpal debridement, primary & permanent teeth
Endodontic Therapy or Primary Teeth
D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth
(excluding final restoration)
D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth
(excluding final restoration)
Endodontic Therapy
(Including Treatment Plan, Clinical Procedures and Follow-up
Care)
D3310 Anterior (excluding final restoration)
D3320 Bicuspid (excluding final restoration)
D3330 Molar (excluding final restoration)
D3331 Treatment root canal obstruction -non-surgical access
D3332 Incomplete endodontic therapy; inoperable, unrestorable or
fractured tooth
D3333 Internal Root Repair of perforation defects
Endodontic Retreatment
D3346 Retreatment of previous root canal therapy - anterior
$237.21
$279.69
$348.15
$390.63
BR
$106.21
$218.33
$56.64
$398.89
$205.35
$341.06
$256.10
$169.94
$631.38
$934.67
$1,013.52
BR
BR
BR
BR
$84.96
$81.43
$174.66
$175.84
$168.77
$181.74
$531.07
$636.11
$980.56
$227.76
$585.36
$194.72
$911.07
D3347 Retreatment of previous root canal therapy - bicuspid
D3348 Retreatment of previous root canal therapy - molar
Apexification/Recalcification Procedures
D3351 Apexification/recalcification - initial visit (apical closure/calcific
repair of perforations, root resorption, etc.)
D3352 Apexification/recalcification - interim medication replacement
(apical closure/calcific repair of perforations, root resorption, etc.)
D3353 Apexification/recalcification - final visit (includes completed root
canal therapy - apical closure/calcific repair or perforations, root
resorption, etc.)
Apicoectomy/Periradicular Services
D3410 Apicoectomy/periradicular surgery - anterior
D3421 Apicoectomy/periradicular surgery - bicuspid (first root)
D3425 Apicoectomy/periradicular surgery - molar (first root)
D3426 Apicoectomy/periradicular surgery - (each additional root)
D3430 Retrograde filling - per root
D3450 Root amputation - per root
D3460 Endodontic endosseous implant
D3470 Intentional re-implantation (including necessary splinting)
Other Endodontic Procedures
D3910 Surgical procedure for isolation of tooth with rubber dam
D3920 Hemisection (including any root removal,) not including root canal
therapy
D3950 Canal preparation and fitting of performed dowel or post
D3999 Unspecific endodontic procedure, by report
Surgical Services (Including Usual Postoperative Care)
D4210 Gingivectomy or gingivoplasty - four or more contiquous teeth or
bounded teeth spaces per quadrant
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or
bounded teeth spaces per quadrant
D4240 Gingival flap procedure, including root planing - four or more
contiguous teeth or bounded teeth spaces per quadrant
D4241 Gingival flap procedure, including root planing - one to three
contiguous teeth or bounded teeth spaces per quadrant
D4245 Apically positioned flap
D4249 Clinical crown lengthening - hard tissue
D4260 Osseous surgery (including flap entry and closure) - four or more
contiguous teeth or bounded teeth spaces per quadrant
D4261 Osseous surgery (including flap entry and closure) - one to three
contiguous teeth or bounded teeth spaces per quadrant
D4263 Bone replacement graft - first site in quadrant
D4264 Bone replacement graft - each additional site in quadrant
D4265 Biologic materials to aid in soft and osseous tissue regeneration
D4266 Guided tissue regeneration - resorbable barrier, per site
D4267 Guided tissue regeneration - nonresorbable barrier, per site,
(includes membrane removal)
D4268 Surgical revision procedure per tooth
D4270 Pedicle soft tissue graft procedure
D4271 Free soft tissue graft procedure (including donor site surgery)
$1,073.93
$1,291.07
$385.54
$167.58
$566.47
$477.95
$846.17
$957.10
$318.64
$234.85
$475.59
$2,281.22
$947.65
$123.91
$370.56
$168.77
BR
$486.22
$278.10
$891.01
$891.01
$640.82
$1,016.10
$944.12
$944.12
$434.29
$217.15
BR
$523.98
$673.86
BR
$1,063.31
$1,092.81
D4273 Subepithelial connective tissue graft procedures, per tooth
D4274 Distal or proximal wedge procedure (when not performed in
conjunction with surgical procedures in the same anatomical
area)
D4275 Soft tissue allograft
D4276 Combined connective tissue and double pedicle graft, per tooth
Non-Surgical Periodontal Service
D4320 Provisional splinting - intracoronal
D4321 Provisional splinting - extracoronal
D4341 Periodontal scaling and root planing - four or more teeth per
quadrant
D4342 Periodontal scaling and root planing - one to three teeth, per
quadrant
D4355 Full mouth debridement to enable comprehensive evaluation and
diagnosis
D4381 Localized delivery of antimicrobial agents via a controlled release
vehicle into diseased crevicular tissue, per tooth, by report
Other Periodontal Services
D4910 Periodontal maintenance
D4920 Unscheduled dressing change (by someone other than treating
dentist)
D4999 Unspecified periodontal procedure, by report
Complete Dentures (Including Routine Post-Delivery Care)
D5110 Complete denture - maxillary
D5120 Complete denture - mandibular
D5130 Immediate denture - maxillary
D5140 Immediate denture - mandibular
Partial Dentures (Including Routine Post-Delivery Care)
D5211 Maxillary partial denture - resin base (including any conventional
clasps, rests and teeth)
D5212 Mandibular partial denture - resin base (including any
conventional clasps, rests and teeth)
D5213 Maxillary partial denture - cast metal framework with resin
denture bases (including any conventional clasps, rests and
teeth)
D5214 Mandibular partial denture - cast metal framework with resin
denture bases (including any conventional clasps, rests and
teeth)
D5225 Maxillary partial denture – flexible base (including any clasps,
rests and teeth)
D5226 Mandibular partial denture – flexible base (including any clasps,
rests and teeth)
D5281 Removable unilateral partial denture - one piece cast metal
(including clasps and teeth)
Adjustments to Dentures
D5410 Adjust complete denture - maxillary
D5411 Adjust complete denture - mandibular
D5421 Adjust partial denture - maxillary
D5422 Adjust partial denture - mandibular
$1,165.98
$329.26
BR
BR
$426.03
$526.34
$218.33
$218.33
$153.42
BR
$138.08
$118.02
BR
$1,416.18
$1,416.18
$1,351.27
$1,351.27
$1,156.54
$1,259.54
$1,416.18
$1,416.18
BR
BR
$915.79
$77.89
$77.89
$77.89
$77.89
Repairs to Complete Dentures
D5510 Repair broken complete denture base
D5520 Replace missing or broken teeth - complete denture (each tooth)
Repairs to Partial Dentures
D5610 Repair resin denture base
D5620 Repair cast framework
D5630 Repair replace broken clasp
D5640 Replace broken teeth - per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture
D5670 Replace all teeth and acrylic on cast metal framework (maxillary)
D5671 Replace all teeth and acrylic on cast metal framework
(mandibular)
Denture Rebase Procedures
D5710 Rebase complete maxillary denture
D5711 Rebase complete mandibular denture
D5720 Rebase maxillary partial denture
D5721 Rebase mandibular partial denture
Denture Reline Procedures
D5730 Reline complete maxillary denture (chairside)
D5731 Reline complete mandibular denture (chairside)
D5740 Reline maxillary partial denture (chairside)
D5741 Reline mandibular partial denture (chairside)
D5750 Reline complete maxillary denture (laboratory)
D5751 Reline complete mandibular denture (laboratory)
D5760 Reline maxillary partial denture (laboratory)
D5761 Reline mandibular partial denture (laboratory)
Interim Prosthesis
D5810 Interim complete denture (maxillary)
D5811 Interim complete denture (mandibular)
D5820 Interim partial denture (maxillary) (includes any necessary clasps
and rests)
D5821 Interim partial denture (mandibular) (includes any necessary
clasps and rests)
Other Removable Prosthetic Services
D5850 Tissue conditioning, maxillary
D5851 Tissue conditioning, mandibular
D5860 Overdenture - complete, by report
D5861 Overdenture - partial, by report
D5862 Precision attachment, by report
D5867 Replacement of replaceable part of semi-precision or precision
attachment (male or female component)
D5875 Modification of removable prosthesis following implant surgery
D5899 Unspecified removable prosthodontic procedure, by report
Maxillofacial Prosthetics
D5911 Facial moulage (sectional)
D5912 Facial moulage (complete)
D5913 Nasal prosthesis
D5914 Auricular prosthesis
D5915 Orbital prosthesis
$224.23
$123.91
$177.03
$236.02
$218.33
$123.91
$177.03
$230.13
BR
BR
$430.76
$551.13
$544.05
$544.05
$295.04
$295.04
$298.58
$298.58
$354.04
$354.04
$428.40
$428.40
$686.85
$738.77
$531.07
$564.11
$135.71
$135.71
BR
BR
BR
BR
BR
BR
$359.94
$359.94
$7,590.70
$7,590.70
$10,271.98
D5916
D5919
D5922
D5923
D5924
D5925
D5926
D5927
D5928
D5929
D5931
D5932
D5933
D5934
D5935
D5936
D5937
D5951
D5952
D5953
D5954
D5955
D5958
D5959
D5960
D5982
D5983
D5984
D5985
D5986
D5987
D5988
D5999
D6010
D6040
D6050
D6053
D6054
D6055
D6056
D6057
D6058
D6059
Ocular prosthesis
Facial prosthesis
Nasal spetal prosthesis
Ocular prosthesis, interim
Cranial prosthesis
Facial augmentation implant prosthesis
Nasal prosthesis, replacement
Auricular prosthesis, replacement
Orbital prosthesis, replacement
Facial prosthesis, replacement
Obturator prosthesis, surgical
Obturator prosthesis, definitive
Obturator prosthesis, modification
Mandibular resection prosthesis with guide flange
Mandibular resection prosthesis without guide flange
Obturator prosthesis, interim
Trismus appliance (not for TMD treatment)
Feeding aid
Speech aid prosthesis, pediatric
Speech aid prosthesis, adult
Palatal augmentation prosthesis
Palatal lift prosthesis, definitive
Palatal lift prosthesis, interim
Palatal lift prosthesis, modification
Speech aid prosthesis, modification
Surgical stent
Radiation carrier
Radiation shield
Radiation cone locator
Fluoride gel carrier
Commissure splint
Surgical splint
Unspecified maxillofacial prosthesis
Implant Services
(Local anesthesia is considered to be part of implant service
procedures)
Surgical placement of implant body: endosteal implant
Surgical placement: eposteal implant
Surgical placement: transosteal implant
Implant Supported Prosthetics
Implant/abutment supported removable denture for complete
edentulous arch
Implant/abutment supported removable denture for partially
edentuous arch
Dental implant supported connecting bar
Prefabricated abutment – includes placement
Custom Abutment - includes placement
Abutment supported porcelain/ceramic crown
Abutment support porcelain fused to metal crown (high noble
metal)
$2,738.67
BR
BR
$2,687.19
BR
BR
BR
BR
BR
BR
$4,086.84
$7,643.81
BR
$6,966.39
$6,061.22
$6,808.26
$855.60
$1,112.87
$3,612.42
$6,860.18
$6,357.45
$5,879.48
BR
BR
BR
$706.91
$1,711.21
$1,711.21
$1,711.21
$145.16
$2,568.00
BR
BR
$2,374.45
$10,919.88
$6,777.58
BR
BR
$603.05
BR
BR
$1,366.60
$1,348.91
D6060 Abutment support porcelain fused metal crown (predominantly
base metal)
D6061 Abutment support porcelain fused to metal crown (noble metal)
D6062 Abutment supported cast metal crown (high noble metal)
D6063 Abutment supported cast metal crown (predominantly base
metal)
D6064 Abutment supported cast metal crown (noble metal)
D6094 Abutment supported crown – (titanium)
D6065 Implant supported porcelain/ceramic crown
D6066 Implant supported porcelain fused to metal crown (titanium,
titanium alloy, high noble metal)
D6067 Implant supported metal crown (titanium, titanium alloy, high
noble metal)
D6068 Abutment supported retainer for porcelain/ceramic FPD
D6069 Abutment supported retainer for porcelain fused to metal FPD
(high noble metal))
D6070 Abutment supported retainer for porcelain fused to metal FPD
(predominantly base metal)
D6071 Abutment supported retainer for porcelain fused to metal FPD
(noble metal
D6072 Abutment supported retainer for cast metal FPD (high noble
metal)
D6073 Abutment supported retainer for cast metal FPD (predominantly
base metal)
D6074 Abutment supported retainer for cast metal FPD (noble metal)
D6194 Abutment supported retainer crown for FPD – (titanium)
D6075 Implant supported retainer for ceramic FPD
D6076 Implant supported retainer for porcelain fused to metal FPD
(titanium, titanium alloy, high noble metal)
D6077 Implant supported retainer for cast metal FPD (titanium, titanium
alloy, high noble metal)
D6078 Implant/abutment supported fixed denture for completely
edentulous arch
D6079 Implant/abut supported fixed denture for partially edentulous arch
Other Implant Services
D6080 Implant maintenance procedures, including: removal of
prosthesis, cleansing of prosthesis and abutments, reinsertion of
prosthesis
D6090 Repair implant supported prosthesis, by report
D6095 Repair implant abutment, by report
D6100 Implant removal, by report
D6190 Radiographic/surgical implant index, by report
D6199 Unspecified implant procedure, by report
Prosthodontics, fixed
D6205 Pontic – indirect resin based composite Not to be used as a
temporary or provisional prosthesis.
D6210 Pontic - cast high noble metal
D6211 Pontic - cast predominantly base metal
D6212 Pontic - cast noble metal
D6214 Pontic – titanium
$1,274.55
$1,300.52
$1,295.80
$1,105.79
$1,178.97
BR
$1,344.19
$1,309.96
$1,271.02
$1,366.60
$1,348.91
$1,274.55
$1,300.52
$1,327.66
$1,201.39
$1,295.80
BR
$1,344.19
$1,309.96
$1,271.02
BR
BR
BR
BR
BR
BR
BR
BR
BR
$835.55
$896.90
$933.49
BR
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6253
D6545
D6548
D6600
D6601
D6602
D6603
D6604
D6605
D6606
D6607
D6624
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6634
D6710
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6793
D6794
D6920
Pontic - porcelain fused to high noble metal
Pontic - porcelain fused to predominantly base metal
Pontic - porcelain fused to noble metal
Pontic-porcelain/ceramic
Pontic - resin with high noble metal
Pontic - resin with predominantly base metal
Pontic - resin with noble metal
Provisional pontic
Fixed Partial Denture Retainers - Inlays/Onlays
Retainer - cast metal for resin bonded fixed prosthesis
Retainer-porcelain/ceramic for resin bonded fixed prosthesis
Inlay - procelain/ceramic for resin bonded fixed prosthesis
Inlay - porcelain/ceramic, three or more surfaces
Inlay - cast high noble metal, two surfaces
Inlay - cast high noble metal, three or more surfaces
Inlay - cast predominantly base metal, two surfaces
Inlay - cast predominantly base metal, three or more surfaces
Inlay - cast noble metal, two surfaces
Inlay - cast noble metal, three or more surfaces
Inlay - titanium
Onlay - porcelain/Ceramic, two surfaces
Only - porcelain/ceramic, three or more surfaces
Onlay - cast high noble metal, two surfaces
Onlay - cast high noble metal, three or more surfaces
Onlay - cast predominantly base metal, two surfaces
Onlay - cast predominantly base metal, three or more surfaces
Onlay - cast noble metal, two surfaces
Onlay - cast noble metal, three or more surfaces
Onlay - titanium
Fixed Partial Denture Retainers - Crowns
Crown – indirect resin based composite Not to be used as a
temporary or provisional prosthesis.
Crown - resin with high noble metal
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown-porcelain/ceramic
Crown - porcelain fused to high noble metal
Crown - porcelain fused to predominantly base metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - ¾ cast predominately base metal
Crown - ¾ cast noble metal
Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Crown - full cast predominantly base metal
Crown - full cast noble metal
Provisional retainer crown
Crown - titanium
Other Fixed Partial Denture Services
Connector bar
$855.60
$767.10
$921.69
$975.98
$933.49
$861.51
$888.99
BR
$855.60
$436.65
$885.11
$945.29
$824.93
$1,011.39
$824.93
$945.29
$824.93
$1,011.39
BR
$885.11
$1,011.39
$824.93
$945.29
$824.93
$945.29
$968.90
$968.90
BR
BR
$802.49
$999.58
$1,017.29
$1,108.17
$855.60
$796.60
$1,031.45
$796.60
$1,017.29
$945.29
$1,047.97
$814.30
$987.78
$1,023.18
BR
BR
$180.57
D6930
D6940
D6950
D6970
D6971
D6972
D6973
D6975
D6976
D6977
D6980
D6985
D6999
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
D7261
D7270
D7272
D7280
D7282
D7283
D7285
D7286
D7287
D7288
D7290
D7291
D7310
Recement fixed partial denture
Stress breaker
Precision attachment
Cast post and core in addition to fixed partial denture retainer
Cast post as part of fixed partial denture retainer
Prefabricated post and core in addition to fixed partial denture
retainer
Core build up for retainer, including any pins
Coping - metal
Each additional cast post - same tooth
Each additional prefabricated post - same tooth
Fixed partial denture repair, by report
Pediatric partial denture, fixed
Unspecified fixed prosthodontic procedure, by report
Oral and Maxillofacial Surgery
Extractions
(Includes Local Anesthesia, Suturing, If Needed, and Routine
Postoperative Care)
Extraction, coronal remnants - deciduous tooth
Extraction, erupted tooth or exposed root (elevation and/or
forceps removal)
Surgical Extractions
(Includes Local Anesthesia, Suturing, If Needed, and Routine
Postoperative Care)
Surgical removal of erupted tooth requiring elevation of
mucoperiosteal flap and removal of bone and/or section of tooth
Removal of impacted tooth - soft tissue
Removal of impacted tooth - partially bony
Removal of impacted tooth - completely bony
Removal of impacted tooth - completely bony, with unusual
surgical complications
Surgical removal of residual tooth roots (cutting procedure)
Other Surgical Procedures
Oroantral fistual closure
Primary closure of a sinus perforation
Tooth reimplantation and/or stabilization of accidentally evulsed
or displaced tooth
Tooth transplantation (includes reimplantation from one site to
another and splinting and/or stabilization)
Surgical access of an unerupted tooth
Mobilization of erupted or malpositioned tooth to aid eruption
Placement of device to facilitate eruption of impacted tooth
Biopsy of oral tissue – hard (bone, tooth)
Biopsy of oral tissue – soft
Exfoliative cytological sample collection
Brush biopsy – transepithelial sample collection
Surgical repositioning of teeth
Transseptal fiberotomy/supra crestal fiberotomy, by report
Alveoloplasty - Surgical Preparation of Ridge For Dentures
Alveoloplasty in conjunction with extractions - per quadrant
$147.52
$286.77
$560.57
$349.32
$306.84
$284.41
$228.94
$626.66
$148.69
$1441.61
BR
BR
BR
BR
BR
$212.43
$237.21
$278.51
$328.08
$460.26
$236.02
$2,374.45
BR
$492.12
$699.82
$539.33
BR
BR
$954.74
$391.81
BR
BR
$444.89
$67.27
$259.63
D7311 Alveoloplasty in conjunction with extractions – one to three teeth
or tooth spaces, per quadrant
D7320 Alveoloplasty not in conjunction with extractions - per quadrant
D7321 Alveoloplasty not in conjunction with extractions – one to three
teeth or tooth spaces, per quadrant
Vestibuloplasty
D7340 Vestibuloplasty - ridge extension (secondary epithelialization)
D7350 Vestibuloplasty - ridge extension (including soft tissue grafts,
muscle reattachment, revision of soft tissue attachment and
management of hypertrophied and hyperplastic tissue)
D7410
D7411
D7412
D7413
D7414
D7415
D7465
D7440
D7441
D7450
D7451
D7460
D7461
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
Surgical Excision of Soft Tissue Lesions
Excision or benign lesion up to 1.25 cm
Excision of benign lesion greater than 1.25 cm
Excision of benign lesion, complicated
Excision of malignant lesion up to 1.25 cm
Excision of malignant lesion greater than 1.25 cm
Excision of malignant lesion, complicated
Destruction of lesion(s) by physical or chemical method, by report
Surgical Excision of Intra-Osseous Lesions
Excision of malignant tumor - lesion diameter up to 1.25 cm
Excision of malignant tumor - lesion diameter greater than 1.25
cm
Removal of benign odontogenic cyst or tumor - lesion diameter
up to 1.25 cm
Removal of benign odontogenic cyst or tumor - lesion diameter
greater than 1.25 cm
Removal of benign nonodontogenic cyst or tumor - lesion
diameter up to 1.25 cm
Removal of benign nonodontogenic cyst or tumor - lesion
diameter greater than 1.25 cm
Excision of Bone Tissue
Removal of exostosis (maxilla or mandible)
Removal of torus palatinus
Removal of torus mandibularis
Surgical reduction of osseous tuberosity
Radical resection of mandible with bone graft
Surgical Incision
Incision and drainage of abscess - intraoral soft tissue
Incision and drainage of abscess – intraoral soft tissue –
complicated (includes drainage of multiple fascial spaces)
Incision and drainage of abscess - extraoral soft tissue
Incision and drainage of abscess – extraoral soft tissue –
complicated (includes drainage of multiple fascial spaces)
Removal of foreign body from mucosa, skin, or subcutaneous
alveolar tissue
Removal of reaction-producing foreign bodies - musculoskeletal
system
Partial ostectomy/sequestrectomy for removal of non-vital bone
Maxillary sinusotomy for removal of tooth fragment or foreign
BR
$354.04
BR
$2,127.79
$6,672.55
$1,483.44
BR
BR
BR
BR
BR
BR
$1,502.33
$2,334.33
$850.88
$1,335.93
$850.88
$1,370.15
$881.57
BR
BR
BR
$7,117.45
$254.90
BR
$1,214.37
BR
$437.83
$485.04
$302.12
$2,402.10
body
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850
D7852
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
Treatment of Fractures - Simple
Maxilla - open reduction (teeth immobilized, if present)
Maxilla - closed reduction (teeth immobilized, if present)
Mandible - open reduction (teeth immobilized, if present)
Mandible - closed reduction (teeth immobilized, if present)
Malar and/or zygomatic arch - open reduction
Malar and/or zygomatic arch - closed reduction
Alveolus -closed reduction may include stabilization of teeth
Alveolus - open reduction, may include stabilization of teeth
Facial bones - complicated reduction with fixation and multiple
surgical approaches
Treatment of Fractures - Compound
Maxilla - open reduction
Maxilla - closed reduction
Mandible - open reduction
Mandible - closed reduction
Malar and/or zygomatic arch - open reduction
Malar and/or zygomatic arch - closed reduction
Alveolus - open reduction stabilization of teeth
Alveolus - closed reduction stabilization of teeth
Facial bones - complicated reduction with fixation and multiple
surgical approaches
Reduction of Dislocation and Management of Other
Temporomandibular Joint Dysfunctions
Open reduction of dislocation
Closed reduction of dislocation
Manipulation under anesthesia
Condylectomy
Surgical discectomy, with/without implant
Disc repair
Synovectomy
Myotomy
Joint reconstruction
Arthrotomy
Arthroplasty
Arthrocentesis
Non-arthroscopic lysis & lavage
Arthroscopy - diagnosis, with or without biopsy
Arthroscopy - surgical: lavage & lysis of adhesions
Arthroscopy - surgical: disc repositioning and stabilization
Arthroscopy - surgical: synovectomy
Arthroscopy - surgical: discectomy
Arthroscopy - surgical: debridement
Occlusal orthotic device, by report
Unspecified TMD therapy, by report
Repair of Traumatic Wounds
Suture of recent small wounds up to 5 cm
Complicated Suturing
(Reconstruction Requiring Delicate Handling of Tissues and Wide
$3,885.04
$2,913.78
$5,051.02
$3,205.27
$2,428.74
$1,431.51
$1,117.59
BR
$7,285.05
$4,565.98
$3,205.27
$6,605.28
$3,267.82
$4,156.47
$1,667.54
$2,259.97
BR
$9,713.78
$4,273.31
$699.82
$401.26
$5,825.20
$5,029.78
$5,759.11
$5,943.21
$4,217.84
$12,020.97
$5,124.19
$8,256.29
$272.62
$545.23
$2,912.59
$3,506.20
$5,029.78
$5,510.10
$5,940.85
$5,243.39
$1,652.20
BR
$236.02
D7911
D7912
D7920
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7953
D7955
D7960
D7963
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D7995
D7996
D7997
D7999
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
Undermining for Meticulous Closure)
Complicated suture - up to 5 cm
Complicated suture - greater than 5 cm
Other Repair Procedures
Skin graft (identify defect covered, location, and type of graft)
Osteoplasty - for orthognathic deformities
Osteotomy – mandibular rami
Osteotomy – mandibular rami with bone graft; includes obtaining
the graft
Osteotomy - segmented or subapical - per sextant or quadrant
Osteotomy - body of mandible
LeFort I (maxilla - total)
LeFort I (maxilla - segmented)
LeFort II or LeFort III (osteoplasty of facial bone for midface
hypoplasia or retrusion) - without bone graft
LeFort II or LeFort III - with bone graft
Osseous, osteoperiosteal or cartilage graft of the mandible or
facial bones - autogenous or nonautogenous, by report
Bone replacement graft for ridge preservation – per site
Repair of maxillofacial soft and/or hard tissue defect
Frenulectomy (frenectomy or frenotomy), separate procedure
Frenulplasty
Excision of hyperplastic tissue - per arch
Excision of pericoronal gingiva
Surgical reduction of fibrous tuberosity
Sialolithotomy
Excision of salivary gland, by report
Sialodochoplasty
Closure of salivary fistula
Emergency tracheotomy
Coronoidectomy
Synthetic graft - mandible or facial bones, by report
Implant - mandible for augmentation purposes (excluding alveolar
ridge), by report
Appliance Removal (not by dentist who placed appliance),
includes removal of archbar
Unspecified oral surgery procedure, by report
Orthodontics
Limited Orthodontic Treatment
Limited orthodontic treatment of the primary dentition
Limited orthodontic treatment of the transitional dentition
Limited orthodontic treatment of the adolescent dentition
Limited orthodontic treatment of the adult dentition
Interceptive Orthodontic Treatment
Interceptive orthodontic treatment of the primary dentition
Interceptive orthodontic treatment of the transitional dentition
Comprehensive Orthodontic Treatment
Comprehensive orthodontic treatment of the transitional dentition
Comprehensive orthodontic treatment of the adolescent dentition
Comprehensive orthodontic treatment of the adult dentition
$971.26
$1,748.97
$2,865.40
$8,577.29
$8,577.29
$8,932.52
$7,964.79
$8,838.11
$10,921.07
$9,200.41
$14,326.97
$20,155.70
BR
BR
BR
$326.90
BR
$486.22
$184.10
BR
$824.00
BR
$2,218.67
$2,117.18
$1,942.52
$4,807.92
BR
BR
$297.40
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
D8210
D8220
D8660
D8670
D8680
D8690
D8691
D8692
D8999
D9110
D9210
D9211
D9212
D9215
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9450
D9610
D9630
D9910
D9911
D9920
D9930
D9940
D9941
D9942
Minor Treatment to Control Harmful Habits
Removable appliance therapy
Fixed appliance therapy
Other Orthodontic Services
Pre-orthodontic treatment visit
Periodic orthodontic treatment visit (as part of contract)
Orthodontic retention (removal of appliances, construction and
placement of retainer(s))
Orthodontic treatment (alternative billing to a contract fee)
Repair of orthodontic appliance
Replacement of lost or broken retainer
Unspecified orthodontic procedure, by report
Adjunctive General Services
Unclassified Treatment
Palliative (emergency) treatment of dental pain - minor procedure
Anesthesia
Local anesthesia not in conjunction with operative or surgical
procedures
Regional block anesthesia
Trigeminal division block anesthesia
Local anesthesia
Deep sedation/general anesthesia - first 30 minutes
Deep sedation/general anesthesia - each additional 15 minutes
Analgesia, anxiolysis, inhalation of nitrous oxide
Intravenous conscious sedation/analgesia - first 30 min
Intravenous conscious sedation/analgesia - each additional 15
minutes
Non-intravenous conscious sedation
Professional Consultation
Consultation (diagnostic service provided by dentist or physician
other than practitioner providing treatment)
Professional Visits
House/extended care facility call
Hospital call
Office visit for observation (during regularly scheduled hours) - no
other services performed
Office visit - after regularly scheduled hours
Case presentation, detailed and extensive treatment planning
Drugs
Therapeutic drug injection, by report
Other drugs and/or medicaments, by report
Miscellaneous Services
Application of desensitizing medicament
Applic desenzt resin-cerv &/or root surf/tooth
Behavior management, by report
Treatment of complications (post-surgical) - unusual
circumstances, by report
Occlusal guard, by report
Fabrication of athletic mouthguard
Repair and/or reline of occlusal guard
BR
BR
$81.43
$391.81
$861.51
$407.15
$213.60
$426.03
BR
$131.00
$64.91
$53.11
$97.94
$53.11
$434.29
$182.93
$84.96
$342.24
$142.80
$73.17
$228.94
$302.12
$415.42
$76.71
$118.02
BR
BR
BR
$49.56
$76.71
BR
BR
$702.19
$324.54
BR
D9950
D9951
D9952
D9970
D9971
D9972
D9973
D9974
D9999
Occlusion analysis - mounted case
Occlusal adjustment - limited
Occlusal adjustment - complete
Enamel microabrasion
Odontoplasty 1-2 Teeth-includes removal of enamel projections
External Bleaching – Per Arch
External Bleaching-Per Tooth
Internal Bleaching-Per Tooth
Unspecified adjunctive procedure, by report
$303.29
$236.02
$834.36
$53.11
$74.36
$341.06
$37.77
$293.13
BR