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Billing Guide

This Billing Guide outlines the workers’ compensation billing requirements for Colorado.

Billing Form Requirements

Forms

Services

DaisyBill Resources

CMS-1500

Professional Services

DME

Most Ambulance Services

CMS-1500 Instructions

UB-04

Facility – Outpatient

Facility – Inpatient

NCPDP

Pharmacy

ADA

Dental

State-Mandated Physician Reporting Requirements

Colorado requires the physician to submit the following reports to document injured worker status.

Report

Form

Requirement

DaisyBill Resources

Physician’s Initial Report of Workers’ Compensation Injury

Form WC 164

Due within 14 days of initial visit

Physician’s Initial Report of Workers’ Compensation Injury Instructions

Physician’s Closing Report of Workers’ Compensation Injury

Form WC 164

Due within 14 days of final visit

Physician’s Closing Report of Workers’ Compensation Injury Instructions

Required Billing Documentation

Rule 16.7 requires providers, except hospitals, to send bills with supporting documentation, including copies of the examination, surgical, and treatment records unless the payor and provider agree otherwise.

Providers must document and retain medical records listing all services rendered to the injured worker. Rule 16.8(B) specifies the details required for such medical records. For each contact with the injured worker, or at least once per week if contact is more frequent, the medical record must include the following:

  1. Patient's name
  2. Date of contact, office visit or treatment
  3. Name and professional designation of person providing the billed service
  4. Assessment or diagnosis of current condition with appropriate objective findings;
  5. Treatment status or patient’s functional response to current treatment;
  6. Treatment plan including specific therapy with time limits and measurable goals and detail of referrals;
  7. Pain diagrams, where applicable;
  8. If being completed by an authorized treating physician, all pertinent changes to work and/or activity restrictions which reflect lifting, standing, stooping, kneeling, hot or cold environment, repetitive motion or other appropriate physical considerations; and
  9. All prior authorization(s) for payment received from the payer (i.e., who approved prior authorization, services authorized, dollar amount, length of time, etc.).

Important Resources

Workers’ Compensation Rules of Procedure, Rule 16 Utilization Standards

These rules define the standard terminology, administrative procedures, and dispute resolution procedures required to implement the Division's Medical Treatment Guidelines and Medical Fee Schedule. With respect to any matter arising under the Colorado Workers' Compensation Act and/or the Workers' Compensation Rules of Procedure and to the extent not otherwise precluded by the laws of this state, all providers and payers shall use and comply with the provisions of the "Medical Treatment Guidelines," Rule 17, and the "Medical Fee Schedule," Rule 18, as incorporated and defined in the Workers' Compensation Rules of Procedure, 7 CCR 1101-3.

Electronic Billing Mandate

Colorado allows electronic transmission of workers’ comp bills when mutually agreed upon by the payor and the provider. With the agreement of the payer, the provider may use the ANSI ASC X12 (American National Standards Institute Accredited Standards Committee) or NCPDP (National Council For Prescription Drug Programs) formats for electronic billing transactions.

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