7 Colo. Code Regs. § 1101-3-18-9
Current through Register Vol. 47, No. 24, December 25, 2024
Section 7 CCR 1101-3-18-9 - QUALITY INITIATIVES(A) OPIOID MANAGEMENT(1) Codes and maximum allowances are payable to the prescribing ATP for a written report with all the following opioid review services completed and documented: (a) ordering and reviewing drug tests for subacute or chronic opioid management;(b) ordering and reviewing Colorado Prescription Drug Monitoring Program (PDMP) results;(c) reviewing the medical records;(d) reviewing the injured worker's current functional status;(e) evaluating the risk of misuse and abuse initially and periodically; and(f) determining what actions, if any, need to be taken. In determining the prescribed levels of medications, the ATP shall review and integrate the drug screening results required for subacute and chronic opioid management, as appropriate; the PDMP and its results; an evaluation of compliance with treatment and risk for addiction or misuse; as well as the injured worker's past and current functional status. A written report also must document the ATP's assessment of the injured worker's past and current functional status of work, leisure, and activities of daily living.
The injured worker should initially and periodically be evaluated for risk of misuse or addiction. The ATP may consider whether the injured worker experienced an opiate-related drug overdose event that resulted in an opiate antagonist being prescribed or dispensed pursuant to § 12-30-110. If the injured worker is deemed to be at risk for an opiate overdose, an opioid antagonist may be prescribed (see section 18-6(C)(5)(c)).
Opioid Management Billing Codes:
Acute Phase: DoWC Z0771, $86.70, per 15 minutes, maximum of 30 minutes per report
Subacute/Chronic Phase: DoWC Z0765, $86.70, per 15 minutes, maximum of 30 minutes per report
(2) Definitions: (a) Acute opioid use refers to the prescription of opioid medications (single or multiple) for duration of 30 days or less for non-traumatic injuries, or six weeks or less for traumatic injuries or post-operatively.(b) Subacute opioid use refers to the prescription of opioid medications for longer than 30 days for non-surgical cases and longer than six weeks for traumatic injuries or post-operatively.(c) Chronic opioid use refers to the prescription of opioid medications for longer than 90 days.(3) Acute opioid prescriptions generally should be limited to three to seven days and 50 morphine milliequivalents (MMEs) per day. Providers considering repeat opioid refills at any time during treatment are encouraged to perform the actions in this section and bill accordingly.(4) When long-term opioid treatment is prescribed, the ATP shall comply with the Division's Chronic Pain Disorder MTG (Rule 17, Exhibit #9), and review the Colorado Medical Board Policy #40-26, "Policy for Prescribing and Dispensing Opioids."(5) Urine drug tests are required for subacute and chronic opioid management and shall employ testing methodologies that meet or exceed industry standards for sensitivity, specificity, and accuracy. The testing methodology must be capable of identifying and quantifying the parent compound and relevant metabolites of the opioid prescribed. In-office screening tests designed to screen for drugs of abuse are not appropriate for subacute or chronic opioid compliance monitoring. Refer to section 18-4(F)(3) for clinical drug screening testing codes and values. (a) Drug testing shall be done prior to the initial long-term drug prescription being implemented and randomly repeated at least annually.(b) While the injured worker is receiving opioid management, additional drug screens with documented justification may be conducted. Examples of documented justification include:(i) Concern regarding the functional status of the injured worker;(ii) Abnormal results on previous testing;(iii) Change in management of dosage or pain; and(iv) Chronic daily opioid dosage above 50 MMEs.(B) QUALITY PERFORMANCE AND OUTCOMES PAYMENTS (QPOP)(1) Providers who are Level I or II Accredited, or who have completed the Division-sponsored Level I or II Accreditation program and have successfully completed the QPOP training may bill separately for documenting functional progress made by the injured worker. Providers must utilize both a Division-approved psychological screen and a Division-approved functional tool. The psychological screen and the functional tool are approved by the Division and are validated for the specific purpose for which they have been created. Provider also must document whether the injured worker's perception of function correlates with clinical findings. The documentation of functional progress should assist the Provider in preparing a successful plan of care, including specific goals and expected time frames for completion, or for modifying a prior plan of care. The documentation must include:(a) Specific testing that occurred, interpretation of testing results, and the weight given to these results in forming a reasonable and necessary plan of care;(b) Explanation of how the testing goes beyond the evaluation and management (E/M) services typically provided by the Provider;(c) Meaningful discussion of actual or expected functional improvement between the Provider and the injured worker.(2) Billing codes and maximum fees: DOWC Z0815, $83.23, for the initial assessment during which the injured worker provides functional data and completes the validated psychological screen, which the Provider considers in preparing a plan of care. This code also may be used for the final assessment that includes review of the functional gains achieved during the course of treatment and documentation of MMI.
DOWC Z0816, $41.62, for subsequent visits during which the injured worker provides follow-up functional data that could alter the treatment plan. The Provider may use this code if the analysis of the data leads to a modification of the treatment plan. The Provider should not bill this code more than once every two to four weeks.
(3) QPOP for post-MMI patients requires prior authorization based on clearly documented functional goals.(C) APP-BASED INTERVENTIONS Providers may write an order for app-based interventions for the purpose of patient education and training to aid in curing and/or relieving the injured worker from the effects of the work injury. A duration for use shall be designated on the order and may be reordered as clinically indicated. The app must be payable by invoice and billed directly to the Payer. Providers who write such orders are not permitted to receive any remuneration from the service Provider for the referral. The maximum allowable charge is $25 per month and may be billed for a maximum duration of three months, or $75 per order. App-based interventions that exceed this allowance require prior authorization. Examples of app-based interventions include apps that utilize artificial intelligence to educate the user about pain neuroscience, chronic pain management, weight loss, mental well-being, glucose management, and home exercise routines.
(D) PILOT PROGRAMS Payers may submit a proposal to conduct a pilot program(s) to the Director for approval. Pilot programs authorized by this Rule shall be designed to improve quality of care, determine the efficacy of clinical or payment models, and provide a basis for future development and expansion of such models.
The proposal for a pilot program shall meet the minimum standards set forth in § 8-43-602 and shall include:
(1) beginning and end date for the pilot program;(2) population to be managed (e.g. size, specific diagnosis codes);(3) Provider group(s) participating in the program;(4) proposed codes and fees; and(5) process for evaluating the program's success. Participating Payers must submit data and other information as required by the Division to examine such issues as the financial implications for Providers and injured workers, enrollment patterns, utilization patterns, impact on health outcomes, system effects and the need for future health planning.
37 CR 13, July 10, 2014, effective 7/30/201438 CR 01, January 10, 2015, effective 2/1/201538 CR 05, March 10, 2015, effective 4/1/201538 CR 11, June 10, 2015, effective 7/1/201538 CR 17, September 10, 2015, effective 1/1/201639 CR 04, February 25, 2016, effective 3/16/201639 CR 13, July 10, 2016, effective 7/30/201639 CR 16, August 25, 2016, effective 9/14/201639 CR 19, October 10, 2016, effective 1/1/201740 CR 03, February 10, 2017, effective 3/2/201740 CR 11, June 10, 2017, effective 7/1/201740 CR 21, November 10, 2017, effective 11/30/201740 CR 18, September 25, 2017, effective 1/1/201840 CR 20, October 25, 2017, effective 1/1/201841 CR 11, June 10, 2018, effective 7/1/201841 CR 19, October 10, 2018, effective 1/1/201941 CR 20, October 25, 2018, effective 1/1/201941 CR 23, December 10, 2018, effective 1/1/201942 CR 01, January 10, 2019, effective 1/30/201942 CR 11, June 10, 2019, effective 6/30/201942 CR 12, June 25, 2019, effective 7/15/201942 CR 21, November 10, 2019, effective 11/30/201942 CR 20, October 25, 2019, effective 1/1/202042 CR 23, December 10, 2019, effective 1/1/202043 CR 03, February 10, 2020, effective 1/1/202043 CR 07, April 10, 2020, effective 4/30/202043 CR 11, June 10, 2020, effective 7/1/202043 CR 16, August 25, 2020, effective 10/14/202043 CR 21, November 10, 2020, effective 1/1/202144 CR 07, April 10, 2021, effective 4/30/202144 CR 08, April 25, 2021, effective 7/1/202144 CR 13, July 10, 2021, effective 7/30/202144 CR 20, October 25, 2021, effective 1/1/202244 CR 23, December 10, 2021, effective 1/1/202244 CR 23, December 10, 2021, effective 1/10/202245 CR 01, January 10, 2022, effective 1/30/202245 CR 11, June 10, 2022, effective 7/1/202245 CR 13, July 10, 2022, effective 8/10/202245 CR 21, November 10, 2022, effective 12/6/202246 CR 01, January 10, 2023, effective 12/6/202245 CR 19, October 10, 2022, effective 1/1/202346 CR 02, January 25, 2022, effective 1/1/202346 CR 02, January 25, 2023, effective 3/2/202346 CR 05, March 10, 2023, effective 3/30/202346 CR 19, October 10, 2023, effective 1/1/202447 CR 21, November 10, 2024, effective 1/1/2025