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No-Fault Update

On April 1, 2019, the 2018 New York Workers’ Compensation Fee Schedule will go into effect.  There are only a few ground rules that will become applicable to No-Fault providers as of April 1, 2019.  However, the 2018 New York Workers’ Compensation Fee Schedule that includes increased reimbursement rates for medical services will not be implemented until October 1, 2020.

The New York State Workers’ Compensation Board has issued an emergency amendment to the No-Fault fee schedule.  The new fee schedule can be purchased from the official publisher here: https://www.optum360coding.com/Product/48505/ 

The New York Workers’ Compensation fee schedule has traditionally applied to the New York State No-Fault system by operation of insurance regulation 83.

The recent changes in the new No Fault fee schedule have caused concern to No-Fault practitioners throughout New York State.  The Department of Financial Services has issued an emergency adoption of an amendment to the No-Fault regulations regarding this new fee schedule. This emergency amendment is officially the Thirty-Fourth Amendment to Part 68 of Title 11 of the Official Compilation of Codes, Rules and Regulations of the State of New York (Insurance Regulation 83).

The emergency amendment to the regulations states clearly that the changes to the amounts that providers can charge for services will not impact the No-Fault system until providers are billing for services rendered on and after October 1, 2020.

On April 1, 2019, the 2018 New York Workers’ Compensation Fee Schedule will go into effect with regard to the following ground rules:

  1. Ground Rule 10 of the Chiropractic Fee Schedule;
  2. Ground Rule 13 of the Behavioral Health Fee Schedule;
  3. Ground Rule 16 of the Podiatry Fee Schedule.

All three of these rules limit those professionals from billing for CPT codes outside of their individual fee schedule.

There is also Ground Rule 19 of the Medical Fee Schedule which prohibits any chiropractor, podiatrist, or provider of behavioral health from billing for CPT codes in the medical fee schedule.

Only the above-referenced ground rules apply to healthcare services rendered on or after April 1, 2019.  Any treatment rendered prior to April 1, 2019 will not be subject to the requirements of the new fee schedule.

Please note the new fee schedule increased reimbursement rates for medical services rendered will not be implemented until October 1, 2020.

One of the most significant additions to the Chiropractic section of the 2018 Workers’ Compensation Fee Schedule is the new Ground Rule 10, which states that chiropractors may NOT bill outside of their section.  Once implemented, Ground Rule 10 will limit the services that chiropractors currently use to treat their No-Fault patients. Chiropractic services that are not specifically found within the Chiropractic Fee Schedule section include manipulation under anesthesia, sensory nerve testing such as pain fiber nerve conduction studies.  Said services will NO LONGER BE REIMBURSABLE.

Note that it is still within the scope of practice for a chiropractor to perform manipulations under anesthesia.  However, reimbursement for manipulation under anesthesia remains under the Medical Section of the new No-Fault fee schedule.

CPT codes for electrodiagnostic testing, such as electromyography and nerve conduction velocity tests, have been added to the chiropractic section and will be billable under No-Fault, albeit at a reduced rate of reimbursement (approximately $500 reduction depending on the geographic location of the services performed).

With respect to providers that administer physical modalities, the maximum reimbursement per day has been increased from 8.0 RVUs to 12.0 RVUs.  Please note there is a limit of 12 RVUs per patient per day, regardless of the number of providers.  This change in the new No Fault fee schedule goes into effect on October 1, 2020.

With regard to range of motion testing, muscle testing and physical performance testing, the RVU listed in the new fee schedule is 0 and will not be reimbursable for any provider commencing on October 1, 2020.  This testing is now considered part of a comprehensive exam and is not separately reimbursable.

Radiologists and MRI facilities should note that the Radiology Ground Rule 3(f) states that imaging studies taken within 7 days of the first imaging study and related to the injury or problem necessitating the first imaging study, and which could have been reasonably performed at one time, shall be subject to reduction.

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