NYSWCB Will Implement New Health Provider Fee Schedules


New York, NY (CompNewsNetwork) - The Chair of the Workers' Compensation Board has adopted regulations to implement new health provider fee schedules that will take effect on December 1, 2010, the same day that the Medical Treatment Guidelines take effect.

The new fee schedules include the following changes:

  1. 30% increase in Evaluation and Management (E&M) services in the medical and podiatry fee schedules.
  2. Restructuring the chiropractic fee schedule to allow chiropractors to bill separately for individual treatment modalities rather than billing for an office visit that includes all treatment.
  3. Addition of ground rules that adopt the Medical Treatment Guidelines as the basis for treatment to the mid and lower back, neck, shoulder and knee.
  4. Update Current Procedural Terminology (CPT) codes to accommodate changes made by the American Medical Association (AMA) in 2009 and 2010. As a result, the new schedules include new and changed CPT codes, and eliminate deleted CPT codes.
  5. Minimal typographical changes.

Evaluation and Management Services Increase

New York's workers' compensation provider fee schedules have not increased in sixteen years. As a result, some of the fee schedules are among the lowest in the country, including those for E&M services. The 30% increase in E&M fees is intended to address this disparity and more fairly compensate medical providers for the work and skill required in the evaluation and management of injured workers.

Chiropractic Care Billing Changes

Historically, the chiropractic fee schedule has not allowed chiropractors to bill for the specific treatment modalities that they employ. Instead, they have billed E&M codes for office visits that are inclusive of all treatment provided at the time. The new proposed fee schedule will allow chiropractors to bill separately for the individual treatment modalities that they use. It adds the physical medicine codes they had previously been unable to bill, while also eliminating several CPT codes that are outside their scope of treatment. Chiropractors will continue to charge E&M codes for the initial evaluation and reevaluation of a patient, but can bill additionally for the specific treatments provided.

Allowing chiropractors to bill by treatment modality is critical to the implementation of the Medical Treatment Guidelines. The treatment guidelines set limits on the frequency and duration of various treatment therapies, including chiropractic manipulation, by modality. Therefore, it is essential that chiropractors report the actual therapy they perform so that they and the payers can monitor their consistency with the guidelines.

Medical Treatment Guidelines

The Medical Treatment Guidelines include new recommendations for various diagnostic tests and treatments relating to the mid and lower back, neck, shoulder and knee. The new fee schedules make clear that the Guidelines set the standard of care and that with limited exceptions treatment consistent with the Guidelines is pre-authorized and therefore must be paid by the carrier without advance permission. Treatment that is outside the Guidelines will not be paid unless a variance is approved by the insurer or the Board.

Current Procedural Terminology (CPT) Code Updates

The AMA, which maintains the CPT codes, updates the codes each year by adding, modifying and deleting CPT codes. The December 2010 fee schedules will adopt the most recent set of CPT codes and will add 283 new codes, modify 115 existing codes, and remove 145 deleted codes.

Other Changes

The new fee schedules also make a number of non-substantive typographical changes.

The cost for all four fee schedules is $85.00.

Finally, over the next twelve months, the Board intends to study the overall health provider fee schedules, including the relative compensation levels between different procedure codes and specialties, the appropriateness of the current geographic regions, and the adequacy of the existing fee levels.

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