On December 31, 2019, the New York State (NYS) Department of Financial
Services (DFS) published in the State Register an emergency regulation (the 35th Amendment to Regulation 83), making clear that the new fee schedule sections
for Acupuncture, Physical, and Occupational Therapy, and the amendment
to the Chiropractic Fee Schedule that were adopted by the NYS Workers
Compensation Board (WBC) will not apply to No-Fault (i.e. to treatment
rendered to automobile accident victims) until October 1, 2020, and shall
only apply to charges for health services performed on or after October 1, 2020. These fee schedule additions/amendments were delayed by the Superintendent
to coincide with the other Workers’ Compensation fee schedules changes
that were already delayed by the DFS until October 1, 2020 (See, 34th Amendment to Regulation 83).
In the Regulatory Impact Statement, the Superintendent of Financial Services
explains that the delay is deemed necessary due to the “significant
adverse impact” that the changes would have on the no-fault system
if implemented on January 1, 2020. Specifically, the Superintendent acknowledges that no-fault insurers and
providers alike need time to adjust their internal bill processing systems.
The Superintendent suggests, and rightfully so, that the failure to provide
an adjustment period would likely “result in inaccurate billing
by providers and incorrect reimbursements from insurers [and that] these
issues ultimately will increase fee schedule disputes in arbitration and
Fee Schedule Changes Currently in Effect
Presently, there is only one fee schedule rate change in effect—the
new rate for emergency room (ER) services. As of July 15, 2019, the fee
schedule rate for ER services is now one hundred fifty (150%) percent
of the Department of Health’s Enhanced Ambulatory Patient Groups
(“EAPG”) Base Rate Fees, which means that rates fluctuate
based on the quantity and type of services provided.
Four (4) Ground Rules changes are also
currently in effect and they each prohibit the providers to whom these fee schedules
apply from billing under current procedural terminology (CPT) codes not
listed in their own respective fee schedules. The exempted Ground Rules
are as follows: General Ground Rule 10 in the Workers’ Compensation
Chiropractic Fee Schedule, General Ground Rule 13 in the Workers’
Compensation Behavioral Health Fee Schedule, and General Ground Rule 16
in the Workers’ Compensation Podiatry Fee Schedule, and General
Ground Rule 19 in the Workers’ Compensation Medical Fee Schedule. As such, as of January 1, 2020, chiropractors may no longer submit billing
to No-Fault insurers for manipulation under anesthesia (MUA).
Fee Schedule Changes Not Yet in Effect
The Relative Value Unit (RVU) per day cap
across specialties is not yet in effect, and its application is still within each arbitrators’
discretion. For dates of services on or after October 1, 2020, when a
patient receives physical medicine procedures, acupuncture, and/or chiropractic
modalities, the patient may not receive more than
12.0 RVUs per day per accident or illness from
all providers. For a re-evaluation plus modalities, the maximum allowance will be
15.0 RVUs, and for an initial evaluation plus modalities, the maximum allowance will be
Fee Schedule rate reductions for electrodiagnostic (EDX) testing (CPT Codes
9507 – 95913) are not effective until October 1, 2020. For treatment
rendered on or after October 1, 2020, there is over a 50% percent reduction in fees.
The “0” value assigned to MUA is not yet effective. Therefore,
physicians may continue to seek reimbursement for services rendered through September 30, 2020.
Despite the delay imposed by the 35th Amendment to Regulation 83, the fee schedule additions/amendments adopted
by the WCB are still likely to lead to incorrect reimbursements from No-Fault
insurers. Should a denial be received, for treatment rendered on or before
September 30, 2020, which applies the Fee Schedule rate changes or the
Ground Rule changes that are not yet in effect (e.g. the new RVU per day cap
across specialties or the reduction for EDX testing), said denial should be transferred to
Russell Friedman & Associates for immediate review.
The Firm encourages its clients to speak directly with their billing and
coding professionals to obtain a more in depth understanding of the services
that will be impacted by these upcoming fee schedule changes.
As we get closer to the implementation date for No-Fault, the Firm expects
to post additional clarification.