Implementation of New Fee Schedules for Acupuncture, Physical, and Occupational Therapy, and Amendment to Chiropractic Fee Schedule Delayed by the DFS Until October 1, 2020

Posted By Erin S. Stamper || 13-Feb-2020

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.[1] 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.[2] 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 the courts.”[3]

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.[4] 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 18.0 RVUs.

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.

Conclusion

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.


[1] The full text of the 35th Amendment to Regulation 83 can be found on the DFS website via the following link: https://www.dfs.ny.gov/system/files/documents/2019/12/text.pdf

[2] The full text of the Regulatory Impact Statement can be found on the DFS website via the following link: https://www.dfs.ny.gov/system/files/documents/2019/12/sapa_0.pdf

[4] See, Frequently Asked Questions about Regulation 83 and the No-Fault Fee Schedule https://www.dfs.ny.gov/apps_and_licensing/property_insurers/faqs_reg83_nofault_schedule).

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