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This summary sets forth various workers' compensation regulations regarding outpatient physical therapy services.The Workers' Compensation State Regulations resource may serve as a tool to assist in locating regulations. Please send database comments and corrections to advocacy@apta.org.
To the extent an individual or entity wishes to rely upon information contained in this resource, such reliance should be based upon an independent legal review and analysis of applicable law. This resource was prepared for informational purposes only and is not offered or intended, nor should it be relied upon, for legal advice for any specific set of circumstances. Additional legal doctrines, federal and state statutes, and case law not set forth herein may apply to your situation and such laws, rules and regulations can vary from state to state. You should consult with your own attorney to obtain specific legal advice on your particular facts and circumstances and applicable laws, rules, and regulations.
Key Resources/Links
Agency:
IndustrialCommission
Contact Information:
North Carolina WC Contacts
News &Updates:
News & Announcements
Other:
Medical Fees Schedule (See:"Physical Medicine, section 10" and "CPT codes and fees")
Workers' Compensation Act
Workers' Compensation Rules
Therapy Regulations
Question | Response | Detail | Citation |
What is the conversion factor for outpatient therapy services? | Not reported | Schedule of fees provided | |
What is the basis of the fee schedule for outpatient therapy services? | RBRVS | WCRI report; no statute or rule reference located | Workers' compensation medical cost containment: A national inventory, 2011 (WCRI report WC-11-35, April 2011) |
Are there limits on the number of physical therapy visits allowed? | Yes | Not to exceed one visit per day or 30 days without prior approval from the payer | http://www.ic.nc.gov/ncic/pages/feesec10.htm |
Are there limits on payment per visit for outpatient therapy services? | No | ||
Do regulations require use of treatment guidelines? | No | ||
Is a referral required in order to see a physical therapist? | No | PT recognized as treating provider, not subject to referral | Workers' compensation medical cost containment: A national inventory, 2011 (WCRI report WC-11-35, April 2011) |
Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes + / - | MCO not subject to fee schedule (see intro to FS); Provider and insurer can enter into contract for different amount (§ 97-26(sub. c)) |
X |
Can the injured worker be charged for any claim-related services? | No | ||
Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | Yes | Licensed PT assistant under the direction of a licensed physical therapist and support personnel under direct supervision of a licensed provider | http://www.ic.nc.gov/ncic/pages/feesec10.htm |
Are there provider network and/or managed care regulations in place? | Yes | NCGS 97-25.2 | http://www.ncga.state.nc.us/gascripts/statutes/StatutesTOC.pl?Chapter=0097 |
Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | No | ||
Are there regulations regarding Functional Capacity Evaluations (FCEs)? | Yes | Physical Medicine Section 10 (F)(5) Requires preauthorization before scheduling. Paid per provider agreement with insurer CPT Code EV100 |
http://www.ic.nc.gov/ncic/pages/feesec10.htm |
1 While some states use a mandatory fee schedule, many states have provisions for fees to be negotiated above or below the published fee schedule. "Yes + / - " indicates that fees can be negotiated above or below the fee schedule. "Yes -" indicates that fees can only be negotiated below the fee schedule.
The following payer types conduct business in this state.
Private Carriers - Yes
Self-insured Employers or Groups - Yes
Competitive State Fund - No
Exclusive State Fund - No
State Comp Fund (last resort) - No