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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:
Workers' Compensation Board
Contact Information:
New York WCB Contacts
News
& Updates:
Press Releases
Other:
Health Care Information
Medical Care Fee Schedules
Medical Treatment Guidelines
OT/PT-4 Form
Therapy Regulations
| Question | Response | Detail | Citation |
| What is the conversion factor for outpatient therapy services? | Not reported | Regional conversion factors by zip code. OptumInsight maintains/sells outpatient fee schedule - see Physical Medicine chapter of NYS WC Physician Fee Schedule | |
| What is the basis of the fee schedule for outpatient therapy services? | State Relative Value | Relative values established by the state | |
| Are there limits on the number of physical therapy visits allowed? | Yes | Per medical treatment guidelines | http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/MTGOverview.jsp |
| Are there limits on payment per visit for outpatient therapy services? | Yes | When multiple physical medicine procedures and/or modalities are performed on the same day, reimbursement is limited to 12.0 RVUs per patient per accident or illness or the amount billed, whichever is less. Note: When a patient receives physical medicine procedures and/or modalities from more than one provider, the patient is may not receive more than 12.0 RVUs per day per accident or illness from all providers |
Medical Fee Schedule http://www.wcb.ny.gov/content/main/hcpp/FeeSchedules.jsp |
| Do regulations require use of treatment guidelines? | Yes | State specific; adapted from ODG, ACOEM, WA: for neck, mid/low back, shoulder, knee (CTS in draft Jan 2012) | http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/MTGOverview.jsp |
| Is a referral required in order to see a physical therapist? | Yes | Must be referred by treating physician | 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 + / - | Can be negotiated above or below published rate | Workers' compensation medical cost containment: A national inventory, 2011 (WCRI report WC-11-35, April 2011) |
| Can the injured worker be charged for any claim-related services? | Yes | If a claim is denied and the injured worker has signed an A-9 form, the injured worker is responsible for payment. A-9 is recommended on all claims | http://www.wcb.ny.gov/content/main/forms/a9.pdf |
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | Yes | Only licensed physical therapists can provide treatment to injured workers in NYS: see Title 12 NYCRR, Chapter V, Subchapter F, part 349-1.1 | http://government.westlaw.com/linkedslice/default.asp?SP=nycrr-1000 |
| Are there provider network and/or managed care regulations in place? | Yes | WCL 350-Article 10-A NYCRR Title 12, Chapter V, Subchapter C Part 325-8 NYCRR Title 10 Chapter V, Subchapter C, Article 4, Part 732 |
Article 10A http://government.westlaw.com/linkedslice/default.asp?SP=nycrr-1000 (select Title number) |
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | Yes | State of residence fee schedule will apply (if reside and treat out of state, the out of state FS applies; if reside in NYS and treat out of state, NYS FS applies) | http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/FAQs.jsp#outOfState |
| Are there regulations regarding Functional Capacity Evaluations (FCEs)? | Yes | NYS Medical Fee Schedule http://www.wcb.ny.gov/content/main/hcpp/FeeSchedules.jsp |
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 - Yes
Exclusive State Fund - No
State Comp Fund (last resort) - No