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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 and Contact Information:
Department of Labor and Workforce Development.
Other:
Workers' Compensation rules
Medical Fee Schedule
Utilization review
Therapy Regulations
| Question | Response | Detail | Citation |
| What is the conversion factor for outpatient therapy services? | 130% of Medicare | General Information, Section III.I of the Medical Fee book, p. 15 | https://www.tn.gov/content/dam/tn/workforce/documents/injuries/wc_medfeebook.pdf |
| What is the basis of the fee schedule for outpatient therapy services? | RBRVS | Rule 0800-02-18-.01 Medicare-basis for system, applicability, effective date and coding references | https://www.tn.gov/content/dam/tn/workforce/documents/wc_medfeebook.pdf |
| Are there limits on the number of physical therapy visits allowed? | Yes | Utilization review required after 12 visits. General Information, section II.L, page 11 of Medical Fee book |
https://www.tn.gov/content/dam/tn/workforce/documents/wc_medfeebook.pdf |
| Are there limits on payment per visit for outpatient therapy services? | Yes | Rule 0800-02-18-.09(3) No fee allowable for any modalities or therapeutic procedures performed in excess of four (4) modalities, therapeutic procedures, or combination thereof per day per employee. | https://www.tn.gov/content/dam/tn/workforce/documents/wc_medfeebook.pdf |
| Do regulations require use of treatment guidelines? | No | Development of treatment guidelines is in process. | |
| Is a referral required in order to see a physical therapist? | Yes | ||
| Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes - | 0800-02-17-.10 PAYMENT. Cannot be higher than established maximum, but can be lower | https://www.tn.gov/content/dam/tn/workforce/documents/wc_medfeebook.pdf |
| Can the injured worker be charged for any claim-related services? | No | Cannot balance bill per Medical Fee Schedule, page 10 (section II.K.) | https://www.tn.gov/content/dam/tn/workforce/documents/wc_medfeebook.pdf |
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No | Defaults to state practice act | |
| Are there provider network and/or managed care regulations in place? | Yes | TCA 50-6-122(a)(2) and 50-6-124 UR rules 0800-02-06 and in 0800-02-17-.20 Case management rules 0800-02-07 |
https://www.tn.gov/content/dam/tn/workforce/documents/wc_medfeebook.pdf |
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | Yes | Tennessee fee schedule applies per section II.F. of the Tennessee Workers' Compensation Medical Fee Schedule | https://www.tn.gov/content/dam/tn/workforce/documents/wc_medfeebook.pdf |
| Are there regulations regarding Functional Capacity Evaluations (FCEs)? | Yes | 0800-02-18-.09(4) | https://www.tn.gov/content/dam/tn/workforce/documents/wc_medfeebook.pdf |
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