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Garden City, New York 11530

NO FAULT UPDATE

March 21, 2019

Effective April 1, 2019, the New 2018 New York Workers’ Compensation Fee Schedule will go into effect.  On February 6, 2019, the NYS Department of Financial Services (DFS) issued an Emergency Amendment to Regulation 68 delaying the roll-out of the changes for New York No Fault.  

 

This resulted in the following action:

  • Only specific ground rules will become applicable to No-Fault providers on April 1, 2019.

  • The increased reimbursement rates for medical services will not be implemented until October 1, 2020.

The new fee schedule can be purchased from the official publisher here: https://www.optum360coding.com/Product/48505/ 

 

The New York Workers’ Compensation fee schedule has traditionally applied to the New York State No-Fault system by operation of Insurance Regulation 83. 

 

The recent changes in the new No Fault fee schedule have caused concern to No-Fault practitioners throughout New York State.  The Department of Financial Services has issued an emergency adoption of an amendment to the No-Fault regulations regarding this new No-Fault fee schedule. This emergency amendment is officially the Thirty-Fourth Amendment to Part 68 of Title 11 of the Official Compilation of Codes, Rules and Regulations of the State of New York (Insurance Regulation 83).

 

The emergency amendment to the regulations states clearly that the changes to the amounts that providers can charge for services will not impact the No-Fault system until health care providers bill for services rendered on and after October 1, 2020. 

 

On April 1, 2019, the 2018 New York Workers’ Compensation Fee Schedule will go into effect with regard to the following ground rules:

  1. Ground Rule 10 of the Chiropractic Fee Schedule;

  2. Ground Rule 13 of the Behavioral Health Fee Schedule;

  3. Ground Rule 16 of the Podiatry Fee Schedule.

All three of these rules limit those professionals from billing for CPT codes outside of their section of the fee schedule.

 

There is also Ground Rule 19 of the Medical Fee Schedule which prohibits any chiropractor, podiatrist, or provider of behavioral health from billing for CPT codes in the medical fee schedule.

 

Only the above-referenced ground rules apply to healthcare services rendered on or after April 1, 2019. 

 

All treatment through October 1, 2020 should be billed at the current rates using the CPT coded that reside within the providers section of the fee schedule.

 Any treatment rendered prior to April 1, 2019 will not be subject to the requirements of the new fee schedule.

 

Please note the new fee schedule which increased reimbursement rates and limited covered services for medical services rendered will NOT be implemented until October 1, 2020. 

 

One of the most significant additions to the Chiropractic section of the 2018 Workers’ Compensation Fee Schedule is the new Ground Rule 10, which states that chiropractors may NOT bill outside of their section.  Once implemented, Ground Rule 10 will limit the services that chiropractors currently utilize to treat their No-Fault patients.

 

PLEASE FEEL FREE TO CONTACT OUR OFFICE TO DISCUSS YOUR NO-FAULT CONCERNS.

 

Services such as Manipulation Under Anesthesia “MUA” which are within the lawful scope of practice for Chiropractic have been removed from the Chiropractic Section of the Fee Schedule and will NO LONGER BE REIMBURSABLE as of April 1, 2019. 

 

Note that it is still within the scope of practice for a chiropractor to perform manipulations under anesthesia.  However, reimbursement for manipulation under anesthesia remains in the Medical Section of the new No-Fault fee schedule only.

 

CPT codes for electrodiagnostic testing, such as electromyography and nerve conduction velocity tests, contained within the chiropractic section and will still be billable under No-Fault, beginning October 1, 2020, at a reduced rate of reimbursement (approximately $500 reduction depending on the geographic location of the services performed). Until October 1, 2020 you should continue to use the CURRENT Fee Schedule. 

 

With respect to providers that administer physical modalities, the maximum reimbursement per day has been increased from 8.0 RVUs to 12.0 RVUs.  Please note there is a limit of 12 RVUs per patient per day, regardless of the number of providers.  This change in the new No Fault fee schedule goes into effect on October 1, 2020.

 

With regard to range of motion testing muscle testing, unlisted neurological testing and physical performance testing (in Chiropractic fee schedule), the RVU listed in the new fee schedule is 0 and will not be reimbursable for any provider commencing on October 1, 2020.  This testing is now considered part of a comprehensive exam and is no longer separately reimbursable.

 

Radiologists and MRI facilities should note that the Radiology Ground Rule 3(f) states that imaging studies taken within 7 days of the first imaging study and related to the injury or problem necessitating the first imaging study, and which could have been reasonably performed at one time, shall be subject to reduction.

 

THERE ARE STRATEGIES THAT CAN BE INCORPORATED IN YOUR PRACTICE THAT CAN MAXIMIZE YOUR REIMBURSEMENT UNDER THE NEW NO-FAULT FEE SCHEDULE AND ALLOW YOU TO MAXIMIZE PATIENT CARE WITHIN THE NEW RESTRICTIONS.

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