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January 1, 2020Dear Customer:The State of New York has revised the Official New York State Workers’Compensation Medical Fee Schedule effective January 1, 2020. The enclosed pageswill update the 2018 edition (effective April 1, 2019) with the updates effectiveJanuary 1, 2020.The new Official New York State Workers’ Compensation Acupuncture and Physical &Occupational Therapy Fee Schedules booklet is not included in this update. Thisbooklet is available separately by calling Optum360 at 1.800.464.3649, option 1.Sincerely,Optum360LWCNY18R2525 Lake Park Boulevard Salt Lake City, UT 84120 800.464.3649 Fax 801.982.4033
Assembly InstructionsOfficial New York State Workers’ Compensation Medical Fee SchedulePlease follow these instructions to assemble your book. Insert the pages in theNEW Pages column. The OLD Pages should be retained for dates of service prior toJanuary 1, 2020.Tab SectionsOld PagesNew PagesMedical Fee ScheduleTitle/Disclaimer pagesTitle/Disclaimer pagesIntroduction and General Guidelines3–811 – 1619 – 203–811 – 1619 – 20AEvaluation and Management27 – 2827 – 28ASurgery59 – 6659 – 66Radiology255 – 256255 – 256Pathology and Laboratory279 – 282279 – 282Medicine331 – 332331 – 332APhysical Medicine371 – 376371 – 376Title/Disclaimer pagesTitle/Disclaimer pagesContentsContents1–81–8Title/Disclaimer pagesTitle/Disclaimer pagesIntroduction and General Guidelines3–73–7Medicine17 – 1817 – 18Physical Medicine21 – 2221 – 22Title/Disclaimer pagesTitle/Disclaimer pagesIntroduction and General Guidelines3–83–8Surgery25 – 3025 – 30Radiology47 – 4847 – 48Pathology and Laboratory51 – 5451 – 54Behavioral Health Fee ScheduleIntroduction and General GuidelinesChiropractic Fee SchedulePodiatry Fee Schedule
OFFICIALNEW YORK STATE WORKERS’ COMPENSATIONMEDICALFEE SCHEDULEEffective 4/1/2019Revisions Effective 1/1/2020UWCNY18R2
COPYRIGHT 2018 State of New YorkFee data 2018 Oputm360, LLC.CPT codes, descriptions, and two-digit numeric modifiers only, 2017 American MedicalAssociationAnesthesia base units only, 2017 American Society of AnesthesiologistsAll rights reserved. Printed in the United States of America. No part of this publication may bereproduced or transmitted in any form or by any means, electronic or mechanical, includingphotocopy, recording, or storage in a database retrieval system, without the prior writtenpermission of the publisher.Made in the USA1.800.464.3649
OPTUM360 NOTICEThe Official New York State Workers’ Compensation Medical FeeSchedule is designed to be an accurate and authoritativesource of information about medical coding andreimbursement. Every reasonable effort has been made toverify its accuracy, and all information is believed reliable atthe time of publication. Absolute accuracy, however, cannotbe guaranteed.Optum360 worked closely with the New York Workers’Compensation Board in the development, formatting, andproduction of this fee schedule. However, all decisionsresulting in the final content of this schedule were madesolely by the New York State Workers’ Compensation Board.This publication is made available with the understandingthat the publisher is not engaged in rendering legal and otherservices that require a professional license.For additional copies of this publication or other feeschedules, please call 1.800.464.3649.AMERICAN MEDICAL ASSOCIATION NOTICECPT 2017 American Medical Association. All rightsreserved.Fee schedules, relative value units, conversion factors and/orrelated components are not assigned by the AMA, are notpart of CPT, and the AMA is not recommending their use.The AMA does not directly or indirectly practice medicine ordispense medical services. The AMA assumes no liability fordata contained or not contained herein.CPT is a registered trademark of the American MedicalAssociation.AMERICAN SOCIETY OF ANESTHESIOLOGISTS’NOTICERelative Value Guide 2017 American Society ofAnesthesiologists. All Rights Reserved.Relative Value Guide is a relative value study and not a feeschedule. It is intended only as a guide. ASA does notdirectly or indirectly practice medicine or dispense medicalservices. ASA assumes no liability for data contained or notcontained herein.Relative Value Guide is a registered trademark of theAmerican Society of Anesthesiologists.NEW YORK WORKERS’ COMPENSATION BOARDFILING NOTICEThe Medical Fee Schedule was duly filed in the Office of theDepartment of State, and constitutes Sections 329.1 and329.3 of Title 12 of the Official Compilation of Codes, Rules,and Regulations of the State of New York.OUR COMMITMENT TO ACCURACYOptum360 is committed to producing accurate and reliablematerials. To report corrections, please emailaccuracy@optum.com. You can also reach customer serviceby calling 1.800.464.3649, option 1.REVISED PRINTINGThis revised printing contains revisions effective January 1,2020.
FOREWORDThe Workers’ Compensation Board is pleased to present the updated version of theOfficial New York State Workers’ Compensation Medical Fee Schedule.The revised fee schedule is an essential tool for health care providers and those payingthe cost of health care services under the New York State Workers’ Compensationsystem. This schedule provides comprehensive billing guides, which will allow healthcare providers to appropriately describe their services and minimize disputes overreimbursement. Also, this schedule includes many new procedures and codingchanges that have taken place since the previously published fee schedule.This fee schedule could not have been produced without the assistance of manyindividuals. The spirit of cooperation between the provider and payer communities isvery much appreciated. The excellence of this schedule is due, in large part, to thecommitment of many people in the workers’ compensation community. We aregrateful for their efforts.Except where noted, this fee schedule is effective for medical services rendered on orafter April 1, 2019, regardless of the date of accident. The fees established herein arepayable to health care providers authorized or permitted to render care under theWorkers’ Compensation Law, Volunteer Firefighters’ Benefit Law, and VolunteerAmbulance Workers’ Benefit Law.New York State Workers’ Compensation Board
New York State Workers’ Compensation Medical Fee Scheduleidentify four circumstances where the usual follow-up daysconcept does not apply. These four circumstances are asfollows:MMMDescribes services in uncomplicated maternity care.This includes antepartum, delivery, and postpartumcare. The usual global surgery concept does notapply.XXXIndicates that the global surgery concept does notapply.YYYIndicates that the global period is to be establishedby report.ZZZIndicates that the service is an add-on service and,therefore, is treated in the global period of theprimary procedure that is billed in conjunctionwith the ZZZ service. Do not bill these codes withmodifier 51. Reimbursement should not bereduced.Introduction and General GuidelinesSPECIALTY CLASSIFICATIONSThe “C” rating (Consultant in Specialty, e.g.,CS—Consultant-Surgery) may be granted to physicianscertified as specialists by a board recognized by the AmericanBoard of Medical Specialties and the American OsteopathicAssociation. Applicants, who are qualified but have notattained board-certified status as defined above, will begranted a specialty rating without the “C” prefix (e.g., IM,OS, and S).The rating “OP-GP” is given to osteopathic physicians ingeneral practice. The “OP” designation, when combined withone of the specialty ratings, indicates that the specialist is anosteopathic physician (e.g., OPOS, is the proper rating for anosteopathic physician who is a qualified specialist inorthopedic surgery. Upon obtaining Consultant status, asdefined above, a physician may apply for an “OP-COS”rating). Please refer to the Board’s website for a full listing ofrating codes: http://www.wcb.ny.gov/.PC/TC SplitThe PC/TC Split column shows the percentage of theprocedure that is professional or technical. A procedure witha relative value unit of 3.0 and a 40/60 in the PC/TC Splitcolumn would be calculated as follows: 40 percent of thevalue (3.0 x conversion factor x .40 PC) is for theprofessional component of the service, and 60 percent of thevalue (3.0 x conversion factor x .60 TC) represents thetechnical component of the service. The total componentreimbursed should never be more than the professional andtechnical components combined.CPT only 2017 American Medical Association. All Rights Reserved.Revised printing effective 1/1/20203
Introduction and General GuidelinesNew York State Workers’ Compensation Medical Fee ScheduleThis page is intentionally left blank.4CPT only 2017 American Medical Association. All Rights Reserved.Revised printing effective 1/1/2020
New York State Workers’ Compensation Medical Fee ScheduleIntroduction and General GuidelinesPOSTAL ZIP CODES BY REGIONNumerical List of Postal ZIP CodesPostal ZIP codes included in each IIIRegion 099811980Region IIRegion IIIRegion 3901149911599116971179811854CPT only 2017 American Medical Association. All Rights Reserved.Revised printing effective 1/1/20205
Introduction and General GuidelinesNew York State Workers’ Compensation Medical Fee ScheduleCONVERSION FACTORSRegional conversion factors for services rendered on or afterApril 1, 2019.SectionRegion I Region IIE/MRegionIIIRegionIV 12.11 12.11 13.85 15.06Medicine 8.91 8.91 10.19 11.07Physical Medicine 8.43 8.43 9.65 10.48 23.88 23.88 27.34 29.71 202.53 202.53 231.78 251.94 46.77 46.77 53.53 58.19 1.06 1.06 1.21 1.31AnesthesiaSurgeryRadiologyPathology andLaboratoryCategory III codes are subject to the conversion factorapplicable to similar services. See the Category III Codessection for more information.CALCULATING FEES USING RELATIVE VALUES ANDCONVERSION FACTORSExcept as otherwise provided in this schedule, the maximumfee amount is calculated by multiplying the relative value bythe applicable conversion factor. For example, the total feefor code 99213, performed in Region I or Region II, wouldbe calculated as follows:5.83x 12.11(Relative Value)(E/M Section Conversion Factor forRegion I or Region II) 70.60NEW CPT CODESThe table below is a complete list of CPT codes that havebeen added since the June 1, 2012 fee schedule.These codes are identified in the fee schedule with “ 4440144407453504539947533CPT only 2017 American Medical Association. All Rights Reserved.Revised printing effective 1/1/2020
New York State Workers’ Compensation Medical Fee 540827778671186832875068763287910CPT only 2017 American Medical Association. All Rights Reserved.Revised printing effective 912Introduction and General 9915599415994839949099497CHANGED CODESChanged ValuesThe following table is a complete list of CPT andstate-specific codes that have a relative value change, an FUDchange, or a PC/TC split change since the June 1, 2012 feeschedule. Codes that have had a description change, arelisted in a separate table below.7
Introduction and General GuidelinesNew York State Workers’ Compensation Medical Fee ScheduleColumns that are blank for any code either do not apply tothe code or the code was not assigned a value on the currentor previous (June 1, 2012) fee schedule.CODEFor each code listed, the following information is T0.61BRZZZZZZNY 2018 PC/TC Split. This is the PC/TC split forservices rendered on or after April 1, 2019. Only codeswith distinct professional and technical components areassigned a PC/TC split; therefore, many codes will nothave a value in this BRZZZZZZ0228T1.75BRXXXXXXNY 2012 PC/TC Split. This is the PC/TC split effectiveJune 1, XXXXXXNY 2018 RVU. This is the current RVU for servicesrendered on or after April 1, 2019.NY 2012 RVU. This is the RVU effective June 1, 2012.NY 2018 FUD. This is the FUD for services rendered onor after April 1, 2019.NY 2012 FUD. This is the FUD listed in the June 1,2012 fee schedule.These codes are identified in the fee schedule with “ .”CODE8NY 2018 NY 2012RVURVUNY2018FUDNY2012FUDNY 2018 NY 2012PC/TCPC/TCSplitSplitNY 2018 NY 05T0.53BRZZZZZZ0206T37.42BRXXXXXXNY 2018 NY 2012PC/TCPC/TCSplitSplitCPT only 2017 American Medical Association. All Rights Reserved.Revised printing effective 1/1/2020
New York State Workers’ Compensation Medical Fee 148Introduction and General Guidelinesbased on records, hence the importance ofdocumentation. The original official record, such asoperative report and hospital chart, will be given fargreater weight than supplementary reports formulatedand submitted at later dates. For any procedure wherethe relative value unit is listed in the schedule as “BR,”the physician shall establish a relative value unitconsistent in relativity with other relative value unitsshown in the schedule. The insurer shall review allsubmitted “BR” relative value units to ensure that therelativity consistency is maintained. The generalconditions and requirements of the General GroundRules apply to all “BR” items.92140929849398295903970019753299149GENERAL GROUND RULES1A.NYS Medical Treatment GuidelinesTreatment of work-related injuries should be inaccordance with any applicable medical treatmentguidelines adopted by the Chair of the Workers’Compensation Board. If there is a conflict between thefee schedule ground rules and the medical treatmentguidelines, the guidelines will prevail. With limitedexceptions that are clearly identified in the guidelines,treatment that correctly applies the treatmentguidelines is pre-authorized regardless of the cost ofthe treatment. Treatment that is not a correctapplication of, or is outside or in excess of thetreatment guidelines is not authorized unless thepayer or Workers’ Compensation Board has approveda variance.1B.Multiple ProceduresIt is appropriate to designate multiple procedures thatare rendered on the same date by separate entries. Forexample, if a level three established patient office visit(99213) and an ECG (93000) are performed duringthe visit, it is appropriate to designate both theestablished patient office visit and the ECG. In thisinstance, both 99213 and 93000 would be reported.2.Unlisted Service or ProcedureWhen an unlisted service or procedure is provided,the procedure should be identified and the valuesubstantiated “by report” (see Rule 3 below). Allsections will have an unlisted service or procedurecode number, usually ending in “99.”3.Procedures Listed Without Specified RelativeValue UnitsBy report (BR) items: “BR” in the Relative Valuecolumn represents services that are too variable in thenature of their performance to permit assignment ofrelative value units. Fees for such procedures need tobe justified “by report.” Pertinent informationconcerning the nature, extent, and need for theprocedure or service, the time, the skill, andequipment necessary, etc., is to be furnished. Adetailed clinical record is not necessary, but sufficientinformation shall be submitted to permit a soundevaluation. It must be emphasized that reviews areCPT only 2017 American Medical Association. All Rights Reserved.Revised printing effective 1/1/20204.Materials Supplied by Provider:Pharmaceuticals and Durable MedicalEquipmentA) PharmacyA prescriber cannot dispense more than aseventy-two hour supply of drugs with theexceptions of:1.Persons practicing in hospitals as defined insection 2801 of the public health law;2.The dispensing of drugs at no charge to theirpatients;3.Persons whose practices are situated tenmiles or more from a registered pharmacy;4.The dispensing of drugs in a clinic, infirmary,or health service that is operated by oraffiliated with a post-secondary institution;5.The dispensing of drugs in a medicalemergency as defined in subdivision 6 ofsection 6810 of the State Education Law.For pharmaceuticals administered by the medicalprovider in a medical office setting, payment shallnot exceed the invoice cost of the item, applicabletaxes, and any shipping costs associated withdelivery from the supplier of the item to theprovider’s office. There should be no additional“handling” costs added to the total cost of theitem. Bill using procedure code 99070.B) Durable Medical EquipmentPrior to the effective date of the 2020 DurableMedical Equipment Fee Schedule, for durablemedical equipment administered by the medicalprovider in a medical office setting, payment shallnot exceed the invoice cost of the item, applicabletaxes, and any shipping costs associated withdelivery from the supplier of the item to theprovider’s office. There should be no additional11
Introduction and General GuidelinesNew York State Workers’ Compensation Medical Fee ScheduleWhen the condition of the patient requires thedisparate skills of two or more physicians to treatdifferent conditions which do not fall within the scopeof other physicians treating the patient at the sametime (e.g., management of diabetes mellitus in asurgical case), payment is due each physician whoplays an active role in the treatment program. Theservices rendered by each physician shall be distinct,in different disciplines, identifiable, and adequatelydocumented in the records and reports. (Forconsultations, see 99241–99255.)“handling” costs added to the total cost of theitem. Bill using procedure code 99070.Following the effective date of the 2020 DurableMedical Equipment Fee Schedule, all durablemedical equipment supplied shall be billed andpaid using the 2020 Durable Medical EquipmentFee Schedule. The 2020 Durable MedicalEquipment Fee Schedule is/will be available onthe Board’s website. Any item identified asrequiring prior authorization in the 2020 DurableMedical Equipment Fee Schedule or not listed inthe 2020 Durable Medical Equipment FeeSchedule may not be billed without such priorauthorization.Do not bill for or report supplies that arecustomarily included in surgical packages, suchas gauze, sponges, Steri-strips, and dressings;drug screening supplies; and hot and cold packs.These items are included in the fee for themedical services in which such supplies are used.5.7.8.Concurrent CareWhen more than one physician treats a patient for thesame condition during the same period of time,payment is made only to one physician, the onewhose specialty is most relevant to the diagnosis. Forexample, if claims are received from both acardiologist and a general practitioner for thetreatment of a heart condition, or from both anorthopedist and a surgeon for the treatment of a backdisorder, payment is due only to the cardiologist andorthopedist, respectively. Where the concurrent careinvolves overlapping or common services, the feespayable shall not be increased but prorated. Eachphysician shall submit separate bills but indicate ifagreement has been reached on the proration. If noagreement between or among the physicians has beenreached, the matter shall be referred to the MedicalArbitration Committee per Section 13-g of theWorkers’ Compensation Law.12Proration of Scheduled Relative Value Unit FeeWhen the schedule specifies a relative value unit feefor a definite treatment with an inclusive period ofaftercare (follow-up days), and the patient istransferred from one physician to another physician,the employer (or carrier) is only responsible for thetotal amount listed in the schedule. Such amount is tobe apportioned between the physicians. If theconcerned physicians agree to the amounts to beprorated to each, they shall render separate billsaccordingly. If no proration agreement is reached bythem, the amounts payable to each party shall besettled by an arbitration committee appointedpursuant to Section 13-g of the Workers’Compensation Law, without cost to the contestants.When treatment is terminated by the departure of thepatient from New York State before the expiration ofthe stated period of follow-up days, the fee shall bethe portion of the appropriate fee having regard forthe fact that usually the greater portion is earned atthe time of the original operation or service. Whentreatment is terminated by the death of the patientbefore the expiration of follow-up days, the full fee ispayable, subject to proration where applicable.Separate ProceduresCertain procedures are an inherent portion of aprocedure or service and, as such, do not warrant aseparate charge. For example: multiple muscle strains,such as cervical and lumbar areas, extremity, etc.,when treated by other than a specific descriptor listedin the Surgery section will be considered as an entityand not carry cumulative and/or additional charges;that is, the appropriate level of service for office,hospital, or home visits will apply. When such aprocedure is carried out as a separate entity notimmediately related to other services, the indicatedvalue for “separate procedure” is applicable. See alsoSurgery Ground Rule 7.6.Alternating PhysiciansWhen physicians of similar skills alternate in the careof a patient (e.g., partners, groups, or same facilitycovering for another physician on weekends orvacation periods), each physician shall billindividually for the services each personally renderedand in accordance with the Medical Fee Schedule.9.Home VisitsThe necessity for such visits is infrequent in casescovered by the Workers’ Compensation Law. Whennecessary, a statement setting forth the medicalindications justifying such visits shall be submitted.Please refer to the Evaluation and Managementsection for coding of these services.10.Medical TestimonyAs provided in Part 301 of the Workers’Compensation regulations and following direction bythe Board, whenever the attendance of the injuredemployee’s treating or consultant physician orCPT only 2017 American Medical Association. All Rights Reserved.Revised printing effective 1/1/2020
New York State Workers’ Compensation Medical Fee ScheduleIntroduction and General Guidelinespodiatrist is required at a hearing or deposition, suchphysician or podiatrist shall be entitled to anattendance fee of 450. Fees for testimony shall bebilled following a direction by the Board as to the feeamount using code 99075.As provided in Part 301 of the Workers’Compensation regulations and following direction bythe Board, whenever the attendance of the injuredemployee’s treating or consultant chiropractor,psychologist, nurse practitioner, or licensed clinicalsocial worker is required at a hearing or deposition,such provider shall be entitled to an attendance fee of 350. Fees for testimony shall be billed following adirection by the Board as to the fee amount usingcode 99075.11.Ground Rules for Physician Assistants (PA) andNurse Practitioners (NP)Authorized Nurse Practitioners who render care andtreatment in accordance with their scope of
The State of New York has revised the Official New York State Workers' Compensation Medical Fee Schedule effective January 1, 2020. The enclosed pages will update the 2018 edition (effective April 1, 2019) with the updates effective January 1, 2020. The new Official New York State Workers' Comp ensation Acupuncture and Physical &
