Fee Schedule in No-Fault Claims

Payment for licensed, freestanding, ambulatory surgery services and hospital-based ambulatory surgery centers in New York will be made according to the EAPG (Enhanced Ambulatory Patient Grouping) payment methodology. Due to the 33rd Amendment of Regulation 86, payment for ambulatory surgery centers in New Jersey may sometimes also be subject to reimbursement based on EAPG. More information about the EAPG Payment Methodology is online here.

The 33rd amendment primarily affects situations where a patient residing in New York receives treatment from an out-of-state medical provider. Prior to the 33rd amendment to Regulation 83, the maximum permissible charge for treatment received outside of New York State was the prevailing fee in the geographic location of the health provider.

The 33rd amendment limits reimbursement to the lowest of:

1. The amount of the fee in the region in New York State that has the highest applicable amount in the fee schedule for that service;
2. The amount charged by the provider; and
3. The prevailing fee in the geographic location of the provider.

This limitation on reimbursement does NOT apply to:

1. Services provided out-of-state that would constitute emergency care;
2. That is provided to a non-resident of New York State: or
3. A New York State resident who, at the time of treatment, is residing in the jurisdiction where the treatment is being rendered for reasons unrelated to the treatment.

Under these three exceptions, reimbursement is at the lower of the amount charged by the provider and the prevailing fee in the geographic location of the provider. If the jurisdiction where the out-of-state provider renders treatment has established a fee schedule for services rendered in connection with motor vehicle-related injuries, the prevailing fee shall be the amount prescribed in that fee schedule for the respective service.

Add-on codes are procedure codes that are always performed in conjunction with a primary procedure. Significantly, add-on codes are NOT subject to the multiple procedure reduction rule (i.e. full reimbursement).

Add-on codes cannot be considered the primary procedure when determining proper reimbursement as by definition add-on codes must be “listed separately in addition to the primary procedure.”

In the CPT Manual, add-on codes are designated by the “+” symbol and generally include code descriptors including phrases such as “each additional” or “list separately in addition to primary procedure.”

In the New York Worker’s Compensation Medical Fee Schedule, add-on codes are designated by the “+” symbol.

In the New Jersey Fee Schedule, add-on codes are designated by the “X” symbol. However, it should be noted that some codes have been designated as add-on codes post-creation of the New Jersey Fee Schedule. Therefore, the New Jersey Fee Schedule guidelines direct you to the CMS website to check for updates. The most updated list of add-on codes can be found here.

The NCCI PTP-associated modifiers are: 24, 25, 27, 57, 58, 59, 78, 79, 91, E1 – E4, FA, F1- F9, LC, LD, LM, LT, RC, RI, RT, T1 – T9, TA. If any of these modifiers are used appropriately, then the NCCI edit denying reimbursement must be bypassed and reimbursement must be allowed for the secondary code.

The list of NCCI edits has these six columns.

• Column 1 indicates the payable code.
• Column 2 contains the code that is not payable with this particular Column 1 code unless a modifier is permitted and submitted.
• Column 3 indicates if the edit was in existence prior to 1996.
• Column 4 indicates the effective date of the edit.
• Column 5 indicates the deletion date of the edit (if applicable).
• Column 6 indicates if use of a modifier is permitted.

The number in column six will either be 0, 1, or 9. The number “0” in column 6 means there are no modifiers allowed to bypass the edit (i.e. there are no circumstances in which both procedures should be paid for the same patient on the same day by the same provider). The number “1” in column 6 means a modifier is allowed to bypass the NCCI edit and permit reimbursement for the column 2 code. The number 9 means that an NCCI edit does not apply to this code pair; the edit for this code pair was deleted retroactively. For further explanation, click here.

The NCCI edits were created by the Centers for Medicare and Medicaid Services (CMS) in order to reduce improper coding. NCCI consists of two different types of edits: (1) procedure-to-procedure (PTP) edits, known as “NCCI edits;” and (2) units-of-service (UOS) edits, known as Medically Unlikely Edits (MUE).

The PTP edits (NCCI edits) define pairs of HCPCS (Healthcare Common Procedure Coding System) and CPT codes that are in “conflict” and should not be reported together. If two codes in conflict are billed together, payment for one of the two codes might be inappropriate.

In some cases, the conflict may be overcome to permit payment by applying a proper modifier to the billed code(s), such as modifier 59. The UOS edits (MUE) define codes that contain a maximum allowable number of units of service by the same provider, for the same patient, on the same date of service, and on the same claim line. There are six different categories of NCCI edits:

1. PTP edits for practitioner and ASC services.
2. PTP edits for outpatient hospital services.
3. PTP edits for DME.
4. MUEs for practitioner and ASC services.
5. MUEs for outpatient hospital services.
6. MUEs for DME.

The NCCI Edits can be accessed here.

The maximum fee is based on the Average Wholesale Price (AWP) found in the most current prescription Red Book or Medi‐Span database. The pharmacy fee schedule uses a reimbursement price of the AWP, minus 12 percent for brand name drugs plus a $4 dispensing fee. The reimbursement price for generic drugs is AWP, minus 20 percent, plus a $5 dispensing fee.

In situations where New Jersey-based ASCs or hospitals must bill in accordance with the EAPG payment methodology (e.g. the injured patient was a New York resident), reimbursement is calculated in similar fashion to New York-based ASCs and hospitals.

Rates of payment for out-of-state providers in counties contiguous to New York City and New York’s Dutchess, Putnam, Westchester, Rockland and Orange counties will reflect the average APG payment for the same services applicable to New York State providers in those downstate areas.

Out-of-state counties contiguous to the downstate rate region include Sussex, Passaic, Bergin, Hudson, Essex, Middlesex, Union and Monmouth Counties in New Jersey; Pike County in Pennsylvania; and Litchfield and Fairfield Counties in Connecticut.

Rates of payment for all other out-of-state providers will reflect the average APG payment for the same services applicable to providers in upstate New York.

Performing EAPG calculations manually requires that you look up the assigned APG group for the billed code. You must then look up the APG “base weight” for that APG group and multiply that number by the “weight multiplier.” Next, multiply the sum of that number by the established “base rate” for that region, then add the capital add-on fee.

In summary:

APG Group –> Base Weight  X  Weight Multiplier  X  Base Rate + Capital Add-on = Final APG Payment

For further explanation, see page 9-10 of the APG Provider Manual. Additionally, numerous other factors must be considered in determining proper reimbursement amounts. See APG Provider Manual.

EAPG calculations may be done through the 3M coding software or manually. To purchase the 3M software, call (518) 426-4315 or visit 3M.com.

Bills for New York physicians are reimbursed in accordance with the New York Workers’ Compensation Board (WCB) Medical Fee Schedule. New York-based Ambulatory Surgery Centers (ASCs) are reimbursed in accordance with the EAPG (Enhanced Ambulatory Patient Grouping) payment methodology.

Durable Medical Equipment providers (DME) in New York are reimbursed in accordance with the New York DME fee schedule. New Jersey physicians and ASCs are both reimbursed in accordance with the New Jersey fee schedule. If medical providers underbill for their services, that practice limits their reimbursements. The reason: providers cannot receive reimbursements that are greater than the amounts they bill.

The DME Fee Schedule is available online free of charge here.

The New Jersey Fee Schedule Text is available online free of charge here.

The New Jersey Physicians’ and ASC Fee Schedule is available online free of charge here.

The new fee schedule can be purchased from Optum360 for $100 here.

The latest New York WCB Medical Fee Schedule took effect on October 1, 2020, for purposes of no-fault claims. The latest Fee Schedule only applies to health services provided on or after October 1, 2020. If a claim contains dates of service which are both prior to and after October 1, 2020, the portion of the claim incurred prior to that date will not be subject to the amendment.

The new WCB Medical Fee Schedule has new rates for many codes, as the RVU amounts and conversion factors have changed. Overall, the new rates provide a 5 percent increase in reimbursement.

The latest Fee Schedule also has these changes:

• Chiropractors may no longer bill outside their section. As a result, Manipulation Under Anesthesia (MUA) performed by chiropractors will no longer be reimbursed. CPT codes for electrodiagnostic testing contained within the chiropractic section will still be billable at a reduced rate of reimbursement.
• As of October 1, 2020, range of motion testing, muscle testing, unlisted neurological testing and physical performance testing (in the Chiropractic fee schedule), will not be reimbursed for any provider.
• Imaging studies taken within seven 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, will be subject to reduction.

The Workers’ Compensation Board Press Release about the Fee Schedule can be found here.

Find the CPT code for the specific type of service. CPT codes, or Current Procedural Terminology codes, are numbers assigned to every task and service a medical practitioner may provide to a patient. Check the Relative Value Unit (RVU) listed. You then take the RVU number and multiply it by the “conversion factor” listed for that general type of medical service within that region.

In summary, multiply the RVU by the conversion factor to calculate appropriate fees. Note that numerous “Ground Rules” that are listed in the WCB Fee Schedule must also be accounted for.

According to the NYS Dept. of Financial Services, copies of the New York Workers’ Compensation Board Medical Fee Schedule may be purchased from OptumInsight in one of these ways:

• In writing: Send your request to this address: Official New York Workers’ Compensation Medical Fee Schedule, PO Box 88050, Chicago, IL 60680-9920. The price for a hard copy is $100.
• By telephone: call 1-800-464-3649 (option #1).
• Online: Visit this link: New York Workers’ Compensation Medical Fee Schedule.

If an insurance carrier only provides partial payment for your no-fault bills, you may pursue an arbitration or litigation action against them to recover the remainder owed on those bills. In such cases, The Tadchiev Law Firm, P.C., can supply affidavits from Certified Professional Coders (CPC) to ensure its clients receive proper reimbursement for their no-fault claims. Our legal team is knowledgeable on fee-schedule matters has experience in successfully resolving disputes about medical billing.