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White Paper—New York Fee Schedule Analysis for the Industry

—July 24, 2013
White Paper—New York Fee Schedule Analysis for the Industry

An impact analysis of the New York Automobile Medical Fee schedule update of December 1, 2010 on the New York automobile insurance industry was completed by Mitchell ClaimsLab.

Background

The New York Automobile Insurance medical fee schedule (Regulation 83) is based on the New York Workers’ Compensation medical fee schedule. Effective December 1, 2010, the Chairman of the Workers’ Compensation Board adopted regulations that expanded the procedure codes available to chiropractors. The expansion of the chiropractic code set was necessary for the implementation of workers’ compensation treatment guidelines. While the automobile insurance medical fee schedule is based on the fees and ground rules of the Workers’ Compensation fee schedule, it does not incorporate the treatment guidelines.

Historically, chiropractors were limited to 99213 (evaluation & management) to describe the chiropractic and physical medicine services they provided their patients. Subsequent to December 1, 2010, chiropractors were allowed to unbundle the services they provide to patients through the use of chiropractic manipulation and physical medicine procedure codes.

In June 2011, Mitchell ClaimsLab analyzed 35,000 New York Personal Injury (PIP) Claims that received chiropractic treatment with dates of service between December 2009 and May 2011. Mitchell examined bills presented by chiropractors before and after the effective date of the new fee schedule and projected the average chiropractic charge per visit would increase by 58% from $31 to $49 per visit while the allowed amount per visit would increase 17% from $23 to $27 per visit. Interestingly, Mitchell ClaimsLab projected the increase in chiropractic charge per visit for Regions 1, 2 and 3 (52%, 58%, & 74%, respectively) to be greater than those found in Region 4 (45%). Additionally, the projected increase in chiropractic allowed amounts per visit for Regions 1, 2 &3 (15.1%, 18.9% & 19.5%, respectively) were greater than region 4 (14.5%).

Table 1. Summary of New York claims data for chiropractic services before and after the December 1, 2010 fee schedule update as reported June 2011.

It has been two years since the New York automobile medical fee schedule was updated. With an abundance of pre and post fee schedule data available, Mitchell ClaimsLab decided to take another look at the treatment and associated cost of services rendered by chiropractors in the state of New York and the impact made by the fee schedule.

Results

Mitchell ClaimsLab analyzed nearly 20,000 New York Personal Injury (PIP) Claims that received chiropractic treatment in the state of New York. The treatments associated with these claims were divided into two categories, before and after fee schedule update, based on date of service.

Upon examining the bill lines with an allowed amount greater than zero and procedure codes specific to chiropractic manipulative therapy (CMT), physical medicine and evaluation and management services (selected services) rendered by chiropractors, it was determined that the average charge per visit increased 36% from $34 to $46 while the allowed amount per visit increased 18% from $33 to $39. The 18% increase in allowed per visit was slightly higher than originally reported but still better than what it could have been. A 37% increase in allowed amount per visit might have occurred if all chiropractors billed and received payment equal to the daily treatment cap.

Just as reported back in June 2011, the increase in chiropractic charge per visit for the selected services in Regions 1, 2 and 3 (53%, 45% & 65%, respectively) were greater than those found in Region 4 (34%) and the increase in chiropractic allowed amounts per visit for Regions 1, 2 & 3 (22%, 26% & 28%, respectively) were greater than region 4 (18%).

Table 2. Current summary of New York claims data for selected chiropractic services before and after the implementation of the new Fee Schedule.

The fee schedule update brought about some expected changes in provider billing habits along with some unexpected changes. It was easy to anticipate a dramatic increase in chiropractic manipulative therapy and physical medicine services with a corresponding decrease in the evaluation and management code previously used by chiropractors to represent all services rendered on a given date of service (Graph 1). It was a little more challenging to predict which physical medicine services chiropractors would use to complement their chiropractic manipulations. The data collected since the fee schedule update reveals that chiropractors have focused on hot packs and massage therapy. Each of these services represents 23% (combined 46%) of all physical medicine units experienced in New York since the fee schedule update (Graph 2). These procedure codes, when billed in combination with chiropractic manipulation of 3-4 regions (98941) on a single date of service, represent the second and third most frequently encountered procedure code combination billed by chiropractors in New York since the fee schedule update (Graph 3).

Graph 1. Summary of expected billing behavior changes experienced for chiropractic manipulative therapy and evaluation & management services.

Graph 2. Summary of expected billing behavior changes experienced for physical medicine services.

Graph 3. Summary of most frequently encountered procedure code combinations.

The unexpected billing habit changes experienced by the industry remain challenging but several services have experienced dramatic increases in utilization and charge since the fee schedule change. The services seeing increased utilization are range of motion, muscle testing, two limb needle electromyography (EMG) along with pelvic ring and hip manipulation under anesthesia (MUA) (Graph 4). While the total number of units for two limb needle EMG and pelvic ring and hip MUA are relatively small their cost per encounter is very high at approximated $1,700 and $4,200 respectively. When you rank the various procedure code combinations experienced by the industry in New York by total charge two limb needle EMG is number one and MUA is number three (graph 5).

Graph 4. Summary of unexpected billing behavior changes experienced in New York.

Graph 5. Summary of Procedure code combination total charges.

As providers continue to look for ways around the daily treatment cap with unexpected changes in billing behavior, the average allowance per date of service for chiropractors will continue to increase. Since the fee schedule update of December 1, 2010 the industry has experienced an 18% increase in the average amount allowed per date of service for chiropractors. If the average allowed per date of service continues to increase and the industry starts to encounter more chiropractic office visits per claimant an increase in industry cost will quickly replace the flat trend experienced in New York since Q1 2009 (Source: Fast Track PLUS).

In the next phase of this analysis, Mitchell ClaimsLab will look to identify those providers with the greatest impact to claim results brought about by unexpected changes in billing behavior. The goal of this phase is to identify providers and the procedure codes they are using to get around the daily treatment cap. This information will be useful to those interested in developing specific workflow rules to better manage claim outcomes and ensure that only medically necessary treatment is being performed and reimbursed.

Appendix

Graph below demonstrates total charge and allowed amount by quarter for chiropractic providers in New York. Subsequent to the fee schedule update, total charge and allowed steadily decreased and are dramatically lower than projections based on growth rates prior to the fee schedule change.

Total Charged & Total Allowed By Quarter

The fee schedule update allowed chiropractors to unbundle the single procedure the previous fee schedule recognized as chiropractic care (99213) into chiropractic manipulative therapy and physical medicine procedures to more accurate describe the services provided. Chiropractic providers in New York quickly modified their billing practices to comply with the fee schedule update.

Procedure Code Utilization By Quarter
Chiropractic Manipulative Treatment & Office Visit Evaluation

New York chiropractors began to use many physical medicine procedure codes in combination with the chiropractic manipulative therapy. The graph demonstrates how quickly the six most frequently encountered procedure codes were implemented.

Procedure Codes Utilization By Quarter
Modality & Therapeutic Procedure

While the New York Chiropractic fee schedule does not include manipulation under anesthesia, providers continue to bill for these services. While the chiropractic manipulation and physical medicine graphs above demonstrate expected/warranted changes in billing behavior, this graph demonstrates a pattern that is not the result of the fee schedule update. This pattern is more reflective of provider case mix.

Procedure Code Utilization By Quarter
Manipulation Treatment Procedure (Requiring Anesthesia)

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