By using this site, you are consenting to our use of cookies. To find out more visit our privacy policy.
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:
Department of Industrial Relations, Division of Workers'Compensation
Contact Information:
California WC Contact
News & Updates:
California WC
home (Scroll down to "What’s New")
Subscribe to DWCNewsline by sending name, e-mail and telephone to DWCNewsline@dir.ca.gov
Other:
Medical Provider Page
Official Medical Fee Schedule
(OMFS)
Code
of Regulations, Title 8, Chapter 4.5 Article 5.3 - OFMS
Therapy Regulations
| Question | Response | Detail | Citation |
| What is the conversion factor for outpatient therapy services? | $6.15 | http://www.dir.ca.gov/dwc/dwcpropregs/OMFS_TableA9789.11(c)_Final.pdf | |
| What is the basis of the fee schedule for outpatient therapy services? | State Relative Value | California Relative Value studies, 1974, many based on 30 minute units | |
| Are there limits on the number of physical therapy visits allowed? | Yes | 24 visits per injury (not per body part); additional PT allowed for post-surgical treatment, # of visits varies depending on surgery. The 24 visit limit can be exceeded if deemed medically necessary by employer/payer; frequently this 24 visit limit is allowed to be extended for complex injuries or chronic pain conditions. | http://www.dir.ca.gov/dwc/MTUS/MTUS_FAQs.html |
| Are there limits on payment per visit for outpatient therapy services? | Yes | Uses 1994 CPT codes + CA specific codes. Cascade 100/75/50/25 California OMFS: 98770=brief eval (4.0 RV) 98771=limited eval (6.0 RV) 98772=intermediate eval (7.8 RV) 98773=extended eval (11.3 RV) 98774=comprehensive eval (15.0 RV); Unable to bill for more than 2 procedures, each code is 30 minutes, for a max of 60 minute; can bill for an additional 2 modalities codes however. 3rd highest modality paid at 50% of maximum value. 4th highest modality paid at 25% of maximum value |
GENERAL INFORMATION AND INSTRUCTIONS 8 CCR § 9789.11(a)(1) |
| Do regulations require use of treatment guidelines? | Yes | ACOEM Guidelines, and guidelines documented in Medical Treatment Utilization Schedule | http://www.dir.ca.gov/dwc/DWCPropRegs/MTUS_Regulations/MTUS_Regulations.html |
| Is a referral required in order to see a physical therapist? | Yes | PT never recognized as a primary treating provider (PTP). Physical therapy treatment requires a referral from PTP or treating surgeon (California Code of Regulations, Title 8, Section 9789.10. Physician Services -- Definitions {j}). Subject to pre-authorization for all treatment. | http://www.dir.ca.gov/t8/9789_10.html |
| Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes - | California OMFS sets maximum payment for each CPT code; some codes do not have RV and are “relative value not established”; fee is negotiated with the payer (e.g., FCE, work conditioning, worksite assessment.) | California Official Medical Fee Schedule |
| Can the injured worker be charged for any claim-related services? | No | ||
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No | ||
| Are there provider network and/or managed care regulations in place? | Yes | Physician providers must be part of an MPN (Medical provider Network) established by the employer/payer. As of 3/2012, physical therapists are not included in MPNs. An MPN physician may refer the patient to any physical therapist. | California Labor Code Section 4616-4616.7 CA Code of Regulations: Title 8, Chapter 4.5, Subchapter 1, Article 3.5 Medical Provider Networks Medical provider networks website: http://www.dir.ca.gov/dwc/mpn/dwc_mpn_main.html |
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | No | The California fee schedule applies to all patients covered within the California WC system despite receiving treatment in a different state. | |
| Are there regulations regarding Functional Capacity Evaluations (FCEs)? | Yes | Procedure code 97670 paid by report; prior authorization is recommended |
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