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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 Labor and Industrial Relations, Disability Compensation Division
Contact Information:
Hawaii DCD contacts
News & Updates:
N/A
Other:
Administrative Rules and Fee Schedule
See: Chapter 15, Title 12 for rules; Medicare Fee Schedule for fee information
Therapy Regulations
| Question | Response | Detail | Citation |
| Will the new evaluation and reevaluation codes change for workers' compensation claims in 2017? | No. For the time being the codes will not affect motor vehicle and WC payments. | N/A | https://aptahawaii.org/news/cpt-evaluation-codes-changing-january-1-2017 |
| What is the conversion factor for outpatient therapy services? | 110% of Medicare ($33.54 as of 2/28/11) | Chapter 15, Title 12, Exhibit A, Medical Fee Schedule | http://labor.hawaii.gov/dcd/find-a-law/ |
| What is the basis of the fee schedule for outpatient therapy services? | RBRVS | 110% of Medicare per §12-15-90 Workers' compensation medical fee schedule | http://hawaii.gov/labor/dcd/dcd-links/find-a-law |
| Are there limits on the number of physical therapy visits allowed? | Yes | See §12-15-34 Providers of service other than physicians: 20 visits in 60 days post injury; additional 15 in 120 days with approval §12-15-34 Providers of service other than physicians. (a) Frequency and extent of treatment shall not be more than the nature of the injury and the process of a recovery require. Any health care treatment or service performed by a Hawaii licensed or certified provider of service other than a physician shall be directed by the attending physician based on a written prescription signed, dated, and approved by the attending physician. The prescription may authorize up to an initial fifteen treatments of the injury during the first sixty calendar days. For therapists, the prescription may authorize up to an initial twenty treatments of the injury during the first sixty calendar days. | https://labor.hawaii.gov/dcd/files/2012/11/MFS-RULES-WEB.pdf |
| Are there limits on payment per visit for outpatient therapy services? | Yes | Up to 60 minutes and 4 modalities and/or procedures; 90 minutes and 6 mod/proc if there is more than one injury (a second date of injury) per §12-15-34 Providers of service other than physicians (in Chapter 15 of Title 12); Payment for services delivered by PTA discounted to 60% of fee schedule for PT |
http://hawaii.gov/labor/dcd/dcd-links/find-a-law |
| Do regulations require use of treatment guidelines? | No | ||
| Is a referral required in order to see a physical therapist? | Yes | §12-15-34 Providers of service other than physicians. (a) Frequency and extent of treatment shall not be more than the nature of the injury and the process of a recovery require. Any health care treatment or service performed by a Hawaii licensed or certified provider of service other than a physician shall be directed by the attending physician based on a written prescription signed, dated, and approved by the attending physician. | https://labor.hawaii.gov/dcd/files/2012/11/MFS-RULES-WEB.pdf |
| Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes + / - | WCRI report indicates can be negotiated above or below the published rate, but no citation located | Workers' compensation medical cost containment: A national inventory, 2011 (WCRI report WC-11-35, April 2011) |
| 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 | §12-15-36 Physical therapists may have treatment in their discipline carried out by physical therapist assistants...PTA services compensated at 60% of fee schedule | https://labor.hawaii.gov/dcd/files/2012/11/MFS-RULES-WEB.pdf |
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | No | ||
| Are there regulations regarding Functional Capacity Evaluations (FCEs)? | No | ||
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | No |
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) - Yes