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This summary sets forth various workers' compensation regulations regarding outpatient physical therapy services in Ohio.
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:
Bureau of Workers' Compensation (BWC)
Contact Information:
Ohio BWC contacts
Live support (chat) 7:30 am–5:30 pm, ET, excluding holidays
News & Updates:
Subscribe to Provider listserv
Other:
Medical Providers page
BWC Medical Guide
Fee schedule lookup
Medical prior authorization requirements
Use Billing and Reimbursement Manual
Vocational Rehabilitation Services
Ohio has established Special Codes for Ergonomic Implementation (W0513), Ergonomic Study (W0644), Job Analysis (W0645), Transitional Work Services (W0637), Occupational Rehabilitation - Comprehensive, (Work Hardening) initial two (2) hour daily session (W0702), each additional hour (W0703); Other Provider Travel Time (W3050, Z3050), Other Provider Mileage (W3052, Z3052), Work Conditioning (W0710)
Therapy Regulations
| Question | Response | Detail | Citation |
| What is the basis of the fee schedule for outpatient therapy services? | RBRVS | "RBRVS is a nationally accepted medical provider reimbursement methodology. BWC uses RBRVS in its calculation of its provider fee schedule." | www.ohiobwc.com/basics//guidedtour/generalinfo/provglossbrm.asp |
| Are there limits on the number of physical therapy visits allowed? | Yes | All nonemergent treatment requires prior authorization; except - 12 visits in 60 days under presumptive authorization policy for MCOs | www.ohiobwc.com/downloads/blankpdf/OAC4123-6-16.2.pdf www.ohiobwc.com/provider/services/authrequirements/default.asp |
| Are there limits on payment per visit for outpatient therapy services? | Yes | Multiple procedure payment reduction applies to physical medicine section of professional services fee schedule (select view, download and print fee schedule) OAC 4123-6-37.2 |
https://info.bwc.ohio.gov/for-providers/fee-schedules |
| Do regulations require use of treatment guidelines? | Yes | Official Disability Guidelines for MCOs The following rules indicate treatment guidelines may be used. OAC 4123-6-16.1, OAC 4123-6-25. The provider billing and reimbursement manual, Chapter 1 outlines that BWC uses ODG guidelines. |
https://www.bwc.ohio.gov/downloads/blankpdf/BRMChapter1.pdf Pages 1-17 |
| Is a referral required in order to see a physical therapist? | Yes | 4123-6-16.2 Medical treatment reimbursement requests, subsection E | www.ohiobwc.com/downloads/blankpdf/OAC4123-6-16.2.pdf |
| Can outpatient fees be negotiated above or below the fee schedule? 1 | Yes + / - | MCO can contract with providers in or out of the MCO | www.ohiobwc.com/downloads/blankpdf/OAC4123-6-08.pdf |
| Can the injured worker be charged for any claim-related services? | No | An IW cannot be balanced billed or charged a co-pay for authorized services. | https://info.bwc.ohio.gov/ |
| Are there workers' compensation regulations about who can provide services under the direction and supervision of a physical therapist? | Yes | BWC would rely on the physical therapist’s license and scope of practice as well as the license/certification/scope of practice for the individual being supervised by the PT, however, BWC requires direct supervision of any provider who cannot be directly enrolled with BWC. As an example, a PT-A providing care to BWC IWs must be directly supervised. Direct supervision means that the supervisor is present with the PT-A at all times, as opposed to being available in the suite, etc., which is general supervision. Add the following to citation as CHAPTER 2 (ohio.gov) of the Provider Billing and Reimbursement Manual pages 2-6 under non-covered providers. | https://www.bwc.ohio.gov/downloads/blankpdf/BRMChapter2.pdf |
| Are there provider network and/or managed care regulations in place? | Yes | ORC 4121.44/441/442/446; OAC 4123-6 | http://codes.ohio.gov/orc/4121 http://codes.ohio.gov/oac/4123-6 |
| Are there regulations that address which fee schedule applies if an injured worker from this state seeks treatment in another state? | Yes | OAC 4123-6-10 Rule 4123-6-10 - Ohio Administrative Code. An IW may not be able to seek treatment from another state if the provider is not-BWC certified and the treatment is otherwise available within a reasonable distance from the IW by a BWC-certified provider. If the fee schedule for care is higher in another states, BWC considers this a request for a negotiated rate, which would be discussed with the MCO. OAC 4123-6-10 should be reviewed which describes the situations when a payment can be negotiated | https://www.bwc.ohio.gov/downloads/blankpdf/BRMChapter1.pdf |
| Are there regulations regarding Functional Capacity Evaluations (FCEs)? | Yes |
Refer to policy PAYMENT FOR FUNCTIONAL CAPACITY EVALUATION SERVICES…… BRM-29 in New/Revised/Updated Policies in BWC’s Provider Billing and Reimbursement Manual Occupationally-focused FCEs are reimbursed for up to one hour of non-face-to-face time and at a higher reimbursement rate than treatment-focused FCEs. |
https://info.bwc.ohio.gov/static/Providers/BRMNewRevisedUpdatedPolicies.pdf |
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 - No
Self-insured Employers or Groups - Yes
Competitive State Fund - No
Exclusive State Fund - Yes
State Comp Fund (last resort) - No