Analysis based on the September 2 New York State Register, the Workers’ Compensation Board’s revised medical fee-schedule proposal, draft rule text, proposed PT/OT schedule, ground-rule comparison, public-comment assessment, and current OT billing guidance.
New York’s next workers’ compensation fee schedule is taking shape around a careful trade: clearer operating rules for occupational therapy, with the old payment math largely intact. A revised proposal published in the September 2 State Register would write the occupational therapy assistant billing pathway into regulation, require fuller narrative documentation, sharpen prior-authorization instructions, and refresh the schedule’s coding references. The regional conversion factors used to turn OT relative value units into dollars would remain unchanged. The Workers’ Compensation Board has also left the effective date blank, so practices have a proposal to study and comment on rather than a new schedule to use today.
In brief
- The revised proposal entered the State Register on September 2. The Board says it will accept comments for 45 days after publication, and the draft schedule still lists its effective date as “TBD.”
- The proposed rule would require OTA services to be furnished under direct supervision, billed by the Board-authorized OT with modifier CO, and paid at 85% of the OT amount. OTA notes would require the supervising OT’s signature.
- The proposed PT/OT conversion factors remain $7.69 in Regions I and II, $8.79 in Region III, and $9.55 in Region IV. The Board declined to add a general inflation or cost-of-living adjustment in this revision.
The revision moves the rule forward without setting a start date
The Board first published this fee-schedule package in January. After receiving approximately 83 comments, it issued a revised proposal dated August 21 and placed the notice in the September 2 State Register. The agency says comments will be accepted for 45 days after that publication. Counting calendar days places the 45th day on October 17, though the Board’s page describes the period rather than posting a separate deadline date. Comments go to regulations@wcb.ny.gov.
The revision remains one step short of adoption. Every proposed schedule page carries “Effective TBD,” and the regulatory impact statement says the changes would take effect only when a Notice of Adoption is published in the State Register. A clinic should not load the draft fees or ground rules into production billing simply because the documents are now public.
The response to comments is unusually direct on payment. Providers asked for broader increases tied to inflation and the cost of living. The Board made no change to the conversion factors and included no across-the-board cost-of-living adjustment. It describes this package as the first of several intended updates and says later proposals may revisit areas where fees lag.
The proposal writes the OTA billing lane into the rule text
For OT teams, the most consequential language concerns assistants. The proposal says an OTA may provide services under the direct supervision of a Board-authorized occupational therapist. The authorized OT would select a permissible code within the OTA’s scope, append modifier CO, and submit the bill. Payment would be 85% of the amount payable if the OT had furnished the service directly.
The supervision relationship remains visible in the record. OTA clinical notes would need the supervising OT’s cosignature, and an OTA could neither bill independently nor perform a functional capacity evaluation. The proposal also preserves the daily relative-value limits. When an OT and OTA both furnish services on the same date, the OT’s services take priority within that ceiling.
The Board’s current provider pages already describe this operating model: OTAs may treat under an authorized OT’s direction and supervision, and the supervising OT bills with CO at 85%. The proposal matters because it places those terms in the regulation and the incorporated fee schedule. It does not create independent OTA practice or widen the assistant’s state-law scope.
The regional payment math survives intact
The draft retains a physical-medicine conversion factor of $7.69 for Regions I and II, $8.79 for Region III, and $9.55 for Region IV. Those figures are multiplied by a code’s relative value unless the schedule provides a different method. The proposed appendix shows the three OT evaluation codes 97165 through 97167 at 9.47 relative value units and re-evaluation code 97168 at 4.00, with no value change from the 2020 schedule.
That makes the revision operationally important without producing the rate reset many providers requested. A practice modeling the proposal should separate three questions: whether a code remains available, whether its relative value changes, and whether the regional conversion factor changes. A new symbol, description, or modifier instruction does not automatically produce a higher allowed amount.
The same discipline applies to the Board’s estimate of a low-single-digit systemwide cost increase. The regulatory impact statement says the package principally raises selected evaluation-and-management fees, especially in shortage or historically low-paid areas. That estimate covers the full collection of medical schedules. It should not be read as a projected 2% to 3% increase for occupational therapy.
Narrative documentation becomes a ground rule
The proposed PT/OT schedule replaces a short electronic-report instruction with a detailed narrative-report rule. A narrative would accompany every service and place work status in a highly visible location. The record should also include the injury or illness history, objective findings, plan of care, diagnosis or assessment, an explanation of ordered equipment or procedures, and the time used when a code depends on time or needs support for a higher level of billing.
New York’s current OT guidance supplies an important profession-specific boundary. OTs must use the CMS-1500 with a medical narrative and may report whether the patient is working, yet the Board says an OT may not offer the causation opinion or temporary-impairment percentage reserved to other authorized provider types. An EHR template should make the required OT information prominent without inviting clinicians to complete fields outside their role.
Prior authorization receives similar attention. Care that correctly follows an applicable Medical Treatment Guideline generally does not need prior authorization unless another law, rule, or fee-schedule provision requires it. Treatment outside or beyond the guidelines needs an approved variance. Unlisted, miscellaneous, and by-report items carry added documentation and authorization duties, including a comparable code or manufacturer invoice where applicable.
Use the comment window to test the workflow
A useful review starts with the assistant pathway. Identify every service currently furnished by an OTA for a workers’ compensation claimant, confirm the supervising OT’s Board authorization, test the CO modifier and 85% pricing logic, and verify that the daily relative-value ceiling cannot be exceeded when both clinicians treat on the same date. Check that OTA notes route to the OT for timely cosignature and that functional capacity evaluations remain limited to qualified licensed providers.
Next, compare the proposed narrative rule with the actual CMS-1500 attachment produced by the record system. Work status, timed-code minutes, objective findings, plan of care, ordered equipment, and authorization identifiers should survive the trip from the clinical note to the electronic submission partner. Run the exercise on a real de-identified claim instead of judging the template from an empty screen.
Comments will be more useful if they show the Board where the draft succeeds or fails in practice: the service, region, code, staff time, current allowed amount, proposed result, access consequence, and a workable alternative. Until adoption arrives, keep the draft beside the current rules rather than in place of them. The proposal’s central message for OT is clear enough already: cleaner billing rules are coming first, while the larger reimbursement argument continues.