13 Fla. L. Weekly Supp. 179a
Insurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Insurer improperly denied payment for re-reading and interpretation of previously taken lumbar MRI and cervical and lumbar x-rays based on insurer’s belief that those charges were built into provider’s initial office visit, CPT code 99245, billed on same date — Applicable American Medical Association Current Procedural Terminology did not say that reading and interpretation of MRI and x-ray films was included within CPT Code 99245 — Actual interpretation of diagnostic tests/studies is not included in levels of evaluation/management services — There is no requirement that physician doing re-read must have ordered diagnostic studies during a patient encounter — Provider’s motion for summary judgment granted
GARY H. DIBLASIO, M.D., P.A. (Cheryl Baumann), Plaintiff, vs. Progressive Express Insurance Company, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 50-2004-SC-7775-SB-RD. July 15, 2005. Debra Moses-Stephens, Judge. Counsel: Glenn E. Siegel, Boca Raton. Joseph Murasko, North Palm Beach.
AFFIRMED at 14 Fla. L. Weekly Supp. 1027a
ORDER GRANTING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT
This action was heard on June 10, 2005 on Plaintiff’s Motion for Partial Summary Judgment regarding Defendant, Progressive Express Insurance Company’s (PROGRESSIVE) denial of the Plaintiff’s medical bills and separate billing for the re-reading and analysis of x-ray and MRI films, and this Court, having reviewed the affidavits filed, Florida Statute §627.736(5) and the American Medical Association Current Procedural Terminology (CPT) for 2004. Upon consideration, and after hearing argument by counsel for the parties and being otherwise fully advised in the premises, the Court finds as follows:
A. The undisputed facts of this case show:
1. Gary H. DiBlasio, M.D., P.A., (DIBLASIO), filed this action by virtue of an assignment of benefits from the patient Cheryl Baumann (BAUMANN), who was involved in an automobile accident on January 25, 2004.
2. DIBLASIO billed the following CPT codes and amounts for services performed to BAUMANN on March 4, 2004:
a. 72148 with a -26 modifier for his review of previously taken lumbar MRI films, in the amount of $75.00;
b. 72040 with a -26 modifier for his review of previously taken cervical x-ray films, in the amount of $50.00;
c. 72110 with a -26 modifier for his review of previously taken lumbar x-ray films, in the amount of $50.00;
d. 99245 for his initial office visit with BAUMANN, in the amount of $400.00.
3. PROGRESSIVE allowed the full amount of DIBLASIO’S 99245 charge in the amount of $400.00, which is not at issue here. PROGRESSIVE denied the other above-referenced codes billed for DIBLASIO’S re-reading and interpretation of the previously taken lumbar MRI, as well as the cervical and lumbar x-rays. The denial was based on PROGRESSIVE’S belief that those charges are built in to DIBLASIO’S office visit charge. The lumbar MRI and lumbar x-rays were initially performed by Radiology Imaging Associates of Port St. Lucie. The cervical x-rays were initially performed by Frank Giampietro, D.C. It is undisputed that none of these studies were ordered by Dr. DiBlasio.
4. The Plaintiff has filed the affidavit of Gary H. DiBlasio, M.D. that attests that the services performed were medically necessary, related to the January 25, 2004 automobile accident involving BAUMANN, that the bills were timely submitted and were reasonable in amount. The Plaintiff has also filed the affidavits of Mohan Gulatti, M.D. and Craig Lichtblau, M.D. which both attest that all the treatment this patient received from Gary H. DiBlasio, M.D., P.A. was medically necessary, and that all charges for services rendered by Dr. DiBlasio’s office in connection with this patient were reasonable for this area in amount.
5. PROGRESSIVE filed an affidavit of Michael Zeide, M.D. who opined that DIBLASIO’S re-reading and analysis of the previously taken lumbar MRI, aswell as the cervical and lumbar x-rays are included within DIBLASIO’S initial office visit, CPT code 99245 billed on the same date. Further, Dr. Zeide opines that in order for a physician to bill for a re-read of diagnostic films, the physician doing the re-read must have ordered the diagnostic studies during a patient encounter.
B. Law, Analysis, and Allegations Made by the Parties:
1. Florida Statute §627.736(5)(d) requires that “all billings for [medical services rendered] by physicians shall, to the extent applicable, follow the Physicians’ Current Procedural Terminology (CPT) . . . for the year in which services are rendered. . .”
2. Under the heading “Levels of E/M Services”, (evaluation and management), The American Medical Association Current Procedural Terminology (CPT) for 2004, page 2 provides:
The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with the modifier ‘-26′ appended.
3. Under the heading “Office or Other Outpatient Consultations — New or Established Patient,” The American Medical Association Current Procedural Terminology (CPT) for 2004 provides as follows for CPT code 99245:
Office consultation for a new or established patient which requires these three key components:
– a comprehensive history
– a comprehensive examination; and
– medical decision making of high complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity.
Physicians typically spend 80 minutes face-to-face with the patient and/or family.
4. In this case DIBLASIO claims that he followed the CPT guidelines when he billed separately for his re-read and interpretation of the lumbar MRI, the cervical x-rays, and lumbar x-rays with a -26 modifier. These diagnostic tests were initially performed during the patient’s encounter with Radiology Imaging Associates of Port St. Lucie and Frank Giampietro, D.C. DIBLASIO also attached a separate page setting forth his findings as to his review of his reading of the MRI and x-ray films.
5. DIBLASIO alleges that billing a -26 modifier for CPT codes 72148, 72040 and 72110 for the re-read and interpretation of the above-referenced diagnostic studies is not limited to the physician who ordered or referred the patient for these studies. DIBLASIO further claims, and attests to in his affidavit, that he separately reviews these films in order to provide a proper course of treatment under his specialty or area of expertise, Physical Medicine and Rehabilitation.
6. PROGRESSIVE alleges that DIBLASIO unbundled his charges for the reading and interpretation of the MRI and x-ray films referenced above, and should have included these studies within his initial $400.00 office visit charge. Florida Statute §627.736(5)(b)(1)(e) states that “an insurer or insured is not required to pay a claim or charges: for any treatment or service that is upcoded, or that is unbundled when such treatment or services should be unbundled. . .”
7. PROGRESSIVE also claims that DIBLASIO cannot separately bill for his reading and interpretation of the MRI and x-ray films when these studies were not ordered by DIBLASIO.
C. COURT’S FINDINGS
1. The Court agrees with the Plaintiff in that The American Medical Association Current Procedural Terminology (CPT) for 2004 does not say that the reading and interpretation of the MRI and x-ray films is included within CPT Code 99245. Furthermore, the actual interpretation of diagnostic tests/studies is not included in the levels of E/M services. Therefore, DIBLASIO did not unbundle the CPT codes 72148-26, 72040-26 and 72110-26 from the 99245 E/M service CPT code billed for date of service March 4, 2004. The interpretation of these films is also not limited to the doctor who ordered these tests.
2. The Court also finds that the conflicting affidavits filed in this case do not create any genuine issue of material fact because the law pursuant to the Statute and CPT code book is clear on their face, to which DIBLASIO complies.
THEREFORE, Plaintiff’s Motion for Partial Summary Judgment is GRANTED in the amount of $175.00 at 80% = $140.00 plus interest due for CPT codes 72148 with a 26 modifier, 72040 with a 26 modifier, and 72040 with a 26 modifier.
The Court reserves jurisdiction to award attorneys fees and costs in favor of the Plaintiff.
* * *
