13 Fla. L. Weekly Supp. 375b
Insurance — Personal injury protection — Coverage — Medical expenses — Re-read and interpretation of diagnostic studies — Unbundling from office visit — Where re-reading and interpreting diagnostic studies is not included in office visit CPT code and not included in levels of evaluation and management services, medical provider did not unbundle CPT codes for re-reading and interpreting MRI and x-rays from office visit code — CPT guidelines pertaining to re-reading and interpreting diagnostic studies do not restrict medical provider from billing for re-reading and interpreting studies ordered by another provider
GARY H. DIBLASIO, M.D., P.A., Plaintiff, vs. PROGRESSIVE AUTO PRO INSURANCE COMPANY, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County. Case No. 50-2005-SC-007325-XXXX-SB. January 9, 2006. Debra Moses-Stephens, Judge. Counsel: Glenn E. Siegel, Boca Raton. Joseph Murasko, North Palm Beach. Tammy Dembo, Tampa.
ORDER GRANTING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT
This action was heard on December 16, 2005 on Plaintiff’s Motion for Partial Summary Judgment regarding Defendant, Progressive Auto Pro 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 2005. 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 Ronneshia Harris (HARRIS), who was involved in an automobile accident on May 1, 2004.
2. At issue in this Motion for Partial Summary Judgment, DIBLASIO billed the following CPT codes and amounts for services performed to HARRIS on February 21, 2005:
a. 72141 with a -26 modifier for a review of a previously taken MRI of the cervical spine, in the amount of $75.00;
b. 72040 with a -26 modifier for his review of previously taken x-ray films of the cervical spine, in the amount of $50.00;
c. 72100 with a -26 modifier for his review of previously taken x-rays of the lumbar spine, in the amount of $50.00.
3. PROGRESSIVE denied the above-referenced codes billed for DIBLASIO’S re-reading and interpretation of the previously taken cervical spine 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 cervical spine MRI was initially performed by Glades General Hospital on July 21, 2004. The cervical and lumbar x-rays were also initially performed by Glades General Hospital on May 26, 2004. 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 May 1, 2004 automobile accident involving HARRIS, that the bills were timely submitted and were reasonable in amount.
5. PROGRESSIVE filed affidavits of Michael Zeide, M.D. and Robert Grant who opined that DIBLASIO’S re-reading and analysis of the previously taken cervical MRI, as well as the cervical and lumbar x-rays are included within DIBLASIO’S initial office visit, CPT code 99205 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 2005, 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. (emphasis added).
3. Under the heading “Office or Other Outpatient Consultations New or Established Patient,” The American Medical Association Current Procedural Terminology (CPT) for 2005 provides as follows for CPT code 99205:
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 cervical 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 Glades General Hospital. 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 72141, 72040 and 72100 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 $350.00 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.
8. In opposition to the “Levels of E/M Services”, (evaluation and management), The American Medical Association Current Procedural Terminology (CPT) referenced above, PROGRESSIVE has provided the CPT Assistant from October 1997, Volume 7, Issue 10, which notes that the clause:
“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 [only] refers to the instance where a physician provides the initial interpretation of the film and prepares a separate distinctly identifiable signed written report.”
9.The Plaintiff argues that this publication is hearsay and provides someone’s interpretation of this clause for the truth of the matter asserted, and is therefore inadmissible. The Plaintiff also argue that this publication from 1997 is nearly nine years old, while the CPT guidelines provided by the American Medical Association regarding this issue has remained unchanged. Since this provision in the CPT manual is clear and unambiguous in its face, this Court will not go beyond its express terms. See Holly, M.D. v. Albert W. Auld, M.D. and Rosomoff, M.D. v. Albert W. Auld, M.D., 450 So.2d 217 (Fla. 1984); Young v. State of Florida, 678 So.2d 427 (Fla. 4th DCA 1996). The Court agrees with the Plaintiff’s position.
C. COURT’S FINDINGS
1. The Court agrees with the Plaintiff in that The American Medical Association Current Procedural Terminology (CPT) for 2005 does not say that the reading and interpretation of the MRI and x-ray films is included within CPT Code 99205. 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 72141 -26, 72040 -26 and 72100 -26 from the 99205 E/M service CPT code billed for date of service February 21, 2005. 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 and unsubstantiated CPT assistant newsletter 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.
3. Furthermore, the Court finds that with respect to the Current Procedural Terminology (CPT) guidelines pertaining to the re-read and interpretation of diagnostic studies noted above in this Order under paragraph B2 (Law, Analysis, and Allegations Made by the Parties), the phrase “ordered during a patient encounter” does not restrict the billing for the interpretation of diagnostic test(s) only to the physician who ordered such studies. In this case, DIBLASIO performed an interpretation of diagnostic tests that were previously ordered by different physicians who prepared reports interpreting such. DIBLASIO subsequently reported his findings separately with the modifier -26, and therefore complied with the CPT guidelines.
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 72141 with a 26 modifier, 72040 with a 26 modifier, and 72100 with a 26 modifier.
The Court reserves jurisdiction to award attorneys fees and costs in favor of the Plaintiff upon a proper Motion filed by the Plaintiff.
* * *
