15 Fla. L. Weekly Supp. 495b
Insurance — Personal injury protection — Declaratory judgment — Recoding of CPT codes — Where insurer did not make determination that CPT code for unattended electrical stimulation was improperly or incorrectly upcoded or unbundled but, rather, recoded CPT code that Medicare Part B fee schedule does not recognize to synonymous code in HCPCS system recognized by Medicare Part B fee schedule and explained action in explanation of benefits, insurer was not required to contact medical provider before changing code
TRI-COUNTY SPINE INJURY CENTER, INC. f/k/a HOLISTIC HEALTHCARE CLINIC, INC., a Florida Corporation, (a/a/o JUDINE RICHARD), Plaintiff, vs. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County, Civil Division. Case No. 07-06395 COSO 61. March 5, 2008. Arlene J. Simon, Judge. Counsel: Russel Lazega, for Plaintiff. Reuven T. Herssein, Law Offices of Herssein & Herssein PA, North Miami, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FOR FINAL SUMMARY JUDGMENT WITH RESPECTTO COUNT I OF PLAINTIFF’S COMPLAINT SEEKING A DECLARATORY JUDGMENT
THIS CAUSE came before the Court on hearing on February 26, 2008 on Defendant’s Motion for Final Summary Judgment with Respect to Count I of Plaintiff’s Complaint. Count I of the Plaintiff’s Complaint is a Declaratory Action on Defendant’s recoding of CPT Code 97014 to HCPCS Code G0283. The Court, having reviewed the motion, the Court file, legal authorities and having heard argument of counsel, finds as follows:
Factual Background:This is a P.I.P. case where the Plaintiff submitted charges to the Defendant for medical services rendered to the assignor, Judine Richard, from May through July 2006. The bill to the insurer included charges for unattended electrical stimulation, billed as CPT Code 97014.
Upon receipt of the bill, Progressive timely issued an Explanation of Benefits (“E0B”) to the Plaintiff. The EOB’s all indicate that Progressive pays 200% of the Medicare Part B allowable amount for that medical service. For CPT Code 97014 the EOB indicates that the service is reimbursed at the maximum allowable amount of 200% of the Medicare Part B Fee Schedule for HCPCS code G0283.
Count I of the Plaintiff’s Complaint seeks a declaratory judgment alleging that the Defendant acted in violation of Florida Statutes §627.736(5)(b)(1)(e) (2003), by improperly “re-coding” a charge submitted that was neither unbundled or upcoded, without first contacting the provider. The Plaintiff contends that when Progressive switched CPT Code 97014 to HCPCS Code G0283 on its EOB’s, Progressive was in violation of Florida Statutes §627.736(5)(b)(1)(e) (2003). Plaintiff contends that the Defendant was required to contact the Plaintiff provider prior to using HCPCS Code G0283 on its EOB for unattended electrical stimulation.
Defendant seeks final summary judgment as to Count I of Plaintiff’s Complaint, and alleges that Plaintiff’s Declaratory Action is based upon the incorrect portion of the P.I.P. Statute and that Defendant complied with Florida Statute §627.736(4)(b), Florida Statute 627.736(5)(d). Defendant also contends that Florida Statute §627.736(5)(b)(1)(e) is inapplicable in this instance.
Legal Conclusions:
When a provider bills an insurer for medical services, Florida Statute section 627.736(5)(d) states in pertinent part,
. . .All billings for such service rendered by providers shall, to the extent applicable, follow the Physicians’ Current Procedural Terminology (CPT) or Healthcare Correct Procedural Coding System (HCPCS). . .
Thus, according to the PIP Statute, a provider may utilize either one of the coding systems mentioned, the HCPCS system or the CPT coding system, to bill an insurer.
The undisputed record evidence indicates that the American Medical Association (“AMA”) defines CPT Code 97014 as unattended electrical stimulation. The undisputed record evidence also indicates that the AMA defines HCPCS Code G0283 as unattended electrical stimulation. Accordingly, CPT code 97014 and HCPCS Code G0283 are synonymous for the same service — unattended electrical stimulation.
Fla. Stat. §627.736(5)(b)(1)(e) states in pertinent part as follows:
. . . To facilitate prompt payment of lawful services, an insurer may change codes that it determines to have been improperly or incorrectly upcoded or unbundled, and may make payment based on the changed codes, without affecting the right of the provider to dispute the change by the insurer, provided that before doing so, the insurer must contact the health care provider and discuss the reasons for the insurer’s change and the health care provider’s reason for the coding, or make a reasonable good faith effort to do so, as documented in the insurer’s file;
The key portion of Fla. Stat. §627.736(5)(b)(1)(e), the portion that the Plaintiff fails to highlight, is that Fla. Stat. §627.736(5)(b)(1)(e) deals with a situation where an insurer makes a determination that there was an improperly or incorrectly upcoded or unbundled, service.
In this case, the record evidence is clear that Progressive never made a determination of an improper upcode or unbundled service. Progressive simply switched to the HCPCS coding system for that particular medical service because Medicare Part B, while recognizing unattended electrical stimulation as a valid service, does not recognize CPT code 97014. Medicare Part B does, however, recognize HCPCS Code G0283. Because Progressive reimburses at 200% of the allowable Medicare Part B rate for that service, Progressive used HCPCS code G0283 for unattended electrical stimulation on the EOB’s to the provider.
Florida Statutes §627.736(4)(b) states in pertinent part,
. . .When an insurer pays only a portion of a claim or rejects a claim, the insurer shall provide at the time of the partial payment or rejection an itemized specification of each item that the insurer had reduced, omitted or declined to pay and any information that the insurer desires the claimant to consider related to the medical necessity of the denied treatment or to explain the reasonableness of the reduced charge, provided that this shall not limit the introduction of evidence at trial. . .
In response to the Plaintiff’s submission of CPT Code 97014, the Defendant reimbursed the Plaintiff at maximum allowable amount of 200% of the Medicare Part B Fee Schedule, which was explained on the Explanation of Benefits forms submitted to the Plaintiff and in compliance of Florida Statutes §627.736(4)(b).
Progressive reimbursed the provider for CPT Code 97014, based on its consideration of the synonymous code recognized by the Medicare Part B fee schedule, namely HCPCS Code G0283, and provided an explanation to the Plaintiff for its actions.
The record evidence indicates that Progressive never made a determination that CPT code 97014 was improperly or incorrectly upcoded or unbundled. Accordingly, Progressive was not required to contact the Plaintiff before changing CPT code 97014 to HCPCS code G0283 pursuant to Fla. Stat. §627.736(5)(b)(1)(e). Progressive complied with the requirements of Florida Statutes §627.736(4)(b) and Florida Statutes §627.736(5)(d). Fla. Stat. §627.736(5)(b)(1)(e) is not applicable to this code and in this instance.
Accordingly, it is hereby:
ORDERED AND ADJUDGED that PROGRESSIVE AMERICAN INSURANCE COMPANY’S Motion for Final Summary Judgment with Respect to Count I of Plaintiff’s Complaint is GRANTED.
