16 Fla. L. Weekly Supp. 181a
Online Reference: FLWSUPP 162WELLE
Insurance — Personal injury protection — Coverage — Medical expenses — Nerve conduction testing — Where medical provider performed NCV but did not perform needle electromyography procedure, insurer properly reimbursed provider using Participating Physician Fee Schedule for Medicare Part B — Motion for summary judgment on duty of insurer to provide payment for services not listed in coding system on date of service is denied where disputed issue of material fact exists as to whether CPT code is valid CPT code or was deleted from coding system prior to date of service
ALL FAMILY CLINIC OF DAYTONA BEACH, INC., d/b/a FLORIDA MEDICAL ASSOCIATES, As assignee of PATRICIA WELLER, Plaintiff, vs. STATE FARM FIRE & CASUALTY COMPANY, Defendant. County Court, 7th Judicial Circuit in and for Volusia County. Case No. 2007-33447-COCI, Division 82. August 4, 2008. David H. Foxman, Judge. Counsel: Jon E. Benezette, Daytona Beach, for Plaintiff. James B. Eubanks, James C. Rinaman, III & Associates, P.A., Jacksonville, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FOR SUMMARY JUDGMENT IN PART AND DENYING IN PART
This cause having come on to be heard on July 11, 2008 and the Defendant having filed a written Motion for Summary Judgment. Present before the Court appeared counsel for Defendant, James B. Eubanks, Esquire with counsel for Plaintiff, Jon E. Benezette, Esquire. Having considered the arguments of counsel, the record in this cause, all relevant authority, and being otherwise fully advised, the Court makes the following findings of fact and conclusions of law.
1. On or about August 3, 2007, ALL FAMILY CLINIC OF DAYTONA BEACH, INC., d/b/a FLORIDA MEDICAL ASSOCIATES, As assignee of PATRICIA WELLER (Plaintiff) filed the case sub judice, regarding non-payment of No-Fault benefits for services rendered by Dr. Carol Krause and Dr. Fiaz Jaleel to Patricia Weller, at Plaintiff’s facility on April 3, 2006 and April 21, 2006.
2. Count I of Defendant’s Motion for Summary Judgment addresses the proper reimbursement amount allowable when a medical provider performs an NCV, but does not perform an EMG on a particular date of service.
3. Florida Statute § 627.736(5)(b)(3) states:
Allowable amounts that may be charged to a personal injury protection insurance insurer and insured for medically necessary nerve conduction testing when done in conjunction with a needle electromyography procedure and both areperformed and billed solely by a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461 who is also certified by the American Board of Electrodiagnostic Medicine or by a board recognized by the American Board of Medical Specialties or the American Osteopathic Association or who holds diplomate status with the American Chiropractic Neurology Board or its predecessors shall not exceed 200 percent of the allowable amount under the participating physician fee schedule of Medicare Part B for year 2001, for the area in which the treatment was rendered. . . . (emphasis added)
4. Florida Statute § 627.736(5)(b)(4) states:
Allowable amounts that may be charged to a personal injury protection insurance insurer and insured for medically necessary nerve conduction testing that does not meet the requirements of subparagraph 3 shall not exceed the applicable fee schedule or other payment methodology established pursuant to s. 440.13.
5. It is uncontested that on April 3, 2006, Plaintiff performed the NCV, but did not perform the EMG.
6. However, on April 7, 2006 State Farm received Plaintiff’s bill for date of service April 3, 2006 which included 6 units of CPT code 95900 and 8 units of CPT code 95904 (NCV/EMG) and Plaintiff billed these CPT codes in violation of the above mentioned statutory provisions, at $597.48 and $686.32, respectively, for a total of $1,283.80.
7. This Court finds that on April 27, 2006 State Farm acted in accordance with Florida Statute §§627.736(5)(b)(3), (4) in reimbursing the Plaintiff using The Participating Physician Fee Schedule of Medicare Part B. State Farm properly approved 6 units of CPT code 95900 at $69.00 per unit for $414.00 and 8 units of CPT code 95904 at $59.00 per unit for $472.00; having a total of $886.00 paid to Plaintiff for such services.
8. Count II of Defendant’s Motion for Summary Judgment addresses the duty of an insurer to provide payment for services that are not listed in the Physicians’ Current Procedural Terminology (CPT) or Healthcare Correct Procedural Coding System (HCPCS), or ICD-9 in effect for the year in which services are rendered.
9. Florida Statute § 627.736(5)(d) states, in pertinent part:
All billings for such services rendered by providers shall, to the extent applicable, follow the Physicians’ Current Procedural Terminology (CPT) or Healthcare Correct Procedural Coding System (HCPCS), or ICD-9 in effect for the year in which services are rendered and comply with the Centers for Medicare and Medicaid Services (CMS) 1500 form instructions and the American Medical Association Current Procedure Terminology (CPT) Editorial Panel and Healthcare Correct Procedural Coding System (HCPCS).
10. On April 27, 2006 State Farm received billing records from Plaintiff regarding services provided on April 21, 2006, which included a $15.00 charge for CPT code J2000.
11. Defendant contends that this code is not listed in the applicable 2006 Healthcare Common Procedure Coding System (HCPCS) and was deleted in 2004.
12. The Court recognized the Affidavit of Connie Coleman in support of Defendant’s Motion for Summary Judgment which attested that the CPT code at issue, J2000, was not a valid code for date of service April 21, 2006 and was deleted in 2004.
13. The Court also recognized the Affidavit of Tonya Browning-Bedell in support of Plaintiff’s Response to Defendant’s Motion for Summary Judgment which attested that the CPT code was valid for date of service April 21, 2006.
14. The Court finds, pursuant to the competing Affidavits, that a material issue fact exists as to the validity of CPT code J2000.
IT IS THEREFORE ORDERED AND ADJUDGED that Defendant’s Motion for Summary Judgment is hereby Granted regarding the April 3, 2006 date of service, and Denied regarding the April 21, 2006 date of service.
