17 Fla. L. Weekly Supp. 589b
Online Reference: FLWSUPP 1707CAPOInsurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Insurer cannot deny payment for CPT code recognizable under Medicare Part B fee schedule on grounds that Medicare’s National Correct Coding Initiative provides that code cannot be billed on same day as another code billed by medical provider where PIP statute forbids insurer from applying utilization limits — No merit to argument that NCCI is payment limitation rather than utilization limitation
BAYVIEW CHIROPRACTIC CENTER P.A., a/a/o JEAN CAPOZZOLI, Plaintiff(s), vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant(s). County Court, 11th Judicial Circuit in and for Miami-Dade County, Civil Division. Case No. 09-00609 SP 26. March 13, 2010. Gloria Gonzalez-Meyer, Judge. Counsel: Martin I. Berger, Samole, Berger & Hicks, P.A., for Plaintiff. Rachel H. Minetree-Alhadeff, Conroy, Simberg, Ganon, Krevans, Abel, Lurvey, Morrow & Schefer, P.A., for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR FINAL SUMMARY JUDGMENT ANDDENYING DEFENDANT’S MOTION FINAL FOR SUMMARY JUDGMENT
THIS CAUSE came before the Court on the 16th day of February, 2010 on Plaintiff’s Motion for Final Summary Judgment and Defendant’s Motion for Final Summary Judgment.
ORDERED AND ADJUDGED as follows:
1. Plaintiff treated Jean Capozzoli for her personal injuries which she sustained in an automobile accident which occurred on October 4, 2008. Capozzoli was insured by State Farm Mutual Automobile Insurance Company under policy number D14089459. Capozzoli assigned her insurance benefits to the Plaintiff who provided chiropractic services on October 17, 2008. The Defendant failed to pay for CPT Code 97124 which is the subject of this litigation.
2. In support of Plaintiff’s Motion for Summary Judgment, Plaintiff has filed the affidavit of Dr. Scott Gilbert, D.C. In his affidavit, Dr. Gilbert details his initial contact, examination, diagnosis, and treatment protocol of Jean Capozzoli. He further asserts in his affidavit that it is his opinion within a reasonable degree of chiropractic certainty, that “that the use of CPT Code 97124 on October 17, 2008 was medically reasonable, necessary, and related to the injuries that she sustained in her October 4, 2008 collision.” The Court finds that the Plaintiff has satisfied their burden of production as to the issues of reasonableness, relation, and necessity.
3. The Court now addresses the affidavit filed in opposition by the Defendant. The Defendant submitted the affidavit of Denisha M. Torres-Lich, a Registered Health Information Administrator who posses a specialized knowledge of coding pursuant to AMA guidelines. Ms. Torres-Lich opined Dr. Gilbert improperly unbundled CPT Code 97124 separately from CPT Code 97140 and cannot be billed on the same day, based upon Medicare’s National Correct Coding Initiative.
4. Florida Statute 627.736 (5)(A)(2)(f) provides a permissive reimbursement scheme, under which an insurer may limit reimbursement to “80 percent of 200 percent of the allowable amount under the participating physician schedule of Medicare Part B or, “if such services, supplies, or care is not reimbursable under Medicare part B, the insurer may limit reimbursement to 80 percent of the maximum reimbursable allowance under workers’ compensation.”
5. The CPT codes at issue in this case is 97124, it is reimbursable under the applicable Medicare Part B fee schedule.
6. The Court must now address whether it was permissible for State Farm to deny payment on recognizable CPT codes under the Medicare part B fee schedule. State Farm argues that such limitations are permissible pursuant to the NCCI edits and such limitations are payment limitations. This Court disagrees. This Court determines that NCCI limitations which prohibit physicians from administering certain services to a patient on the same day are clearly utilization limitations.
7. The current PIP Statute clearly prohibits insurers from applying “any limitation on the number of treatments or other utilization limits that apply under Medicare or worker’s compensation”. Legislative intent is the polestar by which a court must be guided in interpreting the provisions of the law. In ascertaining the legislative intent, a court must consider the plain language of the statute, give effect to all statutory provisions, and construe related provisions in harmony with one another. Florida Department of Revenue v. New Sea Escape Cruise LTD, 894 So.2d 954 (Fla 2005). If the Court was to accept the Defendant’s argument that utilization limits are solely limits on how many times a service can be provided, then the Statute would become redundant. The Court believes this would not be a logical intent of the Legislature. Therefore, based upon the aforementioned findings, Plaintiff’s Motion for Summary Judgment is hereby granted and Defendant’s Motion for Summary Judgment is denied.
