17 Fla. L. Weekly Supp. 854b
Online Reference: FLWSUPP 1709 JARBInsurance — Personal injury protection — Coverage — Medical expenses — Claim form — CPT coding — National Corrective Coding Initiative edits apply to PIP claims — Although provider submitted HCFA form which listed office visit code without required -25 modifier to indicate that it was distinct procedure from chiropractic manipulation performed on the same date, medical bill was nonetheless substantially compliant where provider’s accompanying SOAP notes listed the office visit code with a -25 modifier
CENTURY HEALTH & REHAB, INC., a Florida Corporation (assignee of Jarbath, Guy), Plaintiff, v. STATE FARM FIRE AND CASUALTY COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. 2008-SC-7558. April 23, 2010. Antointte Plogstedt, Judge. Counsel: Russel M. Lazega, The Law Office of Russel Lazega, P.A., miami, for Plaintiff. John Morrow, for Defendant.
ORDER DENYING DEFENDANT’S MOTION FOR FINAL SUMMARY JUDGMENT
THIS CAUSE came before the Court for hearing on March 16, 2010 and March 26, 2010 on Defendant’s Motion for Final Summary Judgment (on the defense of improper coding/unbundling) and the Court, having reviewed the motion and entire Court file; heard argument; reviewed the relevant legal authorities; and been sufficiently advised in the premises, the Court finds as follows:
Factual Background: This is a P.I.P. suit. Plaintiff is an assignee medical provider who rendered medical treatment to Guy Jarbath (hereafter “patient”) for injuries he sustained in a motor vehicle accident on April 14, 2007. Plaintiff submitted bills for dates of service May 16, 2007 through June 21, 2007.
The bill for date of service June 11, 2007 included the following two (2) charges: CPT code 99213 (an office visit for evaluation and management of an established patient) and CPT code 98941 (chiropractic manipulation). Defendant paid code 98941 but did not make any payment for code 99213 (the office visit), claiming that Plaintiff failed to properly code this procedure.
Defendant moves for final summary judgment on its affirmative defense ‘improper coding’ asserting that Plaintiff’s billing was improper and did not comply with the National Corrective Coding Initiative edits (hereafter “NCCI edits”), specifically, Defendant contends that Plaintiff should have appended CPT code 99213 with a -25 modifier to identify to Defendant that the office visit was a distinct procedure from the chiropractic manipulation. Additionally, Defendant asserts that, even if Plaintiff’s coding was proper, Plaintiff has not met the necessary components to bill a code 99213.
Plaintiff responds that its billing was substantially compliant as the Health Insurance Claim Forms (hereafter “HCFAs”) were submitted with the doctor’s SOAP notes, which listed code 99213 with a modifier -25 (identifying that the procedures were distinct).
Conclusions of Law: The court finds that the NCCI edits do apply to P.I.P. and that Plaintiff submitted a HCFA which improperly coded 99213 without the necessary modifier -25. However, on the facts of this particular case only, the parties have agreed that a SOAP note was submitted with the disputed HCFA form and the note contained a clear description of the code as a ” -25 modifier” (specifically, the code “99213 -25 RE-EXAM” was circled on the note).
In the instant case, the Court finds that the medical bill which contained an improperly coded CPT Code 99213 was substantially compliant as the accompanying note clearly contains the required -25 modifier. Both parties agree that the -25 modifier would prevent summary judgment and that the SOAP note accompanying the bill contains this information.
As such, this Court is bound by the Fifth DCA decision, setting substantial compliance as the applicable standard for determining whether a bill is properly complete. Florida Medical & Injury Center, Inc., Etc. v. Progressive Express Insurance Company and Progressive American Insurance Company v. Preziosi West/East Chiropractic, Etc., 35 Fla. L. Weekly D215b (Fla. 5th DCA 2010).
As to Defendant’s additional arguments as to whether the components for code 99213 were met, the Court finds that this is a fact question and Defendant is free to raise the issue before the finder of fact.
Accordingly, it is hereby:
ORDERED AND ADJUDGED that Defendant’s Motion for Final Summary Judgment is DENIED.
