17 Fla. L. Weekly Supp. 1238a
Online Reference: FLWSUPP 1712HERNInsurance — Personal injury protection — Coverage — Medical expenses — National Correct Coding Initiative edits, which bar physicians from administering certain services to patient on same day, are utilization limitations prohibited by PIP statute
ISOT MEDICAL CENTER, CORPORATION, (a/a/o Keith Hernandez), 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. 09-00926 SP 26 (04). September 1, 2010. Honorable Gloria Gonzalez-Meyer, Judge. Martin I. Berger, Samole, Berger & Hicks, P.A., Miami, for Plaintiff. Mark Rose, Roig, Tutan, Rosenberg & Zlotnick, P.A., Deerfield Beach, for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AND FINAL JUDGMENT
THIS CAUSE, having come before this Court upon Plaintiff’s Motion for Summary Judgment, and the Court having heard the argument of the parties on September 1, 2010, it is hereby:
CONSIDERED, ORDERED, and ADJUDGED
1. Plaintiff treated Keith Hernandez for his personal injuries which he sustained in an automobile accident which occurred on June 28, 2008. Keith Hernandez, was insured by State Farm Mutual Automobile Insurance Company under policy number 668681059. Keith Hernandez assigned his insurance benefits to the Plaintiff. Plaintiff provided medical and therapeutic services to Keith Hernandez from July 8, 2008 through October 30, 2008. The Defendant reduced Plaintiff’s charges to 200 percent of the Medicare Part B fee schedule and failed to make any payments for CPT code 97124, for dates of service 7/11/08; 7/21/08; 7/22/08; 7/24/08; 7/25/08; 7/29/08; 7/31/08; 8/1/08; 8/5/08; 8/7/08; 8/14/08; 8/18/08; 8/19/08; 8/21/08; 8/26/08; 8/28/08; 8/29/08; 9/2/08; 9/4/08; 9/5/08; 9/9/08; 9/11/08; 9/12/08; 9/16/08; 9/18/08; 9/19/08; 9/22/08; 9/23/08; 9/25/08; 10/1/08; 10/2/08; 10/7/08; 10/9/08; 10/10/08; 10/13/08; 10/23/08; 10/28/08; and 10/30/08; CPT code 97140 for dates of service 7/24/08; 7/29/08; 7/31/08; 8/5/08; 8/19/08; 8/26/08; 9/2/08; 9/11/08; 9/16/08; 9/18/08; 9/23/08; 9/25/08; 10/2/08; and 10/7/08 and CPT code 97018 for dates of service 7/11/08; 7/21/08; 7/25/08; 8/1/08; 8/18/08; 8/21/08; 8/28/08; 8/29/08; 9/4/08; 9/5/08; 9/12/08; 9/19/08; 9/22/08; 9/30/08; 10/1/08; 10/9/08; and 10/10/08.
2. In support of Plaintiff’s Motion for Summary Judgment, Plaintiff has filed the affidavits of Guido Perez, M.D. and Fernando Perez. In his affidavit, Dr. Perez details his initial contact, examination, diagnosis, and treatment protocol of Keith Hernandez. Dr. Perez asserts in his affidavit that it is his opinion within a reasonable degree of medical certainty that the medical, diagnostic and therapeutic care and treatment received by Keith Hernandez from himself and ISOT Medical Center, Corporation beginning on July 8, 2008 through October 30, 2008, was medically reasonable, necessary, and related to the injuries that Keith Hernandez sustained in his June 28, 2008 automobile collision. Dr. Perez further asserts in his affidavit that it is his opinion within a reasonable degree of medical certainty, that the use of CPT codes 97124, 97018 and 97140 on dates of service between July 8, 2008 through October 30, 2008, was medically necessary, reasonable, and related to the injuries that Keith Hernandez sustained in his June 28, 2008 collision. The Court finds that the Plaintiff has satisfied its 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 Torres-Lich, who possesses a specialized knowledge of coding pursuant to AMA guidelines. Ms. Torres Lich opined that Dr. Perez improperly unbundled CPT Code 97124 separately from CPT Code 97140, CPT Code 97140 from CPT Code 97012, and CPT code 97018 from CPT, code 97140 and that these codes cannot be billed on the same day based upon Medicare’s National Correct Coding Initiative.
4. The Defendant has not filed any evidence in opposition to the issues of reasonableness, relation, and necessity. Therefore, based on the affidavits of Dr. Perez and Fernando Perez, summary judgment is granted in favor of Plaintiff on the issues of reasonableness, relation, and necessity.
5. 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 physicians 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.”
6. The CPT codes at issue in this case, 97124, 97140, and 97018 are reimbursable under the applicable Medicare Part B fee schedule.
7. 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.
8. 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 workers’ 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 state, 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 how many times a service, can be provided, 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 as to Defendant’s First Affirmative Defense.
9. In accordance with this Order Granting Plaintiff’s Motion for Summary Judgment, Defendant, State Farm Mutual Automobile Insurance Company, shall pay the Plaintiff, ISOT Medical Center, Corp., the sum of $2,164.94 in benefits and $436.50 in interest for a total recovery of $2,601.44, that shall bear interest at the rate of 6% per year, for which let execution issue. Additionally, this Court holds that Plaintiff, as the prevailing party to Count I of its Complaint is entitled to its reasonable attorney’s fees under Florida Statute § 627.428 and Florida Statute § 627.736(8) and costs pursuant to Fla. Stat. § 92.231 and Fla. Stat. § 57.041. This Court retains jurisdiction over this matter to determine the amount of attorney’s fees owed to the Plaintiff by the Defendant.
