17 Fla. L. Weekly Supp. 1240a
Online Reference: FLWSUPP 1712NRAMInsurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Unbundling — Insurer cannot deny payment for CPT codes recognizable under Medicare Part B fee schedule on grounds that Medicare’s National Correct Coding Initiative provides that codes cannot be billed on same day as each other and 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
ISOT MEDICAL CENTER, CORPORATION, (a/a/o Nelson Ramirez), Plaintiff(s), vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 11th Judicial Circuit in and for Miami-Dade County, Civil Division. Case No. 09-09301 SP 26 (04). September 1, 2010. Honorable Gloria Gonzalez-Meyer, Judge. Counsel: Martin I. Berger, Samole, Berger & Hicks, P.A., Miami, for Plaintiff. Fernando Roig, Roig, Tutan, Rosenberg & Zlotnick, P.A., for Defendant.
ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT AND FINAL JUDGMENT
THIS CAUSE, having come before this Court upon Plaintiffs Motion for Summary Judgment, and the Court having heard the argument of the parties on August 25, 2010, it is hereby:
CONSIDERED, ORDERED, and ADJUDGED
1. Plaintiff treated Nelson Ramirez for his personal injuries which he sustained in an automobile accident which occurred on February 12, 2009. Morela Montes De Oca was insured by State Farm Mutual Automobile Insurance Company under policy number 676950159. Nelson Ramirez was eligible to receive benefits under Ms. Montes De Oca’s policy of insurance as a passenger of the motor vehicle involved in the collision. Nelson Ramirez assigned his insurance benefits to the Plaintiff. Plaintiff provided medical and therapeutic services to Nelson Ramirez from February 16, 2009 through May 26, 2009. The Defendant reduced Plaintiffs 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 2/24/09, 2/26/09, 3/2/09, 3/3/09, 3/5/09, 3/10/09, 3/12/09, 3/17/09, 3/19/09, 3/24/09, 3/26/09, 3/31/09, 4/2/09, 4/3/09, 4/7/09, 4/9/09, 4/10/09, 4/14/09, 4/16/09, 4/17/09, 4/21/09, 4/23/09, 4/24/09, 5/22/09, and 5/26/09, as well as CPT code 97140 on dates of service 2/24/09, 3/3/09, 3/5/09, 3/10/09, 3/12/09, 3/17/09, 3/19/09, 3/24/09, 3/26/09, 3/31/09, 4/2/09, 4/3/09, 4/7/09, 4/9/09, 4/10/09, 4/14/09, 4/16/09, 4/17/09, 4/21/09, 4/23/09, 4/24/09, 5/22/09, and 5/26/09.
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 Nelson Ramirez. 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 Nelson Ramirez from himself and ISOT Medical Center, Corporation beginning on February 16, 2009 through May 26, 2009, was medically reasonable, necessary, and related to the injuries that Nelson Ramirez sustained in his February 12, 2009 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 code 97124 and 97140 on dates of service between February 16, 2009 through May 26, 2009, was medically necessary, reasonable, and related to the injuries that Nelson Ramirez sustained in his February 12, 2009 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 M. Torres-Lich, a Registered Health Information Administrator 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, and CPT Code 97140 from CPT Code 97012, and that these codes cannot be billed on the same day based upon Medicare’s National Correct Coding Initiative.
4. Defendant has also filed the Affidavit of Peter Millheiser, M.D. The Court finds the Affidavit of Dr. Millheiser to be insufficient to contest the reasonableness, relation, and medical necessity, as the only issue in this case is the application of National Correct Coding Initiative edits to the services at issue, which Dr. Miliheiser’s Affidavit fails to address. 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 and 97140, 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 and 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 $1,961.76 in benefits and $205.11 in interest for a total recovery of $2,166.87, 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.
