17 Fla. L. Weekly Supp. 1116b

Online Reference: FLWSUPP 1711LLAN

Insurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Where medical provider improperly filed claim for CPT code for unbundled service, insurer properly paid benefits for simultaneously billed bundled service code that included denied unbundled service

SENPRI MEDICAL CENTER, INC., a/a/o CARLOS LLANOS, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County. Case No. 09-CC-032088, Division: J. May 17, 2010. Gaston Fernandez, Judge. Counsel: Steven T. Sock, Gonzalez and Associates, Brandon, for Plaintiff. Edwin V. Valen, Oxendine and Oxendine, P.A., Tampa, for Defendant.

ORDER GRANTING DEFENDANT’S MOTION FOR FULL AND FINAL SUMMARY JUDGMENT

This cause came before the Court on April 20, 2010 on Defendant’s Motion for Full and Final Summary Judgment and, after hearing argument of counsel, having reviewed the file herein, and being otherwise fully apprised in the premises, makes the following findings of fact and conclusions of law:

FINDINGS OF FACT

1. Plaintiff, a medical provider, operating under an assignment of benefits executed by the insured, Carlos Llanos, submitted medical charges to Defendant insurer that billed Current Procedural Terminology (CPT) codes 97124 and 97140 on the same patient for the same dates of service on multiple occasions from October 16, 2008 through February 25, 2009.

2. That Defendant, after receiving the aforementioned charges, issued payment for CPT code 97140 and denied payment for CPT code 97124.

3. That Defendant issued explanations of review to the Plaintiff medical provider advising that CPT code 97124 was flagged due to the National Correct Coding Initiative (NCCI) comprehensive edits database.

4. In response, Plaintiff filed the subject Complaint for breach of contract alleging a failure to pay applicable personal injury protection (PIP) benefits.

CONCLUSIONS OF LAW

5. This Court has authority to make determinations regarding the legal propriety of the “coding” of PIP billing, as such determinations are one of statutory construction to be decided as a matter of law. See, Tran Chiropractic and Wellness v. State Farm Mutual Automobile Insurance Company, 16 Fla. L. Weekly Supp. 396a (13th Cir. App. 2009); DiBlasio, M.D., P.A. v. Progressive Express Ins. Co., 14 Fla. L. Weekly Supp. 1027a (15th Cir. Ct. App. 2007).

6. That Florida Statutes §627.736(5)(d) is unambiguous. It requires compliance with the Office of Inspector General Physician Compliance Guidelines and other authoritative treatises designated by rule by the Agency for Health Care Administration. Those authoritative, controlling documents include the Compliance Program Guidance for Individual and Small Group Physician Practices developed by the Office of the Inspector General, located at Vol. 65, No. 194 Federal Register, pp. 59434-59452 (October 5, 2000). Page 59439 includes a section entitled “Coding and Billing.” It references “Failure to Use Coding Modifiers,” the CPT Manual and the NCCI. The explicit, unambiguous provisions of the NCCI prohibit Plaintiff from billing CPT code 97124 separately with CPT code 97140 under the circumstances at issue here.

7. That based on Florida Statutes §627.736(5)(a)(2), §627.736(5)(a)(2)(f), §627.736(5)(a)(3), the Affidavit of Defendant’s coding expert, Denisha Torres-Lich, regarding the Medicare Part B payment limitations contained in the NCCI comprehensive edits database, and the unambiguous provisions of Florida Statute §627.736(5)(d), Plaintiff cannot bill CPT code 97124 separately on the same patient for the same date of service with CPT code 97140. CPT code 97124 is considered a component of the more comprehensive code 97140.

8. This Court is bound by the holding in Tran Chiropractic & Wellness Center, Inc. a/a/o David Leadbetter v. State Farm Mutual Automobile Insurance Company, 16 Fla. L. Weekly Supp. 396(a) (13th Cir. App. 2009) which held that when services are inappropriately unbundled, one contemplates that what happened here would occur: that the lesser codes would simply be denied in favor of a bundled service code that includes the other service(s).

9. Therefore, Defendant was not, and is not, required to pay the unpaid charges and there is no need for consideration of whether or not the improperly billed charges were reasonable, related, and necessary,

It is hereby ORDERED and ADJUDGED:

That Defendant’s Motion for Summary Judgment is GRANTED.

FINAL JUDGMENT

That Plaintiff SENPRI MEDICAL CENTER, INC. a/a/o CARLOS LLANOS, shall recover nothing from Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, and STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY shall go hence without day.

This Court reserves jurisdiction to consider Defendant’s claims for reasonable attorneys’ fees and costs, if any.

[See 18 Fla. L. Weekly Supp. 612c.]