18 Fla. L. Weekly Supp. 1177a
Online Reference: FLWSUPP 1811YOUN Insurance — Personal injury protection — Coverage — CPT coding — Insurer properly withheld payment for CPT code for evaluation and management performed on same date as chiropractic manipulation until and unless medical provider adds modifier required when both codes are billed on same date — Non-prescription drugs — Insurer is responsible for 80% of charge for non-prescription drugs furnished by provider — Although reimbursement for non-prescription drugs is not covered under Medicare Part B , statute allows for reimbursement for medical services not covered by Medicare Part B if service, supplies, or care is allowed under workers’ compensation, and applicable workers’ compensation reimbursement manual allowed for reimbursement to a dispensing practitioner for furnishing over-the-counter drugs
BRADLEY H. YOUNG, D.C., P.A. a/a/o DONALD RICHARDS, and BRADLEY H. YOUNG, D.C., Individually, Plaintiffs, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, A foreign insurance company, Defendant. County Court, 1st Judicial Circuit in and for Okaloosa County, Small Claims Division. Case No. 10-SC-1331-S. March 28, 2011. Jim Ward, Judge.
ORDER
THIS CAUSE having come before the Court upon the parties mutual Motion for Final Summary Disposition, the Court having reviewed and considered the evidence submitted, heard the arguments of the parties, and being otherwise advised in the premises makes the following findings:
1. The Plaintiff, a medical provider, accepted an assignment of benefits from its patient, Donald Rickards, for its treatment and care of Mr. Rickards. The assignment granted to Plaintiff the rights and benefits under State Farm’s policy of Personal Injury Protection insurance (PIP).
2. Pursuant to this assignment, the Plaintiff billed State Farm for services rendered to Mr. Rickards on March 20, 2009, under CPT codes A9150, 99212, 72040, and 72100.
3. State Farm paid for codes 72040 and 72100 at 200% of the medicare schedule (which was less than the billed amount).
4. State Farm did not reimburse the Plaintiff for either CPT code A9150 or 99212.
5. The reason given for failing to reimburse for A9150 is that “the described service, supply, or care is not required to be reimbursed since they are not reimbursable under Medicare or Workers Compensation.”
6. The reason given for failing to reimburse for 99212, is that a modifier was necessary for payment. On March 20, 2009, the Plaintiff billed for CPT code 98941 and 99212. State Farm argues that since the Plaintiff billed for CPT code 98941, he must add the modifier “-25” to the CPT code 99212. Once the Plaintiff adds this modifier the Defendant agrees to pay pursuant to 200% of the medicare schedule.
7. On May 12, 2009, the Plaintiff provided further services for Mr. Rickards and again submitted for reimbursement from State Farm. In addition to other billings for that service date, the Plaintiff billed for CPT code 99212 with a modifier of -25. State Farm paid this CPT code at 200% of the medicare schedule (which was less than the billed amount).
8. Plaintiff has sued to recover the difference between the amounts billed for CPT codes 99212-25, 72040, and 72100 and the amounts paid by State Farm. The Plaintiff has also sued to recover the amounts billed for CPT codes 99212 and A9150.
The Defendant properly paid 200% of the allowable amount under the participating physicians schedule of Medicare Part B for the CPT codes 702040, 72100, and 99212-25.
The Defendant properly withheld payment for the March 20, 2009 billing for CPT code 99212 until and unless the Plaintiff adds the required modifier. The National Correct Coding Initiative notes that if a medical provider bills for CPT codes 98941 and 99212 for the same date of service, then the provider must include the modifier “-25” to 99212 in order to be reimbursed. The Plaintiff provided excerpts of the 2008 ChiroCode Deskbook in support of their argument that the modifier was not required. However, this deskbook indicates that a medical provider would need to append the modifier -25 for a significant, separately identifiable evaluation and management service if performed on the same day as a chiropractic manipulation treatment service. Thus, the deskbook is in agreement with the Defendant’s argument. On March 20, 2009, the Plaintiff performed an evaluation and management of an established patient (CPT code 99212) along with a chiropractic manipulative treatment (CPT code 98941) and thus the Plaintiff was required to append the modifier “-25” to the evaluation and management code 99212 in order to be reimbursed by State Farm.
On March 20, 2009, the Plaintiff provided Mr. Rickards with non-prescription drugs and submitted for reimbursement under CPT code A9150. The Defendant refused reimbursement because non-prescription drugs are not reimbursable by Medicare. However, Section 627.736(5)(a)(2)(f) allows for reimbursement for medical services not covered by Medicare Part B if the services, supplies, or care is allowed under workers’ compensation. The 2008 Florida Workers’ Compensation Health Care Provider Reimbursement Manual, which was in effect on March 20, 2009, allows for reimbursement to a dispensing practitioner for furnishing over the counter drugs. Therefore, State Farm is responsible for reimbursement for 80% of the Plaintiff’s usual charge for the drugs provided so long as that amount does not exceed 20% above the actual cost of the drug furnished. The Court is unaware of any stipulation as to whether the $10 charged for the over the counter drug exceeds 20% above the actual cost of the drug and is unable to rule as to any amount owed by the Defendant for this charge.
Therefore it is hereby ORDERED:
A. The Defendant’s Motion for Summary Judgment is GRANTED as it relates to CPT codes 99212, 72040, 72100, and 99212-25.
B. The Plaintiff’s Motion for Summary Judgment as to liability for reimbursement for CPT code A9150 is GRANTED. The parties will notify the Court if a trial is needed to determine the reimbursement amount for this CPT code.
