18 Fla. L. Weekly Supp. 547a

Online Reference: FLWSUPP 1806CHRI Insurance — Personal injury protection — Coverage — CPT coding — Insurer correctly denied payment for inappropriately unbundled services — National Correct Coding Initiative edits are payment limitations, not utilization limitations that would be prohibited under PIP statute

BRENDA D. CHRISTMAN, Plaintiff, vs. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 7th Judicial Circuit in and for Volusia County. Case No. 2009-10345-CODL, Division 71. February 25, 2011. Bryan A. Feigenbaum, Judge. Counsel: Darren J. Elkind, Deltona, for Plaintiff. James C. Rinaman, III, James C. Rinaman, III & Associates, P.A., Jacksonville, for Defendant.

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

THIS CAUSE came before the Court on January 20, 2011 on Defendant’s Motion for Full and Final Summary Judgment and, after having heard arguments of counsel, having examined the cited authority, reviewed the file herein, and being otherwise fully advised in the premises, makes the following findings of fact and conclusions of law:

FINDINGS OF FACT

1. Plaintiff was involved in a motor vehicle accident on January 15, 2008.

2. Plaintiff received medical treatment on June 19, 2008 from Alvarez Family Chiropractic, LLC.

3. The Plaintiff submitted medical charges to the Defendant insurer that billed Current Procedural Terminology (CPT) codes 95851 (2), 97032, and 97530 for the same patient and the same date of service.

4. The Defendant, after receiving these charges, issued payment for CPT code 97530 and CPT code 97032 and denied payment for CPT code 95851 (2).

5. The Defendant issued an Explanations of Review (EOR) to the Plaintiff advising that CPT code 95851 was flagged due to the National Correct Coding Initiative (NCCI) Comprehensive edits database.

6. Under the NCCI Comprehensive edits database, CPT code 95851 is a component code that would be part of the comprehensive CPT code 97530.

7. In response, Plaintiff filed the subject Complaint demanding, among other financial aspects, $71.36 for breach of contract alleging a failure to pay applicable personal injury protection (PIP) and/or medical payment benefits.

CONCLUSIONS OF LAW

8. As stated in Senpri Medical Center, Inc. (a/a/o Carlos Llanos) v. State Farm Mutual Automobile Insurance Company, 17 Fla, L. Weekly Supp. 1116b (13th Cir., May 2010), and Cega Stress & Esthetic Center, Inc., (a/a/o Christian Velez) v. State Farm Mutual Automobile Insurance Company, 17 Fla. L. Weekly Supp. 830c (13th Cir., May 2010), 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 & Wellness Center, Inc. (a/a/o David Leadbetter) v. State Farm Mutual Automobile Insurance Company, 16 Fla. L. Weekly Supp. 396a (l3th Cir. App., March 2009).

9. Pursuant to Florida Statutes §90.901, §90.902, and §90.903, this Court takes judicial notice of the Federal Register. Vol. 65, No.194. Medicare Part B Physician and Non-Physician Practitioner Fee Schedule for 2008, and the NCCI edits.

10. Florida Statute §627.736 (5)(d) states, in part, “. . .[I]n determining compliance with applicable CPT [the Physicians’ Current Procedural Terminology] and HCPCS [Healthcare Correct Procedural Coding System] coding, guidance shall be provided by the [CPT] or the [HCPCS] in effect for the year in which services were rendered, the Office of the Inspector General (OIG), Physicians Compliance Guidelines, and other authoritative treatises designated by rule by the Agency for Health Care Administration. . . . .” [emphasis added)

11. The Court thus takes judicial notice of the aforementioned sources, and specifically the Centers for Medicare and Medicaid Services’¹ (CMS) annually published National Correct Coding Policy Manual for Medicare Services for CPT code 95851.

12. The Court finds Florida Statute §627.736 (5)(d) is clear. It requires consideration of the OIG which has adopted the NCCI edits.

13. Among those edits, as pointed out by the Affidavit of Defendant’s coding expert, Denisha Torres-Lich, “. . . CPT code 95851 is a component of the more comprehensive code 97530 and cannot be billed separately for the same patient on the same date of service.” (Affidavit, paragraph #8).

14. Based on Florida Statute §627.736 (5) (a), (b), and (d), and the aforementioned sources, the Defendant correctly declined payment for inappropriately unbundled services. See Senpri Medical Center, Inc., Cega Stress & Esthetic Center, Inc., Tran Chiropractic & Wellness Center, Inc., Reinhart Chiropractic Clinic (a/a/o Virginia Thomas) v. State Farm Mutual Automobile Insurance Company, 17 Fla. L. Weekly Supp. 28a (6th Cir., October 2009), Alexandra Healthcare, LLC d/b/a Kirkman Chiropractic (a/a/o Justin Cortes) v. State Farm Mutual Automobile Insurance Company, 17 Fla. L. Weekly Supp. 1029a (9th Cir., May 2010), and SOCC, P.L. d/b/a South Orange Wellness & Injury Center (a/a/o Michelle Badillo) vs. State Farm Mutual Automobile Insurance Company, 17 Fla. L. Weekly Supp. 466a (9th Cir., March 2010).

15. An insurer . . . is not required to pay a claim or charges . . . [f]or any treatment or service that is upcoded, or that is unbundled when such treatment or services should be bundled. Florida Statute §627.736(5)(b)(1)(e).

16. In contrast to the Plaintiff’s interpretation, this Court finds the NCCI edits in this situation to be appropriate payment limitations as opposed to utilization limitations which would be prohibited under Florida Statute §627.736 (5)(a), Contra Friedman Chiropractic Center (a/a/o Noemi Aponte-Ali) v. State Farm Mutual Automobile Insurance Company, 17 Fla. L. Weekly Supp. 1247a (11th Cir., September 2010).

17. The medical provider is not limited from administering certain services, but is appropriately limited from billing for two services, one of which is subsumed by the other, in order to prevent overlapping billing.

18. As stated in Tran Chiropractic & Wellness Center, Inc., “[w]hen 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 services.”

19. Also, in contrast to a line of cases cited by the Plaintiff, John S. Virga, D.C., P.A., (a/a/o Abraham Zevuloni) v. State Farm Mutual Automobile Insurance Company, 17 Fla L. Weekly Supp. 380b (11th Cir., January 2010), John S. Virga, D.C., P.A. (a/a/o Jennifer Crumpler) v. State Farm Mutual Automobile Insurance Company, 17 Fla. L. Weekly Supp. 383a (11th Cir., December 2009), and John S. Virga, D.C., P.A. (a/a/o Yueming Lei) v. State Farm Mutual Automobile Insurance Company, 17 Fla. L. Weekly Supp. 384a (11th Cir., January 2010), the Defendant in the instant case did raise unbundling as an affirmative defense.

20. Therefore, Defendant was not, and is not, required to pay the unpaid charges.

It is hereby ORDERED and ADJUDGED:

That Defendant’s Motion for Full and Final Summary Judgment is GRANTED.

FINAL JUDGMENT

That Plaintiff Brenda D. Christman shall recover nothing from Defendant State Farm Mutual Automobile Insurance Company and shall go hence without day.

This Court retains jurisdiction to consider any further motions.

__________________

¹The Centers for Medicare and Medicaid Services (CMS) is the Federal agency that administers the Medicare Program.