18 Fla. L. Weekly Supp. 314b
Online Reference: FLWSUPP 1803BROW Insurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Partial summary judgment is granted in favor of medical provider on improper coding defense where provider’s expert opined that billing met coding requirements of codebook that is one of treatises for determining coding compliance specified in PIP statute and insurer’s coding expert based opinion that claim was properly denied on “CPT Expert” which is not among specified treatises
RONALD J. TRAPANA, M.D., P.A., a Florida Corporation (assignee of Brownlee, Denavia), Plaintiff, v. PROGRESSIVE AMERICAN INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 09-05332 COCE (56). September 23, 2010. Linda Pratt, Judge.
ORDER GRANTING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT AND DENYING DEFENDANT’S MOTION FORSUMMARY JUDGMENT
THIS CAUSE, came before the court for hearing on September 23, 2010 and the court, having reviewed the motions, the court file, legal authorities and having heard argument of counsel, finds as follows:
Factual Background: This is a P.I.P. case. Denavia Brownlee (hereafter “patient”) presented to the Plaintiff (an orthopedic surgeon) upon a referral from her primary physician (a chirporactic physician) for a second opinion on x-rays taken by the primary physician. Plaintiff examined the patient and reviewed the x-rays of the patient’s cervical and lumbar spine and issued two separate reports: one on the evaluation/management of the patient and the other on the x-ray reviews. Plaintiff billed the Defendant for the aforementioned services as follows: CPT Code 99204 (an initial office visit for the evaluation and management of a new patient) and two charges for CPT Code 76140 (a consultation on x-ray examination made elsewhere). Defendant paid the charge for the office visit (CPT Code 99204), but refused to pay the charges for the consultations on x-rays (CPT Code 76140).
The parties have each filed their respective motions for summary judgment on the Defendant’s “improper coding” defense. Defendant maintains that Plaintiff failed to comply with “all the statutory and policy requirements by failing to bill in accordance with AMA guidelines” when it billed consultation on x-ray charges together with a charge for the physician’s office visit. Plaintiff maintains that its charges were properly billed and complied with the 2008 American Medical Association Current Procedural Terminology codebook as required by the P.I.P. statute.
Conclusions of Law: This court finds that the Plaintiff’s charges for CPT Code 99204 together with CPT Code 76140 were properly billed in compliance with the P.I.P. statute.
Florida Statute s. 627.736(5)(d) sets forth the billing requirements under P.I.P. and provides, inter alia:
All billings for such services rendered by providers shall, to the extent applicable, follow the Physicians’ Current Procedural Terminology (CPT) or Healthcare Correct Procedural Coding System (HCPCS), or ICD-9 in effect for the year in which services are rendered and comply with the Centers for Medicare and Medicaid Services (CMS) 1500 form instructions and the American Medical Association. Current Procedural Terminology (CPT) Editorial Panel and Healthcare Correct Procedural Coding System (HCPCS) . . . in determining compliance with applicable CPT and HCPCS coding, guidance shall be provided by the Physicians’ Current Procedural Terminology (CPT) or the Healthcare Correct Procedural Coding System (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.
Plaintiff has filed the affidavit of its coding expert, who opines that the Plaintiff’s billing met all AMA CPT Coding requirements. Defendant has filed the affidavit of its coding expert who opines that, based upon CPT Expert, the Defendant properly denied the Plaintiff’s claim.
The unambiguous language of Florida Statute s. 627.736(5)(d) requires compliance with AMA CPT Coding requirements. CPT Expert is not one of the treatises set forth in Florida Statute s. 627.736(5)(d) and, as such, the Court finds that the Plaintiff is not required to comply with the CPT Expert.
The undisputed record evidence before the court demonstrates that Plaintiff properly billed CPT Code 99204 together with CPT Code 76140 in compliance with AMA CPT Coding guidelines and, as such, properly billed in compliance with the P.I.P. statute.
Accordingly, it is hereby:
ORDERED AND ADJUDGED that Plaintiff’s Motion for Partial Summary Judgment is GRANTED and that Defendant’s Motion for Summary Judgment is DENIED as to the Defendant’s second affirmative defense “improper coding.”
