18 Fla. L. Weekly Supp. 96a
Online Reference: FLWSUPP 1801ALME Insurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Medical provider cannot bill component treatment charge separately on same insured for same date of service as provider bills comprehensive treatment charge
SENPRI MEDICAL CENTER, INC., a/a/o BENJAMIN ALMEIDA, Plaintiff, vs. STATE FARM FIRE AND CASUALTY COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 09 CC 815 SC, Division L. August 11, 2010. Honarable Ralph Steinberg, Judge. Counsel: James Collins, Gonzalez and Associates, Brandon, for Plaintiff. Edwin V. Valen, Oxendine and Oxendine, P.A., Tampa, for Defendant.
ORDER GRANTING DEFENDANT’S MOTION FORFULL AND FINAL SUMMARY JUDGMENT
This cause came before the Court on July 28, 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:
CONCLUSIONS OF FACT
1. Plaintiff, a medical provider, operating under an assignment of benefits executed by the insured, Benjamin Almeida, 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 April 14, 2008 through May 22, 2008.
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
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.
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.
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 BENJAMIN ALMEIDA, shall recover nothing from Defendant, STATE FARM FIRE AND CASUALTY COMPANY, and STATE FARM FIRE AND CASUALTY COMPANY shall go hence without day.
This Court reserves jurisdiction to consider Defendant’s claims for reasonable attorneys’ fees and costs, if any.
