26 Fla. L. Weekly Supp. 1003a
Online Reference: FLWSUPP 2612SAGMInsurance — Personal injury protection — Coverage — Medical expenses — CPT coding — Claim for re-examination conducted on same date of service as chiropractic manipulation was not payable where medical provider failed to include modifier required by CPT coding guidelines
ADRIAN SAGMAN, DC, PA dba MIRAMAR MEDICAL CENTER (a/a/o Perea, Henry), Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. COCE 16-010768 (53). August 10, 2018. Robert W. Lee, Judge. Counsel: Wajih Shirazi, for Plaintiff. Michael Walsh, Kubiki Draper, PA, Fort Lauderdale, for Defendant.
ORDER GRANTING DEFENDANT’S AMENDED MOTIONFOR PARTIAL SUMMARY JUDGMENTREGARDING CODING OF SERVICES
THIS CAUSE, having come before the Court on the motion of Defendant on its Amended Motion for Partial Summary Judgment Regarding Coding of Services, the Court, having heard argument on August 2, 2018, having reviewed the relevant filings and otherwise having been fully advised in the premises, the Court hereby ORDERS AND ADJUDGES as follows:
On May 8, 2013, the Plaintiff submitted charges to the Defendant for CPT Codes 99213 (a re-examination) and 98941 (spinal manipulations) for services rendered to the Defendant’s insured, Henry Perea. The Plaintiff did not utilize modifier -25 on its submission of CPT Code 99213. The Defendant issued payment to the Plaintiff for CPT Code 98941; however, it denied reimbursement for CPT Code 99213, pursuant to Fla. Stat. 627.736(5)(d), contending that the Plaintiff’s billing of the services fails to comply with the American Medical Association (AMA) Guidelines, as outlined in the Current Procedural Terminology (CPT) Manual for year 2013.
In support of its motion, the Defendant has filed the affidavit of Nicole Bonaparte, CPC, CPC-I. Ms. Bonaparte is a Certified Professional Coder and Certified Professional Coder Instructor who possesses a specialized knowledge of coding pursuant to AMA guidelines. The Court finds, based on a review of Ms. Bonaparte’s curriculum vitae, that she possesses the requisite knowledge, training, and expertise to render an expert opinion on issues pertaining to coding. Pursuant to Ms. Bonaparte’s affidavit, according to the AMA’s CPT Guidelines, December 2007 page 16c:
The complete service of CMT requires a certain amount of preservice and intraservice work that is included as part of the service. This E/M is necessary to determine not only what specific manipulative work will be necessary but also to determine the effectiveness of the service being provided. It is inclusive in the CMT and is not separately reported E/M. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional evaluation and management services including office or other outpatient services (99201-99215). . . may be reported separately using modifier 25 if the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual preservice and postservice work associated with the procedure.
In opposition to the Defendant’s motion, the Plaintiff filed the affidavit of Dr. Adrian Sagman, DC, the Plaintiff’s treating chiropractic physician. In his affidavit, Dr. Sagman opines that “CPT code 99213 is entirely a separate treatment and procedure from chiropractic manipulative treatment that is billed using CPT code 98941. . . Therefore the codes are not capable of being unbundled and must be billed separately as they provide completely distinct and different procedures for the patient under the AMA1.” Additionally, attached to the Plaintiffs affidavit are two State Farm explanations of review (EORs) for treatment of non-party patients, wherein the records show that State Farm has previously allowed reimbursement for CPT Code 99213 when billed on the same date of service as CPT Code 98941. However, the Plaintiff’s affidavit fails to recognize that both of the attached EORs clearly identify that the Plaintiff had in those two instances properly billed the examination as “99213-25,” including the requisite -25 modifier.
Pursuant to Section 627.736(5)(d), Florida Statutes (2013):
All billings for such services rendered by providers must, 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 CMS 1500 form instructions, the American Medical Association CPT Editorial Panel, and the HCPCS. All providers, other than hospitals, must include on the applicable claim form the professional license number of the provider in the line or space provided for “Signature of Physician or Supplier, Including Degrees or Credentials.” 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, Physicians Compliance Guidelines, and other authoritative treatises designated by rule by the Agency for Health Care Administration. [emphasis added]
The Florida legislature has incorporated, by reference, the CPT manual’s guidelines into Fla. Stat. 627.736. As such, to determine whether the Plaintiffs bill’s have been submitted in accordance with F.S. 627.736(5)(b), and potentially payable, we must look to the applicable CPT manual’s guidelines as promulgated by the American Medical Association. State Farm Mutual Automobile Ins. Co. v. Trapana, CACE 12-026306 (AP) (17th Jud. Cir. App.) (2015) [23 Fla. L. Weekly Supp. 98a]; Madock v. Progressive Express Ins. Co., 11 Fla. L. Weekly Supp. 408b (Fla. 13th Cir. Ct. Mar. 3, 2004).
As the AMA CPT coding guidelines clearly establish that a provider must include modifier -25 to identify a separately identifiable examination and management service above and beyond the usual preservice and postservice work associated with chiropractic manipulations as a prerequisite to billing the procedures separately, the Court finds that the Plaintiff’s billing for said services fails to comply with Fla. Stat. 627.736(5)(b) and as such is not payable. As a result of the foregoing, the Defendant’s Motion for Partial Summary Judgment is hereby GRANTED.
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1The Defendant does not dispute whether both an examination and an adjustment were performed. The Defendant solely takes issue with the submission of examination code without the -25 modifier,
