26 Fla. L. Weekly Supp. 994a

Online Reference: FLWSUPP 2612HENRInsurance — Personal injury protection — Coverage — Medical benefits — CPT coding — Unbundling — Insurer properly denied payment for electrodes where payment for electrodes was already included with calculation for payment of electrical stimulation procedure performed during the same encounter, and additional payment would have been considered unbundling and result in duplicative payment

FLORIDA PAIN AND WELLNESS CENTERS, INC., as assignee of Jean Henriquez, Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 13th Judicial Circuit in and for Hillsborough County, Civil Division. Case No. 17-CC-017875. Division I. January 18, 2019. Joelle Ann Ober, Judge. Counsel: Timothy A. Patrick, Tampa, for Plaintiff. Roy A. Kielich, Oxendine and Oxendine, P.A., Tampa, for Defendant.

ORDER GRANTING DEFENDANT’S MOTION FORSUMMARY JUDGMENT AND DENYINGPLAINTIFF’S SECOND AMENDED MOTION FORSUMMARY JUDGMENT

THIS CAUSE came before the Court on November 29, 2018 upon the Defendant’s Motion for Summary Judgment, filed on June 27, 2018, and the Plaintiff’s Second Amended Motion for Summary Judgment, filed on October 16, 2018. Having reviewed the file, having heard arguments from counsel, and being otherwise fully advised in the premises, the Court finds as follows:

1. The Plaintiff has brought the above-styled cause of action seeking allegedly overdue/unpaid Personal Injury Protection (“PIP”) benefits for injuries sustained in an automobile accident which occurred on September 13, 2016.

2. The issue in this case is the Defendant’s denial of payment for CPT/HCPCS Code A4556 (electrodes) that was billed in conjunction with CPT/HCPCS Code G0283 (electrical muscle stimulation) on service date September 22, 2016.

3. Florida Statute Section 627.736(5)(b)l.e. (2016) provides that an insurer is not required to pay a claim or charges for “any treatment or service . . . that is unbundled when such treatment or services should be bundled, in accordance with paragraph (d).” Florida Statute Section 627.736(5)(d) (2016) goes on to require that “all billings for such services rendered by providers must . . . comply with the CMS 1500 form instructions, the American Medical Association CPT Editorial Panel, and the Healthcare Common Procedure Coding System (HCPCS); and must follow the Physicians’ Current Procedural Terminology (CPT), the HCPCS in effect for the year in which services are rendered.” (Emphasis added).

4. “In determining compliance with applicable CPT and HCPCS 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, Physicians Compliance Guidelines, and other authoritative treatises designated by rule by the Agency for Health Care Administration.” Id.

5. The Centers for Medicare & Medicaid Services (“CMS”) states that one component of the Medicare Physician Fee Schedule (“MPFS”) is the Practice Expense (“PE”) Relative Value Unit (“RVU”). CMS and MPFS state that, “PE RVU reflects the costs of maintaining a practice (for example, renting office space, buying supplies and equipment, and staff costs.” See CMS Medicare Learning Network (“MLN”) ICN 006814, MPFS Payment System Series, December 2016. (Emphasis added).

6. The CMS Physician Fee Schedule Final Rule for Calendar Year 2016 (“CMS-1631-FC”) shows that CMS provides a spreadsheet containing the descriptions of various items included in the calculation of the practice expense relative value units. Of note, the CMS-1631-FC _ PUF _SUPPLY spreadsheet states that the items included in the calculation of the practice expense relative value unit of in-office electrical stimulation therapy, HCPCS code G0283, are as follows:

hcps	source	category	cms_code	description	unit	price	nf_quantity	f_quantity	global_period	refererence_code
G0283	RUC	Pharmacy, NonRx	SJ024	electrolyte coupling gel	ml	0.016	1	0	XXX	97014
G0283	RUC	Office Supply, Grocery	SK068	razor	item	0.389	1	0	XXX	97014
G0283	RUC	Gown, Drape	SB022	gloves, non-sterile	pair	0.084	1	0	XXX	97014
G0283	RUC	Accessory, Procedure	SD055	electrode, electrical stimulation	item	1.312	2	0	XXX	97014
G0283	RUC	Pharmacy, NonRx	SJ053	swab-pad, alcohol	item	0.013	1	0	XXX	97014
G0283	RUC	Wound Care, Dressings	SG079	tape, surgical paper 1in (Micropore)	inch	0.002	6	0	XXX	97014

7. Thus, it is clear that payment for two (2) electrodes, regardless of the type, are included within the calculation of the price for CPT/HCPCS Code G0283 for the electrical stimulation service performed in non-facility settings such as a physician office. Therefore, there can be no separate payment for electrical stimulation electrodes which are incident to this procedure.

8. Because payment for electrodes was already included within the calculation for payment of the G0283 electrical stimulation procedure performed during the same encounter, additional payment of CPT/HCPCS Code A4556 would be considered unbundling and result in duplicative payment.

Accordingly, it is hereby ORDERED AND ADJUDGED as follows:

1. The Defendant’s Motion for Summary Judgment, filed on June 27, 2018, is GRANTED.

2. The Plaintiff’s Second Amended Motion for Summary Judgment, filed on October 16, 2018, is DENIED.

3. This Court reserves jurisdiction to consider any applicable claims for reasonable attorneys’ fees and costs, if any.