26 Fla. L. Weekly Supp. 772a
Online Reference: FLWSUPP 2609JACQInsurance — Personal injury protection — Coverage — Medical expenses — CPT codes — Unbundled charges — Where charges for range of motion testing were improperly unbundled from charge for muscle testing performed on same date, insurer properly denied payment for unbundled charges
FOUNDATION CHIROPRACTIC CENTER INC, Patient Jeannine Jacques, Plaintiff/Petitioner v. STATE FARM FIRE & CASUALTY COMPANY, Defendant/Respondent. County Court, 15th Judicial Circuit in and for Palm Beach County, County Civil Division RJ. Case No. 50-2011-SC-003962-XXXX-MB. October 22, 2018. Sherri L. Collins, Judge. Counsel: Frank T. Noska, III, Palm Beach, for Plaintiff. Daniel Kuczler, Roig Lawyers, Deerfield Beach, for Defendant.
FINAL JUDGMENT FOR DEFENDANT
THIS CAUSE came before the Court for hearing on September 21, 2018 on Defendant’s Motion for Summary Judgment, and the Court having heard the arguments of counsel, having reviewed the relevant filings and otherwise having been fully advised in the premises, the Court hereby ORDERS and ADJUDGES as follows:Findings of Fact
1. Plaintiff, Foundation Chiropractic Center, Inc., filed suit seeking damages in a breach of contact cause of action, specifically to recover Personal Injury Protection benefits under a policy of insurance issued by the Defendant, State Farm Fire & Casualty Company, and to the benefit of Jeannine Jacques.
2. The only date of service placed at issue through Foundation Chiropractic Center, Inc.’s complaint was the date of service of February 18, 2008.
3. Foundation Chiropractic Center, Inc.’s medical bill, for the date of service of February 18, 2008, listed the following treatments and corresponding CPT Codes:
a. Muscle Testing — 95831.
b. Range of Motion — 95851.
c. Range of Motion — 95851.
d. Range of Motion — 95851.
4. State Farm issued payment for Muscle Testing — 95831 at 80% of the charged amount.
5. State Farm denied payment for all three Range of Motion — 95851 charges, stating the codes reported by the provider are included in another procedure reported on the bill.
6. In support of its Motion for Summary Judgment, State Farm filed the Affidavit of Nicole Bonaparte, a Certified Professional Coder and a Licensed Professional Medical Coding Curriculum Instructor. Nicole Bonaparte reviewed the treatments and services at issue, and found, “CPT code 95851 is an integral component of CPT code 95831, meaning that 95851, according to the AMA, should not be reported separately when 95831 is performed”.
7. In opposition to State Farm’s Motion for Summary Judgment, Foundation Chiropractic Center, Inc., filed the Affidavit of Carri Vecchio, State Farm’s Corporate Representative, as the only filed evidence in opposition.
8. Plaintiff argued the undisputed facts that State Farm did not process and pay Foundation Chiropractic Center, Inc.’s timely submitted bill for the date of service February 18, 2008 until June 23, 2008. In State Farm’s denial of payment for CPT code 95851, Defendant offered Plaintiff pursuant to Florida Statute 627.736(6)(b), to provide any information to substantiate payment. Foundation Chiropractic Center, Inc. argued that State Farm waived this request because the request was not timely made. The Court rejected Plaintiff’s position.Findings of Law and Ruling
State Farm fully complied with its policy of insurance by issuing payment in the amount of $156.00, or 80% of the billed amount for Muscle Testing – 98531.
State Farm’s denial of Foundation Chiropractic Center, Inc.’s charges for Range of Motion — 95851 were in compliance with the Florida No-Fault Law.
Florida Statute section 627.736(5)(b)1 states:
“An insurer or insured is not required to pay a claim or charge:
e. For any treatment or service that is upcoded, or that is unbundled when such treatment or services should be bundled, in accordance with paragraph (d)”.
Further, Florida Statute section 627.736(5)(d) states:
“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).” Further, “For purposes of paragraph (4)(b), an insurer shall not be considered to have been furnished with notice of the amount of covered loss or medical bills due unless the statements or bills comply with this paragraph. . .”.
Based on the record evidence, including the affidavit of Nicole Bonaparte, this Court finds that the evidence on file shows that there is no genuine issue as to any material fact and that State Farm is entitled to a judgment as a matter of law. Foundation Chiropractic Center, Inc. failed to comply with Florida Statute sections 627.736(5) (b) and (d), as it improperly billed Range of Motion — 95851 when Muscle Testing 95831 was performed the same day. Foundation Chiropractic Center, Inc. did not provide any evidence, and specifically did not provide a specific medical report, in support of its billing both treatments for the same day, or to show its compliance with the requirements of Florida Statute section 627.736(5)(d). Therefore, the Range of Motion — 95851 billing entries were improperly unbundled from Muscle Testing — 95831, and State Farm properly denied these charges.
IT IS HEREBY ORDERED AND ADJUDGED that the Defendant’s Motion for Summary Judgment is hereby granted, and Final Judgment is hereby entered on behalf of Defendant, State Farm Fire & Casualty Company. The Plaintiff, Foundation Chiropractic Center, Inc., shall take nothing by this action. The Court retains jurisdiction for the purpose of determining any motion by State Farm Fire & Casualty Company for Attorney Fees and Costs.
