Geico v. 789456

In Geico v. 789456 filed in 2021, Geico claimed that a PTP was taking place.  Geico claimed that virtually every patient was billed a 99204 examination.  After the examination, each patient was referred for the same modalities which were performed by massage therapists- hot/cold packs; mechanical traction; paraffin baths; electrical stimulation therapy; ultrasound therapy; therapeutic exercises; neuromuscular reeducation; therapeutic activity; and infrared therapy.

Additionally, Geico complained that the Clinics attempted to bill separately for 95851 (range of motion testing) and 95832 (muscle strength testing) even though they should have been included as part of the 99204 examinations.  Geico claims that even if it wasn’t supposed to be included in the 99204 examination charge, that the CPT Assistant states 97750 (physical performance test) was the more appropriate code since 95851 and 95832 were billed on the same day. 

Also, Geico complained that billed and provided “many patients” with L0627 (lumbosacral orthotic/LSO).  Geico states that the LSO is a “rigid, custom-fitted, lower-back brace designed to restrict the movement of the patient’s torso and support the patient’s lumbar spine.  Because of its rigidity and required placement on a patient’s lower back, an LSO must be custom-fitted in order for it to be properly utilized by the patient.  In a legitimate clinical setting, an LSO is reserved for patients who exhibit spinal instability or for patients who have recently undergone spinal surgery, and its prescription is inconsistent with the goals of physical therapy treatment designed to restore and increase range of motion and functionality of the lumbar spine. Unnecessarily immobilizing the lumbar spine may weaken the muscles or lead to muscle atrophy in the lower back. An LSO should not be provided to a patient before that patient has attempted and failed a legitimate course of conservative treatment.