Down-coding acceptableDecember 18, 2018

Urban Well Acupuncture, P.C. v Global Liberty Ins. Co. of N.Y., 2018 NY Slip Op 51833(U)(App. Term 1st Dept. 2018)

“In opposition to defendant-insurer’s prima facie showing of entitlement to summary judgment on the grounds of lack of medical necessity and that the amounts sought exceeded the amounts permitted by the workers’ compensation fee schedule, plaintiff failed to raise a triable issue. Although defendant previously moved for summary judgment, its prior motion contained an unsworn chiropractic IME report. Thus, the court properly considered defendant’s renewed motion based upon substantively identical proof in proper form (see Cespedes v McNamee, 308 AD2d 409 [2003]).

We note that defendant, on reply below, corrected alleged coding errors in plaintiff’s bills and agreed that plaintiff was entitled to an additional $439.25.”

The last paragraph is noteworthy.  The pre-IME bills contained numerous iterations of CPT Code 97810.  The pre-IME billings were paid at either the physician or chiropractor fee schedule.  In Reply, I calculated the 97810’s, reduced them to 97811’s and conceded the chiropractor rate.  The Appellate Term agreed and the case was dismissed, less the additional sums to which Plaintiff is entitled.