An interesting decision on a well known performer of enhanced MUA

CPT CODE 99455 and 99456.  The MOST abused CPT Codes that are billed.  Of course, leave it to someone who bills for MUA and does not believe in the 68.4% and 16% reduction to bill like this.  See,  Flatbush Chiropractic, P.C. v Metlife Auto & Home, 35 Misc.3d 1203(A)(Civ. Ct. Kings Co. 2012)

Below is the arb award:

I thank a friend at Liberty Mutual for informing me of this:

New York No-Fault Arbitration Tribunal:

In the Matter of the Arbitration between:

Bronx Chiropractic Services, PC / Precious Cooper (Applicant)

– and –

Liberty Mutual Insurance Company (Respondent)

AAA Case No. 412010065292; AAA Assessment No. 17 991 08906 11

1

ARBITRATION AWARD

I, Carolynn Terrell-Nieves, Esq., the undersigned arbitrator, designated by the American Arbitration Association pursuant to the Rules for New York State No-Fault

Arbitration, adopted pursuant to regulations promulgated by the Superintendent of Insurance, having been duly sworn, and having heard the proofs and allegations of the parties make the following AWARD:

Injured Person(s) hereinafter referred to as:

Claimant 1. Hearing(s) held on

05/11/11

and declared closed by the arbitrator on 5/11/11.

Marc Schwartz, Esq., for Gene Sigalov, Esq., participated in person for the Applicant. Robert Trestman, Esq., participated in person for the Respondent.

2. The amount claimed in the Arbitration Request, $350.00, was NOT AMENDED at the oral hearing. STIPULATIONS were not made by the parties regarding the issues to be determined.

3. Summary of Issues in Dispute

Whether the Applicant is entitled to a reimbursement of its claim?

4. Findings, Conclusions, and Basis Therefor

Applicant seeks payment in the amount of $350.00 for a chiropractic examination it performed on the Assignor on June 24, 2010. The Respondent timely denied the claim based

on its contention that the CPT code billed by the Applicant, 99456, is a By Report code without an assigned RVU. Further, as per the fee schedule rules, documentation must be

submitted supporting the provider’s charges. In addition, the Respondent argued that the fee charged far exceeds those of any chiropractic evaluation and management service.

The documents contained in the ECF were reviewed prior to/at the time of the hearing.

In support of its claim the Applicant has submitted a medical record memorializing the chiropractic examination in dispute. Of note, said examination was performed by Dr. Robert Super on June 24, 2010. In addition, the Applicant has submitted an Affidavit by Dr. Super concerning his examination of the Assignor and the amount billed for said service.

In support of its contentions, the Respondent has submitted its Explanation of Benefits for the claim in dispute and two pages from the Workers Compensation Fee Schedule. Based on the documents submitted and the arguments of counsel, I find in favor of the Applicant and award it $54.74 for the chiropractic examination performed on the Assignor on

June 24, 2010.

After reviewing the documents submitted and numerous arbitration decisions concerning this particular issue, I must agree with the Respondent’s contention that the amount billed by the Applicant for the chiropractic examination in dispute was excessive. As to Dr. Super’s Affidavit, initially I note that said document discusses the examination he performed on the Assignor, that he reviewed the Assignor’s medical records prior to/after the examination and why his examination was billed under CPT code 99456.

In Dr. Super’s Affidavit, Dr. Super noted that examinations such as the one in dispute “typically” consist of a thirty five to forty five minute face to face consultation and a

thirty to forty minute review of records. However, what Dr. Super “typically” does with other patients does not specifically state what he did with the Assignor in this matter. I also note that when Dr. Super quoted the Fee Schedule as to the components of a 99456 examination,

he failed to note that said examination, according to the Fee Schedule, is for a work related or medical disability examination. However, there has been no evidence submitted by the Applicant that the examination in dispute was work related or a medical disability examination. I also note that in his Affidavit, Dr. Super noted that the examination of June 24, 2010 was performed to see if the Assignor was a candidate for Manipulation under Anesthesia. However, the Applicant has failed to submit any documentary evidence which

demonstrates that a patient being considered for Manipulation under Anesthesia is required to have a work related or medical disability examination before said procedure is performed.  Notably, most disturbing regarding this Affidavit is that it is clearly boiler plate and used in every case before me submitted by this Applicant. Within the Affidavit, Dr. Super references the patient as a (he) when the patient is clearly a (she). Perhaps he is confusing the patient, but how am I to know. I further have had the pleasure of Dr. Super testifying before me and in that instance, he described exactly why and how such an exam was performed and the rationale as to why the exam was so detailed and exactly what he had to do with the patient that he specifically treated. This Affidavit clearly lacks the establishment of medical necessity for the treatment of the claimant in issue, nor does the Affidavit meet the credibility issue as well.

Although Dr. Super in his Affidavit contended that the examination he performed on the Assignor on June 24, 2010 was more comprehensive than an initial chiropractic examination, I still am not persuaded that the examination of June 24, 2010 is correctly billed under 99456. To wit, I have reviewed hundreds of No-Fault cases over the last several years and can’t recall a physician, even a specialist like an orthopedic surgeon who was examining a patient for a possible surgical intervention, who billed anything close to $350.00 for his/her examination of the patient. As such, and because CPT code 99456 specifically states that the examination to be performed is a work related or medical disability examination, I find that the examination performed by Dr. Super on June 24, 2010 should be reimbursed under CPT code 99203 which is the CPT code for an initial examination by a chiropractor. Therefore, the Applicant is entitled to a reimbursement in the amount of $54.74 for the examination o June 24, 2010.

Based on the aforestated, the Applicant is awarded $54.74 and the balance of its claim is denied.  This award is in full disposition of all No-Fault benefit claims submitted to this Arbitrator.