Doctor of Medicine in the House, P.C. v Allstate Ins. Co., 2013 NY Slip Op 23357 (District Ct. Suffolk Co. 2013)
“Paragraph 11 of the New York Compensation Medical Fee Schedule provides:
Multiple Physical Medicine Procedures and Modalities:
When multiple physical medicine procedures and/or modalities are performed on the same day, reimbursement is limited to 8.0 units or the amount billed, whichever is less. The following codes represent the physical medicine procedures and modalities subject to this rule. . .”
“The purpose of the Workers’ Compensation Medical Fee Schedule is to prevent “excessive billing” by each individual provider and not to create an “exhaustion” of benefits competition between claimants as is clearly the intent of Sec. 65-3.15. The fee schedule is a guideline on how to properly fill out and submit a claim. Such a finding is consistent with the Court of Appeals direction to interpret “no-fault” regulations in such a manner as to not frustrate the legislative intent of requiring prompt payment of benefits. See Nyack Hosp. v. Gen. Motors Accept. Corp., 8 NY3d 294 (NY 2007), citing to Med. Soc. of NY v.Serio, 100 NY2d 854 (NY 2003). Paragraph 11 does not indicate that it regulates benefits for “all” claims on any given day.”
“Accordingly, the Court enters judgment for the plaintiff allowing reimbursement for 8 of its claims’ 10 billing units, in the sum of $1,876.76 plus appropriate statutory interest, attorneys fees and costs.”
This is a District Court opinion so its precedential value is limited. I believe ground rule 11 applies to all services, except chiropractor CMT services rendered on the same day as PT/OT/MT services. To hold otherwise could allow $1000 PT service type per diem billing. This decision is against the weight of authority from most arbitrators and other judges.
I would note that in Ashraf Ashour v. Interboro, the fee schedule issue involved CPT Code 97039 when 8 units of PT were already billed and paid from another provider on the same dates of service. The Appellate Term granted our summary judgment motion. So, take Doctor in the House for what it is worth.
