Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co., 2017 NY Slip Op 50101(U)(App. Term 2d Dept. 2017)
I recall prior to heading to a miscellaneous part in Supreme Court with guest visits to Civil Court, Judge Cohen found that a by-report code required compliance in order to make a code compesnsable or a billing overdue. I believed he was wrong and the Appellate Term confirms.
“The record reflects that plaintiff submitted three claim forms to defendant which included charges for 21 sessions of moxibustion, under code 97039, which is described as “Unlisted modality (specify type and time if there was constant attendance)” and for one session of acupressure, under code 99199, which is described as “Unlisted special service, procedure or report.” The workers’ compensation fee schedules do not assign a relative value to either of those codes, but instead have assigned them a “By Report” designation, which requires a provider to furnish certain additional documentation to enable the insurer to determine the appropriate amount of reimbursement. Plaintiff did not provide such documentation with its claim forms and defendant did not, within 15 business days of its receipt of the claim forms, request “any additional verification required by the insurer to establish proof of claim” (11 NYCRR 65-3.5 [b]). As defendant failed to demonstrate upon its motion that it had requested any additional verification from plaintiff seeking the information it required in order to review plaintiff’s claims for services billed under codes 97039 and 99199 of the workers’ compensation fee schedules, defendant was not entitled to summary judgment dismissing so much of the complaint as sought [*2]to recover for services rendered under those codes”
The famous by-report. The Court properly held that a by-report is verification issue. This should not shock anyone; yet, I still see denials and argument based upon the failure to adhere to the by-report guidelines.
4 Responses
Several arbitrators were following the civil court decision (including maslow). so the fact that it was obvious does not change that it was important.
Maslow also holds that on 8 unit cases where the units were paid to another provider, you must spell out who the other units were paid to and the amount of the units that were paid. This flies in the face of Appellate Term case law holding that checking box #18 is enough. Also, in the post Mercury v. Encare environment, this is irrelevant. That case is up at the First Department.
Thank You jason for calling a spade a spade. Judge cohen twisten himself into a pretzel when he made tHat decision. A few months back when defendant cited judge cohen’s decision to him, Judge montalione having read the decision basically said in the footnote that judge cohen was wrong and ciTed the same reasoning as the appellate term. Well i guess the only person who will cite his own decision will be judge cohen. Thank you for bringing light to Judge cohen’s deCision And its Incorrect application of the law and reiterating this after appellate term confirmed your previous reasoNing
I am always honest on here Rookie.