Key Takeaway
Court upholds insurance carrier's repricing of CPT code 64550 to 97014 in no-fault case, demonstrating proper application of workers' compensation fee schedule.
Understanding CPT Code Repricing in No-Fault Insurance Claims
In New York no-fault insurance law, insurance carriers frequently reprice medical procedures using different CPT codes than those originally billed by healthcare providers. This practice involves substituting a billed CPT code with what the carrier considers a more appropriate code, often resulting in lower reimbursement rates. The case of Compas Med., P.C. v 21st Century Ins. Co. illustrates how courts evaluate the validity of such repricing decisions.
CPT code 64550 typically refers to nerve injection procedures, while CPT code 97014 relates to electrical stimulation therapy. When carriers reprice from one code to another, they must demonstrate that the repricing aligns with the actual services provided and complies with applicable fee schedules. This repricing strategy is part of broader fee schedule enforcement mechanisms that carriers use to control costs while ensuring appropriate reimbursement for legitimate medical services.
Jason Tenenbaum’s Analysis:
Compas Med., P.C. v 21st Century Ins. Co., 2017 NY Slip Op 51228(U)(App. Term 2d Dept. 2017)
“Contrary to plaintiff’s further argument, defendant’s proof was sufficient to demonstrate, prima facie, that defendant had fully paid for the services charged under code 64550 of the workers’ compensation fee schedule”
I am sure the carrier repriced 64550 to 97014. The Court held, with an affidavit, the repricing was proper.
Key Takeaway
This decision reinforces that insurance carriers can successfully defend repricing decisions when they provide sufficient documentary evidence, such as affidavits, demonstrating compliance with applicable fee schedules. Healthcare providers challenging repricing must be prepared to counter the carrier’s prima facie showing with compelling evidence that the original CPT code was appropriate for the services rendered.
Legal Update (February 2026): Since this 2017 post, New York’s no-fault fee schedules and CPT code reimbursement rates have likely been subject to multiple regulatory updates and amendments. Practitioners should verify current fee schedule provisions, repricing protocols, and any changes to acceptable CPT code substitution practices under current New York Insurance Department regulations.
