Court approves the chiro rate for Evaluation codes and consultation codes

Charles Deng Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., 2017 NY Slip Op 51460(U)(App. Term 2d Dept. 2017)

“By order entered September 3, 2014, the Civil Court granted plaintiff’s motion to the extent of awarding it $54.74 on its $80 claim for a service billed under CPT code 99203, based upon a workers’ compensation fee schedule reduction, denied the remainder of plaintiff’s motion, and granted the branches of defendant’s cross motion seeking to dismiss the remainder of the complaint, which sought to recover for services billed under CPT codes 97810 and 97811, and so much of the complaint as sought to recover the additional $25.26 on the claim for a service billed under CPT code 99203. Plaintiff appeals, arguing that its motion should have been granted in its entirety and that defendant’s cross motion should have been denied in its entirety.

Contrary to plaintiff’s contention, the proof submitted by defendant in support of its cross [*2]motion was sufficient to give rise to a presumption that the denial of claim forms had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 ). Defendant further demonstrated that it had fully paid plaintiff for the services billed under CPT codes 97810 and 97811 in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors (see Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 ).”

In this case, State Farm did not pay the consultation or evaluation codes.  They were denied as out of scope.  The motion for summary judgment conceded the chiropractor rates.  Civil Court granted judgment as to those rates.  The Appellate Term found this type of after the fact determination was proper.

Related Articles

• NY Acupuncture Fee Schedules: Licensed Practitioners Limited to Chiropractor Rates
• NY Acupuncture Prima Facie Defense: Chiropractor Rate Limitations Upheld
• Understanding Medical Billing and Down-Coding in New York No-Fault Insurance Claims
• Fee Schedule Defense Requirements in No-Fault Insurance Cases
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2017 decision, New York’s no-fault fee schedules have undergone multiple revisions, including updates to workers’ compensation fee schedules that may affect the reimbursement rates for evaluation codes (CPT 99203) and acupuncture services (CPT 97810, 97811) discussed in this case. Practitioners should verify current fee schedule provisions and reimbursement methodologies, as the specific rates and calculation methods referenced may no longer reflect current law.