Key Takeaway
4th DCA ruling on manual muscle testing CPT codes in no-fault insurance - provider failed to justify unbundling evaluation codes with required documentation
ASSOCIATES IN FAMILY PRACTICE OF BROWARD, LLC a/a/o YVETTE BROWN v. ALLSTATE FIRE AND CASUALTY INSURANCE COMPANY, 4D21-173 (Fla. 4th DA 2021)
(1) “Provider billed Allstate using four different Current Procedural Terminology (“CPT”) codes as published in the American Medical Association’s CPT Manual, two of which are relevant to this case: CPT code 99205-25 (“the evaluation and management code”) and CPT code 95832 (“the manual muscle testing code”). Allstate paid the evaluation and management code claim but denied payment for the manual muscle testing code claim. Allstate explained the reason for the denial as follows: “The provider has used modifier -25 to identify that on this date of service, the patient’s condition required a significant, separately identifiable service above and beyond the other service provided … .” In accordance therewith, Allstate requested additional documentation demonstrating the appropriate use of the modifier -25. Provider did not submit the requested additional documentation.”
(2)”We adopt the county court’s well-reasoned order in its entirety. As correctly found by the county court, the evaluation and management code encompassed the manual muscle testing code. As such, in order to unbundle the codes, Provider was required to provide a separate written report explaining why the manual muscle testing was necessary beyond the gross muscle testing encompassed within the evaluation and management service. See State Farm Mut. Auto. Ins. Co. v. R.J. Trapana, M.D., P.A., 23 Fla. L. Weekly Supp. 98a (Fla. 17th Cir. Ct. May 14, 2015) (review of X-rays improperly unbundled from evaluation and management code where the provider did not provide a separate report “solely about his interpretation of the X-rays”). Merely including a notation in the single four-page report and adding a modifier -25 to the evaluation and management code was not enough to bill for the codes separately. Moreover, although Provider later provided the evaluating physician’s affidavit explaining why the manual muscle testing was necessary, this does not change the fact that Provider failed to provide a separate report when submitting its bill.”
Manual muscle testing, It appears, the foundling rule is valid when the initial or follow-up extermination done on the same day as the MMT is rather devoid of data. For all my years of no-fault, the unbundling argument has always confounded me somewhat. Interstingly, this case gives me a new outlook on MMT and unbundling.
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