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
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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) If you’re dealing with a no-fault insurance defense matter, an experienced attorney can help protect your rights.
(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.
(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. J. , 23 Fla. L. Weekly Supp. 98a (Fla. 17th Cir. Ct.
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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.
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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Why This Matters for Your Case
New York's no-fault insurance system, established under Insurance Law Article 51, is one of the most complex insurance frameworks in the country. Every motorist must carry Personal Injury Protection coverage that pays medical expenses and lost wages regardless of fault, up to $50,000 per person.
But insurers routinely deny valid claims using peer reviews, EUO scheduling tactics, fee schedule reductions, and coverage defenses. The Law Office of Jason Tenenbaum has handled over 100,000 no-fault cases since 2002 — from initial claim submissions through arbitration before the American Arbitration Association, trials in Civil Court and Supreme Court, and appeals to the Appellate Term and Appellate Division. Jason Tenenbaum is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
His 2,353+ published legal articles on no-fault practice are cited by attorneys throughout New York. Whether you are dealing with a medical necessity denial, an EUO no-show defense, a fee schedule dispute, or a coverage question, this article provides the kind of detailed case-law analysis that helps practitioners and claimants understand exactly where the law stands.
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New York No-Fault Insurance Law
New York's no-fault insurance system requires every driver to carry Personal Injury Protection (PIP) coverage that pays medical expenses and lost wages regardless of who caused the accident. But insurers routinely deny, delay, and underpay valid claims — using peer reviews, IME no-shows, and fee schedule defenses to avoid paying providers and injured claimants. Attorney Jason Tenenbaum has litigated thousands of no-fault arbitrations and court cases since 2002.
271 published articles in No-Fault
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