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New Jersey court affirms decision that ambulatory surgical centers cannot receive payment for certain coded procedures

By Gabriel Neves | Feb 7, 2019

TRENTON, N.J. (Legal Newsline) – An insurance company that was sued by two clinics regarding the reimbursement of medical procedures for insured clients injured in car accidents has obtained a victory in court.

Judge Richard Hoffman, on the bench of the New Jersey Superior Court Appellate Division, issued a 16-page ruling on Jan. 29 affirming the Superior Court of New Jersey, Law Division, Bergen County decision in the lawsuit filed by New Jersey Manufacturers Insurance Co. (NJM) against Specialty Surgical Center of North Brunswick and Surgicare Surgical Associates of Fair Lawn.

The court affirmed the Law Division's decision that vacated two arbitration awards in favor of the clinics, stating that the personal injury protection coverage fee schedule did not provide payment for non-reimbursable medical procedures performed at ambulatory surgical centers (ASC).

The appeal brought two cases to light.

"In the first case, Claire Fiore, an NJM insured, sustained injury to her lower back in a May 2014 accident involving an automobile. In November 2015, Fiore underwent a lumbar discectomy at the ASC operated by defendant Specialty Surgical Center of North Brunswick," the ruling states.

"Following the procedure, Specialty Surgical sought $32,500 in reimbursement from NJM under (Current Procedural Terminology) code 63030; however, NJM denied payment, claiming the treatment was not medically necessary and further asserting 'the CPT code charged by

the facility – 63030 – had no reimbursement value for the ASC on the Fee Schedule,'" the ruling said.

The next case is of Martino Chizzoniti, who, per the ruling, "also sustained injury to her lower back in a May 2014 accident involving an automobile," and who also had surgery in 2015 in a facility "operated by defendant Surgicare Surgical Associates of Fair Lawn (Surgicare)."

Surgicare then sought $49,000 in reimbursement, but "NJM denied reimbursement because 'the CPT code charged by the facility – 63030 – had no reimbursement value for the ASC on the Fee Schedule,'" the ruling said.

After seeking arbitration, an award was decided against NJM, who appealed to the Law Division and obtained an order vacating the awards.

"We conclude ASCs should not receive reimbursement for CPT code 63030 procedures because no reimbursement was listed in the ASC columns in the fee schedule, as originally proposed," Hoffman wrote.

Superior Court of New Jersey Appellate Division case number A-0319-17T1

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