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2182The Rogak Report: 01 Oct 2009 ** No Fault - Fee Schedule - Knee Surgery **

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  • Lawrence
    Oct 1, 2009
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      In the Matter of the Arbitration between Sun Orthopedic Surgery and Global Liberty Insurance Company of New York, AAA Case No. 412009024888, AAA Assessment No. 17 991 14181 09 (Claim File No. 095700) (Maureen  Callahan, Arbitrator)

      Edited by Lawrence N. Rogak

      This accident occurred on 03/15/09. A knee surgery was performed on the EIP on 05/01/09. Applicant seeks additional fees in connection with that claim. This claim was reduced to $5,419.68. Applicant reduced the total amount of the claim to $8,349.00. Applicant acknowledges payment of $2,929.92. Hence, the new amount in dispute is $5,419.68.

      The surgery itself is not in dispute. The partial payment is a concession of the necessity for same. What is in dispute is the amount billed and reimbursed. It is conceded that there were three billing codes: 29879, 29876, and 29873. The appropriate fee schedule amount is $1,779.64, $1,878.13, and $1,777.35 respectively.

      Applicant argues that his bills were multiplied by modifier 59. He argues that there were three portals for the surgery. He argues that this is a different surgery site and he is entitled to the modifier. Applicant's position paper states that it should be reduced by 50%, that it was not a separate procedure on the 54 year old male.

      Applicant argues that the medical records are clear, that the standard inferior, medical, and lateral portals were established with a surgical scalpel. Applicant makes strong arguments that his client's billing was correct, and that is why his client used modifier 59.

      The official Worker's Compensation Fee Schedule guidelines for the no-fault filings herein, notes that modifier 59, is utilized for distinct procedural service. Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from the other services...modifier 59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstance.

      Absent any persuasive argument by respondent, applicant has made a prima facie showing of entitlement to payment. Hence, he has made a showing of entitlement to payment.

      This claim is in favor of applicant for $5,419.68.

      Comment: Perhaps a peer review by a surgeon, with the professional opinion that this was really one procedure, not three, might have been persuasive.

      Larry Rogak