Court Opinion

ID: 8374764
Source: CourtListenerOpinion
Date Created: 2022-10-20 14:05:53.271609+00
Date Added: 2024-06-11T16:46:23.725964
License: Public Domain

NOT FOR PUBLICATION WITHOUT THE
                   APPROVAL OF THE APPELLATE DIVISION

                                        SUPERIOR COURT OF NEW JERSEY
                                        APPELLATE DIVISION
                                        DOCKET NO. A-0221-21

JIGNYASA DESAI, D.O., LLC                 APPROVED FOR PUBLICATION
on assignment of H.Y.L., 1
                                                 October 20, 2022
         Plaintiff-Appellant,                 APPELLATE DIVISION

v.

NEW JERSEY MANUFACTURERS
INSURANCE COMPANY, 2

     Defendant-Respondent.
________________________________

               Argued October 11, 2022 – Decided October 20, 2022

               Before Judges Whipple, Mawla and Smith.

               On appeal from the Superior Court of New Jersey,
               Law Division, Bergen County, Docket No. L-5247-21.

               S. Gregory Moscaritolo argued the cause for appellant.

               Gregory E. Peterson argued the cause for respondent
               (Dyer & Peterson, PC, attorneys; Gregory E. Peterson,
               on the brief).

1
     We use initials to protect the patient's privacy, pursuant to Rule 1:38-3(a).
2
   Respondent is interchangeably referred to as New Jersey Manufacturer's
Insurance Group and New Jersey Manufacturer's Insurance Company by the
parties and the documents contained within the appellate record.
      The opinion of the court was delivered by

MAWLA, J.A.D.

      Plaintiff Jignyasa Desai, D.O., LLC appeals from a September 20, 2021

Law Division order denying its request to modify an arbitration award

involving defendant New Jersey Manufacturer's Insurance Company (NJM),

regarding reimbursement for nerve tests performed on plaintiff's patient,

H.Y.L. We reverse and remand for entry of an award in plaintiff's favor,

consistent with this opinion.

      The parties' dispute was arbitrated pursuant to the Alternative Procedure

for Dispute Resolution Act (APDRA), N.J.S.A. 2A:23A-1 to -19. A dispute

resolution professional (DRP) found for defendant, and plaintiff appealed to a

three-DRP panel, which affirmed the original award by a majority ruling.

Plaintiff appealed from the panel's decision, and a Law Division judge

affirmed in an oral opinion.

      On this appeal, plaintiff urges us to exercise our supervisory function

and reverse, arguing there is a split in authority in the interpretation of the

governing regulation, N.J.A.C. 11:3-29.4(e). The regulation states:

            [T]he insurer's limit of liability for any medical
            expense benefit . . . not set forth in or not covered by
            the fee schedules shall be a reasonable amount
            considering the fee schedule amount for similar
            services . . . . When a [current procedural terminology
            (CPT)] code for the service performed has been
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            changed since the fee schedule rule was last amended,
            the provider shall always bill the actual and correct
            code found in the most recent version of the . . . [CPT
            book]. The amount . . . the insurer pays for the
            service shall be in accordance with this subsection.
            Where the fee schedule does not contain a reference to
            similar services or equipment as set forth in the
            preceding sentence, the insurer's limit of liability for
            any medical expense benefit for any service or
            equipment not set forth in the fee schedules shall not
            exceed the usual, customary and reasonable [(UCR)]
            fee.

            [Ibid.]

      The American Medical Association (AMA) promulgates CPT codes for

every procedure reimbursable by medical insurance providers. 3          The CPT

codes contain no fee schedules, basic units, relative values, or related listings.

N.J.A.C. 11:3-29.2. Rather, the Commissioner of the New Jersey Department

of Bank and Insurance (DOBI) promulgates the fee schedule. N.J.S.A. 39:6A-

4.6. Therefore, the CPT codes and the fee schedules may sometimes be out of

synch.

      Plaintiff started a course of treatment for H.Y.L., which involved

electromyography and nerve conduction velocity (NCV), or nerve conduction

study tests. Plaintiff received approval for the testing under CPT code 95913,

3
  See CPT Codes, Then and Now, American Medical Association (Aug. 4,
2015),   https://www.ama-assn.org/practice-management/cpt/cpt-codes-then-
and-now.

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which is defined as "[thirteen] or more nerve studies."       It then conducted

twenty separate NCV tests, which contained three different types of tests

coded in the New Jersey fee schedule at the time, including: Eight motor

nerve studies coded under 95903; ten sensory tests under 95904; and two "H"

tests under 95934. These three codes are no longer recognized by the CPT

book and have been consolidated under one current code, 95913. 4 "These

changes were made in an effort to address the overlap in the pre-test and post-

test work involved in the procedures." Ibid. As a result, CPT 95913 does not

differentiate the type of test, rather, the code represents the administration of

"[thirteen] or more" tests.

      Under the old codes, the prices per unit for the tests were as follows:

95903, $176.35; 95904, $135.64; and 95934, $155.93. Thus, the total billed

under the old codes for H.Y.L. would be $3,079.06 ((176.35 x 8) + (135.64 x

10) + (155.93 x 2)). Plaintiff billed $9,585 using CPT 95913. Defendant

reimbursed $2,292.55, representing $176.35, the per unit price of the most

expensive old test code, CPT 95903, multiplied by thirteen.

      Pursuant to N.J.A.C. 11:3-29.4(e), when a code is updated it is cross-

referenced to the old code that it replaced. This process is commonly referred

4
  Nerve Conduction Studies (Codes 95907-95913) (March 2013), AMA CPT
Assistant, https://www.findacode.com/newsletters/ama-cpt-assistant/index.
html.

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to as "cross-walking."5 Plaintiff argued this method required defendant to

"cross-walk" the tests performed back to the old codes, 95903, -04, and -34,

which correspond to the current code, 95913, resulting in an additional

$786.51 for the additional seven tests performed.

       During arbitration, each party provided expert testimony to support its

view of the billing dispute. The DRP found NJM "sufficiently reimbursed"

plaintiff.    Moreover, based on the evidence defendant presented, the DRP

concluded "the relative value units . . . for the NCS portion of the testing has

been modified by the AMA" to lower the value of the testing under the form er

codes.       A majority of the DRP panel affirmed holding "[t]he CPT code

language for CPT 95913 caps reimbursement at [thirteen] studies. There is no

mistake of law or misapplication of the regulation."

       The Law Division judge noted "if this is not decided consistently[,] it's

going to cause more problems going forward . . . ." However, he concluded

"this is a UCR case. It is not a crosswalk situation. And I have no reason to

disturb the factual findings below[,] which led to [the DRP] deciding the case

the way [they] did." The judge further found "[t]his is not a coding dispute

between the parties[]" because it deals with "reimbursement of NCV testing

5
  Crosswalking, MB&CC, https://www.medicalbillingandcoding.org/crosswal
king/.

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. . . under an agreed code."    He concluded the correct method was not to

crosswalk "because the way it's coded now there's no differentiation at all."

The DRP's decision "was supported substantially by the factual information

given to the DRP below and . . . the reason for the CPT code change was to

prevent or someway restrict what was considered at that time as . . . overbilling

by medical providers."

                                       I.

      When parties "knowingly agree[] to resolve their disputes under the

APDRA," they agree to a limited right of appeal. Mt. Hope Dev. Assocs. v.

Mt. Hope Waterpower Project, L.P., 154 N.J. 141, 152 (1998). Once a trial

judge reviews an arbitration award under the APDRA, "[t]here shall be no

further appeal or review" of decisions "confirming, modifying or correcting an

award . . . ." N.J.S.A. 2A:23A-18(b). The exceptions to this rule include when

it is "necessary for [the reviewing court] to carry out its 'supervisory function

over the [trial] courts.'" Morel v. State Farm Ins. Co., 396 N.J. Super. 472,

476 (App. Div. 2007) (quoting Mt. Hope Dev. Assocs., 154 N.J. at 152). Our

supervisory review is warranted "where public policy would require appellate

court review." Mt. Hope Dev. Assocs., 154 N.J. at 152; see also Allstate Ins.

Co. v. Sabato, 380 N.J. Super. 463, 472 (App. Div. 2005).

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      Plaintiff urges us to exercise our supervisory authority to settle a split in

authority and points us to a litany of DRP decisions interpreting N.J.A.C. 11:3-

29.4(e) through the cross-walking methodology. Conversely, defendant's brief

cites several decisions that reach the opposite conclusion. Plaintiff argues our

review is also warranted because the judge exceeded his authority under

APDRA, and his decision did not satisfy the substantial evidence standard.

                                        II.

      Because this dispute regards interpretation of a regulation, our review is

de novo. N.J. Mfrs. Ins. Co. v. Specialty Surgical Ctr. of N. Brunswick, 458

N.J. Super. 63, 70 (App. Div. 2019). On a de novo review of a regulation, we

give "effect to [its] plain language" and look to agency interpretation of the

regulation. In re Young, 471 N.J. Super. 169, 180 (App. Div. 2022) (quoting

In re M.M., 463 N.J. Super. 128, 138 (App. Div. 2020)); N.J. Ass'n of Sch.

Adm'rs v. Schundler, 211 N.J. 535, 549 (2012).

      The plain language of N.J.A.C. 11:3-29.4(e) informs an insurer its "limit

of liability for any medical expense . . . not set forth in . . . the fee schedules

shall be a reasonable amount considering the fee schedule amount for similar

services . . . ." But "[w]here the fee schedule does not contain a reference to

similar services or equipment . . . the insurer's limit of liability . . . shall not

exceed the [UCR]." Ibid.

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      DOBI explained its interpretation of N.J.A.C. 11:3-29.4(e) through the

following hypothetical:

            Q. The CPT code for the service performed has been
            changed since the fee schedule rule was last amended.
            For example, CPT codes 64470 through 64476 for
            facet joint injections have been deleted and replaced
            by codes 64490 through 64495 in the 2010 edition of
            the CPT manual. How should facet joint injections be
            billed and paid?

            A. The provider should always bill the actual and
            correct CPT code that he or she is providing. The
            amount that the insurer pays for the service is
            determined by whether the service is similar to one
            already on the fee schedule as required by N.J.A.C.
            11:3-29.4(e). That is the standard for determining
            whether the fee for a CPT code that is on the fee
            schedule can be used to set a fee for a code that is not
            on the fee schedule. The answer depends on the
            circumstances of each case.

            In the case of [f]acet joint injections, although the
            descriptions of the procedures have been revised and
            reorganized and the new codes have been placed in a
            new subsection of the CPT code book . . . [DOBI]
            notes that the [related value units] for the new codes
            are very similar to those for the deleted codes.

            [Auto Medical Fee Schedule Frequently Asked
            Questions, NJ Department of Banking and Insurance,
            https://www.state.nj.us/dobi/pipinfo/medfeeqa.html
            (last updated February 2011).]

      The plain language of N.J.A.C. 11:3-29.4(e), and DOBI's interpretation

of it, makes clear plaintiff's interpretation is the correct one. Pursuant to the

regulation, the new CPT code, 95913, should be billed to the deleted CPT
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code(s), 95903, 95904, and 95934. The parties do not dispute the new code

substitutes for the deleted ones. Thus, the related value units of the new code

and the deleted ones are similar. Defendant's contention the UCR analysis

should control ignores N.J.A.C. 11:3-29.4(e)'s instruction to consult the fee

schedule and bill based on "similar services" if a code no longer exists in the

CPT book. For these reasons, we reverse and remand for entry of an award in

plaintiff's favor.

                                       III.

      Finally, plaintiff argues we should remand for a determination of

counsel fees. Attorney's fees are allowable "[i]n an action upon a liability or

indemnity policy of insurance, in favor of a successful claimant." R. 4:42-

9(a)(6). The court considers:

             (1) the insurer's good faith in refusing to pay the
             demands; (2) excessiveness of plaintiff's demands; (3)
             bona fides of one or both of the parties; (4) the
             insurer's justification in litigating the issue; (5) the
             insured's conduct in contributing substantially to the
             necessity for the litigation on the policies; (6) the
             general conduct of the parties; and (7) the totality of
             the circumstances.

             [Enright v. Lubow, 215 N.J. Super. 306, 313 (App.
             Div. 1987).]

An award of counsel fees is discretionary. Ibid. (internal citations omitted)

(citing Felicetta v. Com. Ins. Co., 117 N.J. Super. 524, 529 (App. Div. 1971)).

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"Such fees may be allowed on appeal." Maros v. Transamerica Ins. Co., 76

N.J. 572, 579 (1978) (citing Corcoran v. Hartford Fire Ins. Co., 132 N.J.

Super. 234, 244-45 (App. Div. 1975)).

      The issue presented was novel and unsettled. For these reasons, and

because we are unconvinced the Enright factors would favor an award of fees

to plaintiff, we decline to remand for consideration of counsel fees.

      Reversed and remanded. We do not retain jurisdiction.

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