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Florida Fourth DCA rules that medical provider had improperly “unbundled” billing codes to increase the amount billed to the insurance company

On June 23, 2021, in Associates inFamily Practice of Broward, LLC v. Allstate Fire and Casualty Insurance Company, No. 4D21-173,a Personal Injury Protection (“PIP”) case, the Florida Fourth DCA affirmed a county court order in favor of the defendant insurance company after concluding that the plaintiff medical provider had improperly “unbundled” certain billing codes to increase the amount billed to the insurance company. The Fourth DCA found that that while the provider billed under separate codes, the evaluation and management code encompassed the manual muscle testing code. As such, to unbundle the codes, the 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. The Court cited in support 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”). The Court noted that the medical provider had later provided the evaluating physician’s affidavit explaining why the manual muscle testing was necessary but held that this does not change the fact that the medical provider failed to provide a separate report when submitting its bill.

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