A Pennsylvania appellate court has concluded that an examination involving no new medical condition, change in medical condition, or other circumstances that require an examination and assessment above and beyond the usual examination and evaluation for the treatment performed on the same date does not constitute “a significant and separately identifiable service” for which a chiropractor may be paid under 34 Pa. Code § 127.105(e) [Sedgwick Claims Mgmt. Servs. v. Bureau of Workers’ Comp., 2018 Pa. Commw. LEXIS 124 (Apr. 11, 2018)]. Accordingly, a chiropractor treating an injured worker was not entitled to payment for 39 “office visit” charges of $78 each on dates on which he provided chiropractic treatment to the worker and billed for the other treatments.
Following a work-related injury, Claimant and his employer entered into a Compromise and Release Agreement (C&R) that was ultimately approved by a WCJ. Under the C&R, the employer remained obligated to pay reasonable and necessary medical expenses for the Claimant’s shoulder injury. Claimant was treated by a chiropractor as many as three times each week.
During a six-month period, the chiropractor sent the employer’s TPA bills for his treatment of Claimant that included charges of $78.00 per visit for office visits on dates on which he provided chiropractic treatment to Claimant and billed for the other treatments. The TPA denied payment for the office visit charges, but paid the chiropractor for other treatments that he provided on those dates.
The Pennsylvania Statute and Medicare Codes
34 Pa. Code § 127.105(e) permits payment for office visits “only when the office visit represents a significant and separately identifiable service performed in addition to the other procedure.” The Commonwealth Court noted that Section 306(f.1) of the Workers’ Compensation Act and the Medical Cost Containment Regulations, promulgated by the Bureau to implement Section 306(f.1)[77 Pa. Stat. § 531], require health care providers to bill for their treatment of workers’ compensation claimants in accordance with Medicare procedure codes and limit payment to providers based on Medicare reimbursement rates.
The court stressed that federal Medicare case law and administrative decisions have held, in cases of catheter placements and minor surgical procedures, that an examination or evaluation on the same date as another procedure does not constitute a “significant and separately identifiable service” unless it is above and beyond the usual evaluation performed in conjunction with that procedure or is unrelated to the procedure that was performed on the same day.
Payment for Same-Day Exams the Exception, Not the Rule
The court concluded that § 127.105(e) showed a clear intent to make payment for same-day examinations the exception, not the rule. Construing the statute to permit payment of office visit charges for same-day examinations performed on a routine basis without special circumstances unique to the patient’s condition or nature of the treatment session would effectively read this limiting language out of the regulation.