The New Jersey Superior Appellate Court once again ruled the state's payment scheduled took precedence over CMS' fee schedule, LegalNewsLine reports.
What you should know:
1. This is the second time the appellate court vacated an arbitration award to a clinic. In both instances, the court vacated the award on the grounds that the CPT code did not appear in the state's fee schedule, despite its inclusion in CMS' fee schedule.
https://www.beckersasc.com/asc-coding-billing-and-collections/state-fee-schedule-takes-precedence-over-cms-list-new-jersey-court-rules-5-insights.html
2. In this case, a patient had a lower back surgery in May 2014, after she was involved in an automobile accident. The patient had her procedure performed at Surgicare Surgical Associates of Fair Lawn (N.J.).
3. Surgicare sought reimbursement under CPT code 63030 because it was on CMS' fee schedule. New Jersey Manufacturers Insurance Co. denied the claim because CPT code 63030 was not on the state's fee schedule.
4. Like the first case, an arbitration panel ruled against the insurer, finding in favor of the surgery center. Once again, the appellate court reversed the ruling on the grounds that New Jersey's fee schedule takes precedence over CMS' fee schedule.
5. Judge Richard Hoffman wrote in his decision, "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."