The New Jersey appellate court ruled in favor of the New Jersey Department of Banking and Insurance as regards PIP procedures payable in an ASC, in a lawsuit brought by several New Jersey ASCs.
"The issue at hand was that while these procedures, including spine, were on the CMS ASC approved list since 2015, they had not been added to the fee schedule by the Department," said Jeff Shanton, president of the New Jersey Association of Ambulatory Surgery Centers. "While the Department has long opined that a CPT code needs to appear on the fee schedule for payment, during previous court testimony in years past over PIP, they had also stated that they follow CMS rules, guidelines and the manual, thus this lawsuit."
The ruling further stated: "The fact that Medicare now includes the CPT code [63030, which was used in the proceeding] does not result in the automatic amendment of the fee schedule; instead we conclude it is the Department, not Medicare, that amends the fee schedule."
"This decision while disappointing, was not unexpected by NJAASC," said Mr. Shanton. "Indeed in meeting with the Department last fall, we had pressed them to promulgate the fee schedule changes, which would have included the 2015 spine codes they had sent to certain stakeholders for review back in the fall of 2017. NJAASC will be presenting its own ideas to the Department regarding PIP procedures allowed and payment, and we have offered our help in order to get this issue resolved."
See the ruling here.