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State fee schedule takes precedence over CMS list, New Jersey court rules — 5 insights

A New Jersey court ruled auto insurers don't need to reimburse ASCs for codes in CMS' fee schedule if they aren't also included in a state's fee schedule, according to an FC&S Legal report reprinted by New Jersey Law Journal.

What you should know:

1. The case centers on a woman who underwent a lumbar discectomy at Township, N.J.-based Specialty Surgical Center of North Brunswick after a car accident in November 2015.

2. The ASC sought $32,500 in reimbursement from the woman's automobile insurer, New Jersey Manufacturers Insurance Company, under CPT code 63030. NJM denied payment because the code was not on the New Jersey Department of Banking and Insurance's personal injury protection fee schedule for ASCs.

3. The ASC appealed the decision, and it went to arbitration. The arbitration panel ruled in favor of the ASC and awarded the center $25,500. NJM sought to reverse the award, saying the arbitration panel made its decision based on " an erroneous and prejudicial application of the law to the fact."

4. A trial court vacated the award because code 63030 was not on the state's fee schedule for ASCs. The ASC appealed on the grounds that CMS added code 63030 to the approved procedures list Jan. 1, 2015.

5. In the latest ruling, the appellate court affirmed the trial court's decision that the state's reimbursement fee schedule preceded CMS' fee schedule. The court said, "the fact that the CMS claims manual included the CPT code did 'not result in the automatic amendment of the fee schedule,'" adding that the state department ultimately amends its own fee schedule.

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