Preview
FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023
CIVIL COURT OF THE CITY OF NEW YORK
COUNTY OF BRONX
PAK HONG SIK MD, MEDICAL CARE P.C. Index No: 707340/21
A/A/O ADAM SCHULMAN,
Plaintiff,
DEFENDANT’S EXPERT
– against – WITNESS DISCLOSURE
STATE FARM MUTUAL AUTO. INS. CO.,
Defendant.
PLEASE TAKE NOTICE THAT, the defendant hereby expects to call at trial the following
witness:
1. Defendant intends to call Lori Ercolini, RN, CPC, to testify at trial.
2. Lori Ercolini, RN, CPC, is expected to testify regarding his review of the bills and medical
records at issue, and the correct fee schedule.
3. Lori Ercolini, RN, CPC, is a certified professional coder. A copy of Lori Ercolini, RN,
CPC,’s curriculum vitae is annexed hereto.
4. Lori Ercolini, RN, CPC, 's fee schedule/coding report is annexed hereto.
Defendant reserves the right to supplement and/or amend this response up to and including the time
before trial pursuant to C.P.L.R. § 3101 (d).
Dated: September 27, 2023 ____________________________________
By: Nicole R. McErlean
FREIBERG, PECK & KANG, LLP
Attorneys for Defendant
200 Business Park Drive – Suite 206
Armonk, NY 10504
P.: (212) 252-9550x133
F.: (212) 252-9552
E.: nmcerlean@fplawfirm.com
File No.: 8000.0240
TO: SANDERS GROSSMAN ARONOVA, PLLC
Attorneys for Plaintiff
100 Garden City Plaza, Suite 500
Garden City, NY 11530
(516) 741-4799
0 8000.0240/LC
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CIVIL COURT OF THE CITY OF NEW YORK
COUNTY OF BRONX
---------------------------------------------------------------X
PAK HONG SIK, MEDICAL CARE, P.C.,
A/A/O
ADAM SCHULMAN Index No.: 707340/21
Plaintiff AFFIDAVIT
- against -
STATE FARM MUTUAL AUTOMOBILE
INSURANCE COMPANY,
Defendant.
---------------------------------------------------------------X
STATE OF NEW YORK)
) ss.:
COUNTY OF SARATOGA)
DOL: 2/23/19
CLAIM No.: 52-7945-W65
INDEX No.: 707340/21
CLIENT FILE No.: 8000.0240
CMC No.: 456664-1
DATE OF SERVICE: 9/5/19
AMOUNT IN DISPUTE: $2,978.16
I, Lori Ercolini RN, CPC, being duly sworn, deposes and states as follows, under penalties of perjury, as follows,
have been requested to conduct a review of bills listed from Pak Hong Sik / Medical Care, P.C., and to indicate
whether the correct CPT codes were applied and billed correctly. As such, I based this review on records as listed
below.
I, Lori Ercolini RN, CPC, have personal knowledge of the facts at issue being a Certified Professional Coder,
credentialed with the American Academy of Professional Coders (AAPC). To become credentialed with the AAPC,
I was required to take classes in medical coding and medical billing as well as compliance and pass a coding test
administered by the AAPC. I have more than 20 years of coding experience in multispecialty coding. As a Certified
Professional Coder, I am proficient in ICD-9 codes, ICD-10 CPT codes and Healthcare Common Procedure Coding
System (HCPCS) Level II. To maintain my credentials, I must complete 36 continuing education credits every two
years.
Additionally, I have over 20 years’ experience as a Nurse Bill Reviewer with a large insurance company. I am
experienced in the use of CPT codes for the State of New Jersey Department of Banking & Insurance Automobile
Medical Fee Schedule and for NYS auto and workers compensation insurance as well as the WC/NF Fee Schedule
and ground rules.
Review of Records:
Reviewed the NF-3 Form submitted by Pak Hong Sik / Medical Care, P.C., for the following dates of
service: 9/5/19
Reviewed Denial of Claims Form for treatment for the following dates of service: 9/5/19
Reviewed Explanation of Review for the following dates of service: 9/5/19
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FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX
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Claimant: Adam Schulman
CMC No: 456664-1
Page 2 of 4
Reviewed Records by Pak Hong Sik / Medical Care, P.C., for treatment for the following dates of service:
9/5/19
Professional Code Review
Bill #1: 9/5/19 by Pak Hong Sik / Medical Care, P.C. a/a/o Adam Schulman
Bill Audit Findings
Billed Correct Payable
Line DOS CPT Code CPT Code Definition Rationale
Amount CPT Code Amount
Unlisted neurological or
See
1 9/5/19 95999 $1490.58 neuromuscular diagnostic 95999 x 2 $212.94
Summary
procedure
Unlisted neurological or
See
2 9/5/19 95999 $1916.46 neuromuscular diagnostic 95999 x 2 $212.94
Summary
procedure
Total $3407.04 Total $425.88
TOTAL ALLOWED AMOUNT = $425.88
TOTAL AMOUNT ALREADY REIMBURSED = $428.88 – Paid $431.17; $2.29 of that was interest
TOTAL AMOUNT OWED = $0.00 (Overpayment of $3.00)
References:
Introduction and General Guidelines, Evaluation and Management and Medicine Guidelines per CPT descriptions
established by the AMA, as utilized in The Official New York Workers’ Compensation Medical Fee Schedule,
NYS Regulation 83, NYS Office of Professions and AMA Knowledge Base, NY Workers’ Compensation Medical
Fee Schedule.
Summary:
Note: Per the NY Workers’ Compensation Medical Fee Schedule, Introduction and General Guidelines, “This
edition of the Official New York Workers’ Compensation Medical Fee Schedule uses CPT procedure codes,
modifiers and descriptions and where appropriate the American Society of Anesthesiologists’ relative value guide.
Please refer to the CPT book for an explanation of coding rules and regulations not listed in this schedule.”
New York State Department of Financial Services, 11NYCRR 68 (Regulation 83)
§ 68.5Health services not set forth in schedules
If a professional health service is performed which is reimbursable under section 5102(a)(1) of the Insurance Law,
but is not set forth in fee schedules adopted or established by the superintendent, and:
(a) If the superintendent has adopted or established a fee schedule applicable to the provider, then the provider
shall establish a fee or unit value consistent with other fees or unit values for comparable procedures shown
in such schedule, subject to review by the insurer; or
(b) If the superintendent has not adopted or established a fee schedule applicable to the provider, then the
permissible charge for such service shall be the prevailing fee in the geographic location of the provider
subject to review by the insurer for consistency with charges permissible for similar procedures under
schedules already adopted or established by the superintendent.
Services rendered on this bill are performed by an MD in the zip of service 11212 which is in region IV of NY and
the conversion factor for is $8.45 according to the Introduction and General Guidelines of the NY Workers’
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Claimant: Adam Schulman
CMC No: 456664-1
Page 3 of 4
Compensation Medical Fee Schedule. They have billed Bill #1 for date of service 9/15/19 with 95999 x 14 and
95999 x 18.
The documentation provided for the date of service of 9/15/19 indicates they performed Pain Fiber Nerve
Conduction Testing on the upper and lower extremities bilaterally. The bill submitted reflects testing on upper and
lower extremities bilaterally. They are trying to bill for the pain fiber testing with CPT 95999 which is a BR (By
Report) code.
Currently there is no CPT code for Pain Fiber Nerve Conduction Testing in the NY fee schedule. The CPT
guidelines found in CPT Assistant Article May 2011/Volume 21 issue 5 page 10 indicates that codes 0106T-0110T
are to be used for this procedure, however, this range of codes are also “BR” codes with no relative values in the
NY fee schedule. A newer CPT Assistant August 2018 where they are stating that 95999 is the code to be used.
However, all of these codes are BR codes.
In this situation Ground Rules #2 and 3 on page 13 in the Intro & General Guidelines section of the Medical Fee
Schedule would apply. Per New York Workers' Compensation fee schedule General Rule #3 titled "Procedures
without Specified Unit Values", for any procedure where the unit value is listed in the schedule as "BR", the
physician shall establish a unit value consistent in relativity with other unit values shown in the schedule. The
ground rules also state that the insurer shall review all submitted "BR" unit values to ensure that the relativity
consistency is maintained. The amount allowed is based on documented time, skill, and equipment.
Using Ground Rule 3 in the Medical Fee Schedule the relative value of code 95904, which is 12.60, would be used
as a reference value for the test performed since this would be the closest and consistent in relativity. This is only
the RVU that is being used and NOT the application of the CPT code 95904. Sensory NCSs (CPT 95904) are
performed by applying electrical stimulation near a nerve and recording the response from a distant site along the
nerve. Response parameters include amplitude, latency, configuration and sensory conduction velocity. This test
is per extremity not per nerve. The report for 9/15/19 indicates tests were performed on upper and lower extremities,
bilaterally; therefore, 2 units can be allowed for the testing of both the upper and 2 units can be allowed for lower
extremities. They have billed with code 95999, the relative value of code 95904 is used, and 2 units are allowed
for the upper extremities and 2 units for the lower extremities. As mentioned above the provider is an MD in region
IV, and the conversion factor would be $8.45.
Calculation for Bill #1:
RVU x Conversion Factor = Fee Schedule Amount.
95599 x 14 > 0106T-0110T x 2 > 95904 x 2 = (12.60 x 8.45) x 2 = 106.47 x 2 = $212.94
95599 x 18 > 0106T-0110T x 2 > 95904 x 2 = (12.60 x 8.45) x 2 = 106.47 x 2 = $212.94
TOTAL = $425.88
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FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023
Claimant: Adam Schulman
CMC No: 456664-1
Page 4 of 4
TOTAL BILLED AMOUNT FOR ALL BILLS = $3,407.04
TOTAL ALLOWED AMOUNT FOR ALL BILLS = $425.88
TOTAL AMOUNT ALREADY REIMBURSED FOR ALL BILLS = $428.88
TOTAL AMOUNT OWED FOR ALL BILLS = $0.00 (Overpayment of $3.00)
r rco mi, , PC Dûte
STATE OF NEW YORK}
COUNTY OF SARATOGA} ss:
On the day of Ùfl . 2021 before me the undersigned, personally appeared Lori Ercolini, personally
known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed
to the within instrument and acknowledged to me that he/she executed the same in his/her capacity and that by
his/her signature on the instr ent, the individu or the person upon behalf of which the individual acted, executed
the instrument.
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NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023
1 ntroduction and Genera
uide ines
Workers'
The Official New York Compensation Medical Fee procedures they perform, or the services they render. The
Schedule shows physician services and their relative value sections in this schedule are:
units. The services are listed by Current Procedural
Terminology (CPT®) codes. The relative value set for each Section CPT Codes
CPT service is based on comparative magnitude among
Evaluation and Management 99201-99499
various services and procedures. The relative values within
each section apply only to that section. CPT is a registered Anesthesia 00100-01999,
trademark of the American Medical Association (AMA). 99100-99140
Surgery 10021-69990
The accompanying instructions and ground rules explain the
application of these procedure descriptors and relative value Radiology (including Nuclear 70010-79999
units in medical practice. All sections of the book may be Medicine and Diagnostic
used by any or all physicians, appropriate surgery codes are Ultrasound)
not confined to use by surgeons, nor is the medicine section
Pathology and Laboratory 80047-89398
confined to use by internists, etc.
Medicine 90281-96999,
Because the Medical Fee Schedule is applicable to all of New 97802-99091,
York State, a large and diverse geographical area, the relative 99143-99199,
value units contained herein do not necessarily reflect the 99500-99607
charges of any individual physician or the pattern of charges
in any specific area of New York.
Physical Medicine 97001-97800
A primary purpose of the schedule is to provide a precise Category III Codes 0019T-0301T
description and coding of the services provided by New York
workers'
physicians in the care of compensation covered The sections are organized to the type of service
according
patients and to ensure the proper payment for such services and variations of overhead expense ratios for providing the
by assuring that they are specifically identifiable. services. Therefore, each section uses a single conversion
factor.
Workers'
This edition of the Official New York Compensation
Medical Fee Schedule uses CPT procedure codes, modifiers, II codes are not reimbursable services and are not
Category
and descriptions and, where appropriate, the American included in this schedule.
Anesthesiologists'
Society of Relative Value Guide®. Please
refer to the CPT book for an explanation of coding rules and
Introductory Information
regulations not listed in this schedule.
The introductory ground rules that precede the data in each
section include definitions, references, prohibitions, and
directions for proper use. It cannot be emphasized too
FORMAT that the introductory ground rules be read and
strongly
Workers'
The Official New York Compensation Medical Fee understood before using the data in this schedule.
Schedule consists of eight sections. Each section has
instructions that precede the codes, descriptions, and values· Additional Schedules
The schedule is divided into sections for structural purposes
The Psychology schedule, Chiropractic schedule, and
only. Physicians are to use the sections that contain the
Podiatry schedule, included with this publication, have also
been published as separate schedules. To purchase these
CPTonly © 2011AmericanMedical Association. All RightsReserved. 1
Hewsed
Präting
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Workers'
Introduction and General Guidelines New York Compensation Medical Fee Schedule
schedules separately from the Medical Fee Schedule, contact NC
OptumInsight at 1.800.464.3649, option 1. NC represents services that are not covered by the State of
New York. These services have no reimbursement allowance
workers'
and are not covered under compensation
guidelines.
How To INTERPRET FEE SCHEDULE DATA
Workers'
There are six columns used in the Official New York
Compensation Medical Fee Schedule. The columns FUD
vary by
section throughout the schedule. The FUD column lists the follow-up days included in a
surgical global charge. In counting
procedure's follow-up
Code days, day one is the day of surgery, not the discharge day
The State of New York has determined the number of
The Code column lists the American Medical Association's
follow-up days in this schedule and these follow-up days are
CPT code. CPT 2012 is used by arrangement with the AMA.
consistent with those found in the Medicare Physician Fee
Any altered CPT codes are identified with the registered
Schedule. Follow-up days will be designated as 000 (O
trademark symbol (®). State-specific codes are identified
follow-up days), 010 (10 follow-up days), or 090 (90
with the infinity symbol ( ).
follow-up days). Medicare also uses letter designations to
identify four circumstances where the usual follow-up days
Add-on, Modifier 51 Exempt, and Moderate (Conscious) concept does not apply These four circumstances are as
Sedation Icons follows:
The following icons identify add-on codes, modifier 51
exempt codes, and codes where moderate
MMM Describes services in uncomplicated maternity care.
(conscious)
sedation rules apply:
This includes antepartum, delivery, and postpartum
care. The usual global surgery concept does not
+ Add-on service-Add-on codes have been apply
designated in the CPT book as being additional or
XXX Indicates that the global surgery concept does not
supplemental procedures that are carried out in
addition to the primary procedure. ªPPlY
YYY Indicates that the global period is to be established
G Modifier 51 exempt service-Modifier 51 exempt
codes have not been identified as add-on services by report.
but are exempt from modifier 51 when performed
ZZZ Indicates that the service is an add-on service and,
in conjunction with other services.
therefore, is treated in the global period of the
primary procedure that is billed in conjunction
0 Moderate (conscious) sedation-Services listed
with the ZZZ service. Do not bill these codes with
with the moderate (conscious) sedation icon
modifier 51. Reimbursement should not be
identify services where special moderate
reduced.
(conscious) sedation rules apply See Ground Rule
12 later in this Introduction for an explanation of
these coding and reimbursement rules. PC/TC Split
The PC/fC Split column shows the percentage of the
Description procedure that is professional or technical. A procedure with
a relative value unit of 3.0 and a 40/60 in the PC/fC Split
This manual lists full 2012 CPT code descriptions.
column would be calculated as follows: 40 percent of the
value (3.0 x conversion factor x .40 = PC) is for the
Relative Value
professional component of the service, and 60 percent of the
The Relative Value column lists the relative value used to value (3.0 x conversion factor x .60 = TC) represents the
calculate the fee amount for a service. Except as otherwise technical component of the service. The total component
provided in this schedule, the maximum fee amount is reimbursed should never be more than the professional and
calculated by multiplying the relative value by the applicable technical components combined.
conversion factor. Conversion factors are listed later in this
chapter.
SPECIALTY CLASSlFICATIONS
as
"C"
Some services do not have a relative value because they are The rating (Consultant in Specialty, e.g.,
report"
too variable or new. These "by services are identified CS-Consultant-Surgery) may be granted to physicians
"BR." certified as specialists by a board recognized by the American
with
Board of Medical Specialties and the American Osteopathic
Association. Applicants, who are qualified but have not
attained board-certified status as defined above, will be
2 CPTonly © 2011AmericanMedical Association. All RightsReserved.
Rewsed
Printing
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Workers'
New York Compensation Medical Fee Schedule Introduction and General Guidelines
"C"
granted a specialty rating without the prefix (e.g., IM, Description
Rating
OS, and S).
IM-EDM Endocrinology, Diabetes and
"OP-GP" Metabolism
The rating is given to osteopathic physicians in
"OP"
general practice. The designation, when combined with IM-END Endocrinology
one of the specialty ratings, indicates that the specialist is an
osteopathic physician IM-GE Gastroenterology
(e.g., OPOS, is the proper rating for an
osteopathic physician who is a qualified specialist in IM-GM Geriatric Medicine
orthopedic surgery. Upon obtaining Consultant status, as
"OPCOS" IM-HEM Hematology
defined above, a physician may apply for an
rating). IM-IC Interventional Cardiology
. . IM-ID Infectious Diseases
Rating Description
IM-NEPH Nephrology
AL Allergy/Immunology
IM-ONCL Medical Oncology
AL-CLI Clinical Laboratory Immunology
M- Rseases
AL-DLI Diagnostic ulmonary
Laboratory Immunology
IM-RHE Rheumatology
AN Anesthesiology
IM-SM Sports Medicine
AN-CCM Critical Care Medicine
NS Neurological Surgery
AN-PM Pain Management
NS-CCM Critical Care Medicine
CRS Colon/Rectal Surgery
NUM Nuclear Medicine
D Dermatology
- udear
D-CLDI Clinical and Laboratory Dermatological Radology
Immunology NUM-RP Radioisotopic Pathology
D-DI Dermatological Immunity/Diagnostic O Ophthalmology
D-DP Dermatological Pathology OG Obstetrics/Gynecology
D-PD Pediatric Dermatology OG-CCM Critical Care Medicine
EM Emergency Medicine OG-MFM Maternal/Fetal Medicine
EM-MT Medical Toxicology OG-ONC Gynecologic Oncology
EM-PEM Pediatric Emergency Medicine OG-RE Reproductive Endocrinology
EM-SM Sports Medicine OL Otolaryngology
EM-UHM Undersea and Hyperbaric Medicine OL-ON Otology/Neurotology
FP Family Practice OL-PO Pediatric Otolaryngology
FP-ADM Adolescent Medicine OL-PSHN Plastic Surgery Within the Head and
Neck
FP-GM Geriatric Medicine
OS Orthopedic Surgery
FP-SM Sports Medicine
OS-HS Hand Surgery
GP General Practice
. . P Pediatrics
IM Internal Medicme
P-ADM Adolescent Medicine
IM-ADM Adolescent Medicine
. P-CCM Critical Care Medicine
IM-CCEP Clinical Cardiac Electrophysiology
P-CD Cardiology
IM-CCM Critical Care
P-CLI Clinical and Laboratory Immunology
IM-CD Cardiology
. P-DBP Developmental-Behavioral Pediatrics
IM-CE Cardiac Electrophysiology
- magnos
IM-CLI Clinical and Laboratory aboratory Immunology
Immunology
P-END Endocrinology
IM-CVD Cardiovascular
P-GE Gastroenterology
IM-DI Diagnostic Immunology
CPTonly © 2011AmericanMedical Association. All RightsReserved 3
Revised
Printing
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Workers'
introduction and General Guidelines New York Compensation Medical Fee Schedule
Rating Description Rating Description
P-ID Infectious Diseases PN Psychiatry/Neurology
P-MT Medical Toxicology PN-ADP Addiction Psychiatry
P-ND Neurodevelopmental Disabilities PN-CHAP Child and Adolescent Psychiatry
P-NEPH Nephrology PN-CHN Child Neurology
P-NPER Neonatal-Perinatal Medicine PN-CHP Child Psychiatry
P-PEM Emergency Medicine PN-CNPH Clinical Neurophysiology
P-PHO Hematology/Oncology PN-FPSY Forensic Psychiatry
P-PUL Pulmonology PN-GER Geriatric Psychiatry
P-RHE Rheumatology PN-N Neurology
P-SM Sports Medicine PN-ND Neurodevelopmental Disabilities
PA Pathology PN-P Psychiatry
PA-AP Anatomic Pathology PN-PM Pain Management
PA-BB Blood Banking PS Plastic Surgery
PA-CB Clinical Bacteriology PS-HS Hand Surgery
PA-CC Clinical Chemistry R Radiology
PA-CLP Clinical Pathology R-DRA Diagnostic Radiology
PA-CM Clinical Microbiology R-DRNR Diagnostic Radiology/Nuclear Medicine
PA-CP Chemical Pathology R-DRO Diagnostic Roentgenology
PA-CY Cytopathology R-DRP Diagnostic Radiological Physics
PA-DP Dermatopathology R-MNP Medical Nuclear Physics
PA-FOP Forensic Pathology R-NR Nuclear Radiology
PA-HEM Hematology R-NRAD Neuroradiology
PA-IP Immunology R-PR Pediatric Radiology
PA-MC Medical Chemistry R-R Radiology
PA-MGP Molecular Genetic Pathology R-RAO
Preview
FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 CIVIL COURT OF THE CITY OF NEW YORK COUNTY OF BRONX PAK HONG SIK MD, MEDICAL CARE P.C. Index No: 707340/21 A/A/O ADAM SCHULMAN, Plaintiff, DEFENDANT’S EXPERT – against – WITNESS DISCLOSURE STATE FARM MUTUAL AUTO. INS. CO., Defendant. PLEASE TAKE NOTICE THAT, the defendant hereby expects to call at trial the following witness: 1. Defendant intends to call Lori Ercolini, RN, CPC, to testify at trial. 2. Lori Ercolini, RN, CPC, is expected to testify regarding his review of the bills and medical records at issue, and the correct fee schedule. 3. Lori Ercolini, RN, CPC, is a certified professional coder. A copy of Lori Ercolini, RN, CPC,’s curriculum vitae is annexed hereto. 4. Lori Ercolini, RN, CPC, 's fee schedule/coding report is annexed hereto. Defendant reserves the right to supplement and/or amend this response up to and including the time before trial pursuant to C.P.L.R. § 3101 (d). Dated: September 27, 2023 ____________________________________ By: Nicole R. McErlean FREIBERG, PECK & KANG, LLP Attorneys for Defendant 200 Business Park Drive – Suite 206 Armonk, NY 10504 P.: (212) 252-9550x133 F.: (212) 252-9552 E.: nmcerlean@fplawfirm.com File No.: 8000.0240 TO: SANDERS GROSSMAN ARONOVA, PLLC Attorneys for Plaintiff 100 Garden City Plaza, Suite 500 Garden City, NY 11530 (516) 741-4799 0 8000.0240/LC 1 of 39 FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 CIVIL COURT OF THE CITY OF NEW YORK COUNTY OF BRONX ---------------------------------------------------------------X PAK HONG SIK, MEDICAL CARE, P.C., A/A/O ADAM SCHULMAN Index No.: 707340/21 Plaintiff AFFIDAVIT - against - STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. ---------------------------------------------------------------X STATE OF NEW YORK) ) ss.: COUNTY OF SARATOGA) DOL: 2/23/19 CLAIM No.: 52-7945-W65 INDEX No.: 707340/21 CLIENT FILE No.: 8000.0240 CMC No.: 456664-1 DATE OF SERVICE: 9/5/19 AMOUNT IN DISPUTE: $2,978.16 I, Lori Ercolini RN, CPC, being duly sworn, deposes and states as follows, under penalties of perjury, as follows, have been requested to conduct a review of bills listed from Pak Hong Sik / Medical Care, P.C., and to indicate whether the correct CPT codes were applied and billed correctly. As such, I based this review on records as listed below. I, Lori Ercolini RN, CPC, have personal knowledge of the facts at issue being a Certified Professional Coder, credentialed with the American Academy of Professional Coders (AAPC). To become credentialed with the AAPC, I was required to take classes in medical coding and medical billing as well as compliance and pass a coding test administered by the AAPC. I have more than 20 years of coding experience in multispecialty coding. As a Certified Professional Coder, I am proficient in ICD-9 codes, ICD-10 CPT codes and Healthcare Common Procedure Coding System (HCPCS) Level II. To maintain my credentials, I must complete 36 continuing education credits every two years. Additionally, I have over 20 years’ experience as a Nurse Bill Reviewer with a large insurance company. I am experienced in the use of CPT codes for the State of New Jersey Department of Banking & Insurance Automobile Medical Fee Schedule and for NYS auto and workers compensation insurance as well as the WC/NF Fee Schedule and ground rules. Review of Records: Reviewed the NF-3 Form submitted by Pak Hong Sik / Medical Care, P.C., for the following dates of service: 9/5/19 Reviewed Denial of Claims Form for treatment for the following dates of service: 9/5/19 Reviewed Explanation of Review for the following dates of service: 9/5/19 2 of 39 FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 Claimant: Adam Schulman CMC No: 456664-1 Page 2 of 4 Reviewed Records by Pak Hong Sik / Medical Care, P.C., for treatment for the following dates of service: 9/5/19 Professional Code Review Bill #1: 9/5/19 by Pak Hong Sik / Medical Care, P.C. a/a/o Adam Schulman Bill Audit Findings Billed Correct Payable Line DOS CPT Code CPT Code Definition Rationale Amount CPT Code Amount Unlisted neurological or See 1 9/5/19 95999 $1490.58 neuromuscular diagnostic 95999 x 2 $212.94 Summary procedure Unlisted neurological or See 2 9/5/19 95999 $1916.46 neuromuscular diagnostic 95999 x 2 $212.94 Summary procedure Total $3407.04 Total $425.88 TOTAL ALLOWED AMOUNT = $425.88 TOTAL AMOUNT ALREADY REIMBURSED = $428.88 – Paid $431.17; $2.29 of that was interest TOTAL AMOUNT OWED = $0.00 (Overpayment of $3.00) References: Introduction and General Guidelines, Evaluation and Management and Medicine Guidelines per CPT descriptions established by the AMA, as utilized in The Official New York Workers’ Compensation Medical Fee Schedule, NYS Regulation 83, NYS Office of Professions and AMA Knowledge Base, NY Workers’ Compensation Medical Fee Schedule. Summary: Note: Per the NY Workers’ Compensation Medical Fee Schedule, Introduction and General Guidelines, “This edition of the Official New York Workers’ Compensation Medical Fee Schedule uses CPT procedure codes, modifiers and descriptions and where appropriate the American Society of Anesthesiologists’ relative value guide. Please refer to the CPT book for an explanation of coding rules and regulations not listed in this schedule.” New York State Department of Financial Services, 11NYCRR 68 (Regulation 83) § 68.5Health services not set forth in schedules If a professional health service is performed which is reimbursable under section 5102(a)(1) of the Insurance Law, but is not set forth in fee schedules adopted or established by the superintendent, and: (a) If the superintendent has adopted or established a fee schedule applicable to the provider, then the provider shall establish a fee or unit value consistent with other fees or unit values for comparable procedures shown in such schedule, subject to review by the insurer; or (b) If the superintendent has not adopted or established a fee schedule applicable to the provider, then the permissible charge for such service shall be the prevailing fee in the geographic location of the provider subject to review by the insurer for consistency with charges permissible for similar procedures under schedules already adopted or established by the superintendent. Services rendered on this bill are performed by an MD in the zip of service 11212 which is in region IV of NY and the conversion factor for is $8.45 according to the Introduction and General Guidelines of the NY Workers’ 3 of 39 FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 Claimant: Adam Schulman CMC No: 456664-1 Page 3 of 4 Compensation Medical Fee Schedule. They have billed Bill #1 for date of service 9/15/19 with 95999 x 14 and 95999 x 18. The documentation provided for the date of service of 9/15/19 indicates they performed Pain Fiber Nerve Conduction Testing on the upper and lower extremities bilaterally. The bill submitted reflects testing on upper and lower extremities bilaterally. They are trying to bill for the pain fiber testing with CPT 95999 which is a BR (By Report) code. Currently there is no CPT code for Pain Fiber Nerve Conduction Testing in the NY fee schedule. The CPT guidelines found in CPT Assistant Article May 2011/Volume 21 issue 5 page 10 indicates that codes 0106T-0110T are to be used for this procedure, however, this range of codes are also “BR” codes with no relative values in the NY fee schedule. A newer CPT Assistant August 2018 where they are stating that 95999 is the code to be used. However, all of these codes are BR codes. In this situation Ground Rules #2 and 3 on page 13 in the Intro & General Guidelines section of the Medical Fee Schedule would apply. Per New York Workers' Compensation fee schedule General Rule #3 titled "Procedures without Specified Unit Values", for any procedure where the unit value is listed in the schedule as "BR", the physician shall establish a unit value consistent in relativity with other unit values shown in the schedule. The ground rules also state that the insurer shall review all submitted "BR" unit values to ensure that the relativity consistency is maintained. The amount allowed is based on documented time, skill, and equipment. Using Ground Rule 3 in the Medical Fee Schedule the relative value of code 95904, which is 12.60, would be used as a reference value for the test performed since this would be the closest and consistent in relativity. This is only the RVU that is being used and NOT the application of the CPT code 95904. Sensory NCSs (CPT 95904) are performed by applying electrical stimulation near a nerve and recording the response from a distant site along the nerve. Response parameters include amplitude, latency, configuration and sensory conduction velocity. This test is per extremity not per nerve. The report for 9/15/19 indicates tests were performed on upper and lower extremities, bilaterally; therefore, 2 units can be allowed for the testing of both the upper and 2 units can be allowed for lower extremities. They have billed with code 95999, the relative value of code 95904 is used, and 2 units are allowed for the upper extremities and 2 units for the lower extremities. As mentioned above the provider is an MD in region IV, and the conversion factor would be $8.45. Calculation for Bill #1: RVU x Conversion Factor = Fee Schedule Amount. 95599 x 14 > 0106T-0110T x 2 > 95904 x 2 = (12.60 x 8.45) x 2 = 106.47 x 2 = $212.94 95599 x 18 > 0106T-0110T x 2 > 95904 x 2 = (12.60 x 8.45) x 2 = 106.47 x 2 = $212.94 TOTAL = $425.88 4 of 39 FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 Claimant: Adam Schulman CMC No: 456664-1 Page 4 of 4 TOTAL BILLED AMOUNT FOR ALL BILLS = $3,407.04 TOTAL ALLOWED AMOUNT FOR ALL BILLS = $425.88 TOTAL AMOUNT ALREADY REIMBURSED FOR ALL BILLS = $428.88 TOTAL AMOUNT OWED FOR ALL BILLS = $0.00 (Overpayment of $3.00) r rco mi, , PC Dûte STATE OF NEW YORK} COUNTY OF SARATOGA} ss: On the day of Ùfl . 2021 before me the undersigned, personally appeared Lori Ercolini, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity and that by his/her signature on the instr ent, the individu or the person upon behalf of which the individual acted, executed the instrument. 5 of 39 FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 1 ntroduction and Genera uide ines Workers' The Official New York Compensation Medical Fee procedures they perform, or the services they render. The Schedule shows physician services and their relative value sections in this schedule are: units. The services are listed by Current Procedural Terminology (CPT®) codes. The relative value set for each Section CPT Codes CPT service is based on comparative magnitude among Evaluation and Management 99201-99499 various services and procedures. The relative values within each section apply only to that section. CPT is a registered Anesthesia 00100-01999, trademark of the American Medical Association (AMA). 99100-99140 Surgery 10021-69990 The accompanying instructions and ground rules explain the application of these procedure descriptors and relative value Radiology (including Nuclear 70010-79999 units in medical practice. All sections of the book may be Medicine and Diagnostic used by any or all physicians, appropriate surgery codes are Ultrasound) not confined to use by surgeons, nor is the medicine section Pathology and Laboratory 80047-89398 confined to use by internists, etc. Medicine 90281-96999, Because the Medical Fee Schedule is applicable to all of New 97802-99091, York State, a large and diverse geographical area, the relative 99143-99199, value units contained herein do not necessarily reflect the 99500-99607 charges of any individual physician or the pattern of charges in any specific area of New York. Physical Medicine 97001-97800 A primary purpose of the schedule is to provide a precise Category III Codes 0019T-0301T description and coding of the services provided by New York workers' physicians in the care of compensation covered The sections are organized to the type of service according patients and to ensure the proper payment for such services and variations of overhead expense ratios for providing the by assuring that they are specifically identifiable. services. Therefore, each section uses a single conversion factor. Workers' This edition of the Official New York Compensation Medical Fee Schedule uses CPT procedure codes, modifiers, II codes are not reimbursable services and are not Category and descriptions and, where appropriate, the American included in this schedule. Anesthesiologists' Society of Relative Value Guide®. Please refer to the CPT book for an explanation of coding rules and Introductory Information regulations not listed in this schedule. The introductory ground rules that precede the data in each section include definitions, references, prohibitions, and directions for proper use. It cannot be emphasized too FORMAT that the introductory ground rules be read and strongly Workers' The Official New York Compensation Medical Fee understood before using the data in this schedule. Schedule consists of eight sections. Each section has instructions that precede the codes, descriptions, and values· Additional Schedules The schedule is divided into sections for structural purposes The Psychology schedule, Chiropractic schedule, and only. Physicians are to use the sections that contain the Podiatry schedule, included with this publication, have also been published as separate schedules. To purchase these CPTonly © 2011AmericanMedical Association. All RightsReserved. 1 Hewsed Präting 6 of 39 FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 Workers' Introduction and General Guidelines New York Compensation Medical Fee Schedule schedules separately from the Medical Fee Schedule, contact NC OptumInsight at 1.800.464.3649, option 1. NC represents services that are not covered by the State of New York. These services have no reimbursement allowance workers' and are not covered under compensation guidelines. How To INTERPRET FEE SCHEDULE DATA Workers' There are six columns used in the Official New York Compensation Medical Fee Schedule. The columns FUD vary by section throughout the schedule. The FUD column lists the follow-up days included in a surgical global charge. In counting procedure's follow-up Code days, day one is the day of surgery, not the discharge day The State of New York has determined the number of The Code column lists the American Medical Association's follow-up days in this schedule and these follow-up days are CPT code. CPT 2012 is used by arrangement with the AMA. consistent with those found in the Medicare Physician Fee Any altered CPT codes are identified with the registered Schedule. Follow-up days will be designated as 000 (O trademark symbol (®). State-specific codes are identified follow-up days), 010 (10 follow-up days), or 090 (90 with the infinity symbol ( ). follow-up days). Medicare also uses letter designations to identify four circumstances where the usual follow-up days Add-on, Modifier 51 Exempt, and Moderate (Conscious) concept does not apply These four circumstances are as Sedation Icons follows: The following icons identify add-on codes, modifier 51 exempt codes, and codes where moderate MMM Describes services in uncomplicated maternity care. (conscious) sedation rules apply: This includes antepartum, delivery, and postpartum care. The usual global surgery concept does not + Add-on service-Add-on codes have been apply designated in the CPT book as being additional or XXX Indicates that the global surgery concept does not supplemental procedures that are carried out in addition to the primary procedure. ªPPlY YYY Indicates that the global period is to be established G Modifier 51 exempt service-Modifier 51 exempt codes have not been identified as add-on services by report. but are exempt from modifier 51 when performed ZZZ Indicates that the service is an add-on service and, in conjunction with other services. therefore, is treated in the global period of the primary procedure that is billed in conjunction 0 Moderate (conscious) sedation-Services listed with the ZZZ service. Do not bill these codes with with the moderate (conscious) sedation icon modifier 51. Reimbursement should not be identify services where special moderate reduced. (conscious) sedation rules apply See Ground Rule 12 later in this Introduction for an explanation of these coding and reimbursement rules. PC/TC Split The PC/fC Split column shows the percentage of the Description procedure that is professional or technical. A procedure with a relative value unit of 3.0 and a 40/60 in the PC/fC Split This manual lists full 2012 CPT code descriptions. column would be calculated as follows: 40 percent of the value (3.0 x conversion factor x .40 = PC) is for the Relative Value professional component of the service, and 60 percent of the The Relative Value column lists the relative value used to value (3.0 x conversion factor x .60 = TC) represents the calculate the fee amount for a service. Except as otherwise technical component of the service. The total component provided in this schedule, the maximum fee amount is reimbursed should never be more than the professional and calculated by multiplying the relative value by the applicable technical components combined. conversion factor. Conversion factors are listed later in this chapter. SPECIALTY CLASSlFICATIONS as "C" Some services do not have a relative value because they are The rating (Consultant in Specialty, e.g., report" too variable or new. These "by services are identified CS-Consultant-Surgery) may be granted to physicians "BR." certified as specialists by a board recognized by the American with Board of Medical Specialties and the American Osteopathic Association. Applicants, who are qualified but have not attained board-certified status as defined above, will be 2 CPTonly © 2011AmericanMedical Association. All RightsReserved. Rewsed Printing 7 of 39 FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 Workers' New York Compensation Medical Fee Schedule Introduction and General Guidelines "C" granted a specialty rating without the prefix (e.g., IM, Description Rating OS, and S). IM-EDM Endocrinology, Diabetes and "OP-GP" Metabolism The rating is given to osteopathic physicians in "OP" general practice. The designation, when combined with IM-END Endocrinology one of the specialty ratings, indicates that the specialist is an osteopathic physician IM-GE Gastroenterology (e.g., OPOS, is the proper rating for an osteopathic physician who is a qualified specialist in IM-GM Geriatric Medicine orthopedic surgery. Upon obtaining Consultant status, as "OPCOS" IM-HEM Hematology defined above, a physician may apply for an rating). IM-IC Interventional Cardiology . . IM-ID Infectious Diseases Rating Description IM-NEPH Nephrology AL Allergy/Immunology IM-ONCL Medical Oncology AL-CLI Clinical Laboratory Immunology M- Rseases AL-DLI Diagnostic ulmonary Laboratory Immunology IM-RHE Rheumatology AN Anesthesiology IM-SM Sports Medicine AN-CCM Critical Care Medicine NS Neurological Surgery AN-PM Pain Management NS-CCM Critical Care Medicine CRS Colon/Rectal Surgery NUM Nuclear Medicine D Dermatology - udear D-CLDI Clinical and Laboratory Dermatological Radology Immunology NUM-RP Radioisotopic Pathology D-DI Dermatological Immunity/Diagnostic O Ophthalmology D-DP Dermatological Pathology OG Obstetrics/Gynecology D-PD Pediatric Dermatology OG-CCM Critical Care Medicine EM Emergency Medicine OG-MFM Maternal/Fetal Medicine EM-MT Medical Toxicology OG-ONC Gynecologic Oncology EM-PEM Pediatric Emergency Medicine OG-RE Reproductive Endocrinology EM-SM Sports Medicine OL Otolaryngology EM-UHM Undersea and Hyperbaric Medicine OL-ON Otology/Neurotology FP Family Practice OL-PO Pediatric Otolaryngology FP-ADM Adolescent Medicine OL-PSHN Plastic Surgery Within the Head and Neck FP-GM Geriatric Medicine OS Orthopedic Surgery FP-SM Sports Medicine OS-HS Hand Surgery GP General Practice . . P Pediatrics IM Internal Medicme P-ADM Adolescent Medicine IM-ADM Adolescent Medicine . P-CCM Critical Care Medicine IM-CCEP Clinical Cardiac Electrophysiology P-CD Cardiology IM-CCM Critical Care P-CLI Clinical and Laboratory Immunology IM-CD Cardiology . P-DBP Developmental-Behavioral Pediatrics IM-CE Cardiac Electrophysiology - magnos IM-CLI Clinical and Laboratory aboratory Immunology Immunology P-END Endocrinology IM-CVD Cardiovascular P-GE Gastroenterology IM-DI Diagnostic Immunology CPTonly © 2011AmericanMedical Association. All RightsReserved 3 Revised Printing 8 of 39 FILED: BRONX CIVIL COURT - CIVIL 09/27/2023 04:25 PM INDEX NO. CV-707340-21/BX NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/27/2023 Workers' introduction and General Guidelines New York Compensation Medical Fee Schedule Rating Description Rating Description P-ID Infectious Diseases PN Psychiatry/Neurology P-MT Medical Toxicology PN-ADP Addiction Psychiatry P-ND Neurodevelopmental Disabilities PN-CHAP Child and Adolescent Psychiatry P-NEPH Nephrology PN-CHN Child Neurology P-NPER Neonatal-Perinatal Medicine PN-CHP Child Psychiatry P-PEM Emergency Medicine PN-CNPH Clinical Neurophysiology P-PHO Hematology/Oncology PN-FPSY Forensic Psychiatry P-PUL Pulmonology PN-GER Geriatric Psychiatry P-RHE Rheumatology PN-N Neurology P-SM Sports Medicine PN-ND Neurodevelopmental Disabilities PA Pathology PN-P Psychiatry PA-AP Anatomic Pathology PN-PM Pain Management PA-BB Blood Banking PS Plastic Surgery PA-CB Clinical Bacteriology PS-HS Hand Surgery PA-CC Clinical Chemistry R Radiology PA-CLP Clinical Pathology R-DRA Diagnostic Radiology PA-CM Clinical Microbiology R-DRNR Diagnostic Radiology/Nuclear Medicine PA-CP Chemical Pathology R-DRO Diagnostic Roentgenology PA-CY Cytopathology R-DRP Diagnostic Radiological Physics PA-DP Dermatopathology R-MNP Medical Nuclear Physics PA-FOP Forensic Pathology R-NR Nuclear Radiology PA-HEM Hematology R-NRAD Neuroradiology PA-IP Immunology R-PR Pediatric Radiology PA-MC Medical Chemistry R-R Radiology PA-MGP Molecular Genetic Pathology R-RAO