THE INTEGRATION OF EMR AND CASE MANAGEMENT SOFTWARE: COMPLIANCE, INTEROPERABILITY, AND THE 21ST CENTURY CURES ACT
PIP BILLING FOR UNLISTED SERVICES: A GUIDE FOR MEDICAL PROVIDERS
PERSONAL INJURY SUMMIT TM
MARCH 8TH, 2025 ORLANDO, FL
PERSONAL INJURY SUMMIT TM MARCH 8TH, 2025 ORLANDO, FL
SUCCEEDING UNDER TORT REFORM PART 5 SHOCKWAVE THERAPY…CAN YOU AFFORD TO NOT HAVE IT IN YOUR PRACTICE? IS A MATERIAL MISREPRESENTATION DEFENSE THE DEATH OF A CLAIM?
From the Editor
I’m really excited to share with you this new issue. I believe that the amazing contributions made by our advertisers, all of whom are top experts in their fields, will really give you useful and practical tips to help you in your PI practice. As always, I encourage you to get in touch with us if you have any questions or would like to share with us any challenges you’re having so that we may focus future content on addressing them. Remember, this publication is made just for you!
I also want to invite you all to join us at our next Personal Injury Summit® which is scheduled for Saturday, March 8th, 2025 at the Citrus Club in Orlando, Florida. If you have not yet attended one of our PI Summits, you really don’t want to miss this event. We offer expert classes on business, medical and legal topics relevant to the PI industry, and we provide an environment where doctors and lawyers come together for a full day or learning and making meaningful connections to help grow their PI practice. If you’re interested in participating as an expert speaker, sponsor or to get Early Bird tickets, check out our website or contact us for more information. I cannot emphasize enough how important it is for you to be there, and I look forward to the opportunity to meet you all face to face.
Sincerely,
Angely C. Maria EDITOR IN CHIEF
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By Marty Kotlar, DC, CPCO, CBCS, COF
QUESTION: Dr Kotlar, “I have heard there are new diagnosis codes for 2025. Do any of them relate to personal injury?”
ANSWER: Yes, there are many ICD-10 code updates that physical therapists, chiropractors, medical doctors and other healthcare providers that treat personal injury patients should be aware of because they relate to back pain and spinal disc pathology.
The official ICD-10 code guidelines for 2025 take effect on October 1, 2024, and remain in effect until September 30, 2025. The updates include 252 new codes, 36 deleted codes, and 13 codes were revised.
There are 8 new ICD-10 codes that relate to low back pain, lower extremity pain and disc degeneration:
• M51.360: Other intervertebral disc degeneration, lumbar region with discogenic back pain only
• M51.361: Other intervertebral disc degeneration, lumbar region with lower extremity pain only
• M51.362: Other intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain
• M51.369: Other intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain
• M51.370: Other intervertebral disc degeneration, lumbosacral region with discogenic back pain only
• M51.371: Other intervertebral disc degeneration, lumbosacral region with lower extremity pain only
• M51.372: Other intervertebral disc degeneration, lumbosacral region with discogenic back pain and lower extremity pain
• M51.379: Other intervertebral disc degeneration, lumbosacral region without mention of lumbar back pain or lower extremity pain
There is 1 new ICD-10 code that relates to low back muscle dysfunction:
• M62.85: Dysfunction of the multifidus muscles, lumbar region
There are 5 new shoulder ICD-10 codes:
• M65.90: Unspecified synovitis and tenosynovitis, unspecified site
• M65.91: Unspecified synovitis and tenosynovitis, shoulder
• M65.911: Unspecified synovitis and tenosynovitis, right shoulder
• M65.912: Unspecified synovitis and tenosynovitis, left shoulder
• M65.919: Unspecified synovitis and tenosynovitis, unspecified shoulder
There are 4 new upper arm ICD-10 codes:
• M65.92: Unspecified synovitis and tenosynovitis, upper arm
• M65.921: Unspecified synovitis and tenosynovitis, right upper arm
• M65.922: Unspecified synovitis and tenosynovitis, left upper arm
• M65.929: Unspecified synovitis and tenosynovitis, unspecified upper arm
There are 4 new thigh ICD-10 codes:
• M65.95: Unspecified synovitis and tenosynovitis, thigh
• M65.951: Unspecified synovitis and tenosynovitis, right thigh
• M65.952: Unspecified synovitis and tenosynovitis, left thigh
• M65.959: Unspecified synovitis and tenosynovitis, unspecified thigh
There are 4 new ankle and foot ICD-10 codes:
• M65.97: Unspecified synovitis and tenosynovitis, ankle and foot
• M65.971: Unspecified synovitis and tenosynovitis, right ankle and foot
• M65.972: Unspecified synovitis and tenosynovitis, left ankle and foot
• M65.979: Unspecified synovitis and tenosynovitis, unspecified ankle and foot
The official ICD-10 code guidelines for 2025 take effect on October 1, 2024, and remain in effect until September 30, 2025.
Additional Comments
Acute traumatic versus chronic or recurrent musculoskeletal conditions. Many musculoskeletal conditions are a result of previous injury or trauma to a site or are recurrent conditions. Bone, joint or muscle conditions that are the result of a healed injury are usually found in chapter 13 of the Tabular List. Email info@targetcoding.com for a copy of the Tabular List.
In ICD-10, the trauma episodes of care are designated by 3 types of encounters. Initial encounter, subsequent encounter and sequelae. Use the letter A for initial encounter. This occurs when the patient is receiving active treatment for the condition, and you are the first provider the patient visits for the present condition. Use the letter D for subsequent encounters. This is for follow up visits after the patient has seen another provider. Use the letter S for sequela. Sequela is a late effect problem as a result of the original problem. This is used for complications or conditions that arise as a direct result of a condition.
If you’d like to know the ICD-10 codes that pay for the most treatment, email info@targetcoding.com to receive a FREE ICD-10 code cheat sheet. ■
By Tiffanny J. Anghel, MHA
As the legal industry increasingly relies on technology to streamline operations, the integration of physician electronic medical record (EMR) retrieval with case management software has emerged as a critical advancement. This integration not only enhances efficiency but also plays an important role in ensuring compliance with regulatory standards, particularly those related to Information Blocking Rules, healthcare and legal interoperability, and the 21st Century Cures Act. The healthcare information technology sector is highly regulated so law firms should seek to support vendors who are HIPAA compliant and maintain SOC2 and ISO certifications.
Traditionally, obtaining medical records for legal cases was a labor-intensive process, fraught with delays and errors. Law firms and legal professionals often had to navigate through a maze of paperwork, manual requests, and follow-ups with healthcare providers. However, the advent of digital transformation has changed this landscape.
Leading case management software platforms now offer integrated EMR retrieval services, enabling legal professionals to access critical medical records swiftly and accurately. These integrations allow for seamless data transfer, reducing the time spent on administrative tasks and minimizing the risk of errors. As a result, law firms can focus more on case strategy and client service, and enhance overall productivity.
Compliance with the 21st Century Cures Act and Information Blocking
The 21st Century Cures Act, enacted in 2016, has been a driving force behind promoting greater interoperability in healthcare by mandating secure and accessible electronic health information (EHI). A key provision prohibits Information Blocking — practices that unreasonably obstruct access, exchange, or use of EHI. The Office of the National Coordinator for Health Information Technology (ONC) and the FDA can impose substantial fines for violations. To comply, medical records must be securely shared without undue interference, with all data requests starting with consent obtained through state-approved, HIPAAcompliant forms. Integrated EMR retrieval systems within case management software enable law firms to access medical records efficiently, with automated workflows, timely requests, follow-ups, and alerts to prevent delays.
Legal Interoperability, the ability of different information systems to work together within and across organizational boundaries, is a cornerstone of the 21st Century Cures Act. In the context of EMR retrieval, interoperability ensures that law firms can access and utilize medical records from various healthcare providers without compatibility issues. This capability ensures that medical records from disparate sources can be accessed, analyzed, and incorporated into legal cases without unnecessary delays or technical hurdles. By minimizing compatibility issues and technical hurdles, interoperability reduces delays in legal processes and ensures that all relevant medical information can be incorporated into legal cases promptly and accurately.
Law firms should also engage in due diligence by reviewing the vendor's certification status, asking for audit reports, and ensuring that the vendor's practices align with the firm’s internal compliance policies. Regular audits and assessments should also be conducted to ensure ongoing compliance and security. In a sector as regulated and sensitive as healthcare information technology, law firms cannot afford to take risks with their data security. When selecting a vendor for electronic medical record retrieval and other healthcare-related services, law firms should prioritize those that hold SOC 2, and ISO as these certifications are not just checkboxes but are indicative of a vendor’s dedication to maintaining secure, compliant, and high-quality operations. ■
Tiffanny J. Anghel, MHA HEAD OF PARTNERSHIPS YOCIERGE & YC API
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River City Funding, a Florida based company, is dedicated to meeting your clients’ needs with a conservative and hasslefree approach. We understand the importance of assisting the injured without hindering case settlements. Built on trust and transparency, River City Funding is here when your clients need us most! Whether they are compensating for lost income, covering medical bills, or managing daily expenses, we can help.
By Matt Synder
It seems like everywhere you go now you see more and more ads by chiropractors offering shockwave therapy. What exactly is it and why is it becoming so popular?
The essential principle behind shockwave therapy (or ESWT) revolves around the action of shockwaves, which are rapid but short duration acoustic waves that carry energy and can propagate through tissues. Acting as a mechanical stimulus, ESWT promotes healing via mechanotransduction, and the biological responses include tissue regeneration, wound healing, angiogenesis and bone remodeling in addition to alleviating pain by means of hyperstimulation analgesia. The mechanotransduction created by ESWT triggers angiogenic and tissue regeneration responses at cellular and molecular levels, generating beneficial therapeutic effects including increased oxygen and blood circulation, recruitment of stem cells, collagen, substance P, and an increase in VEGF. Common indications showing promising results with ESWT include the treatment of various musculoskeletal disorders, including tendinitis, epicondylitis, plantar fasciitis, trocanteritis, golfer’s elbow, tennis elbow, frozen shoulder, patellar tendonitis, and many others.
The therapy itself isn’t new. In fact, the Europeans have been using shockwave therapy for over 30 years. The Canadians system for over 20 years. In the past 10 years it has started to become popular in the USA. Focused shockwave (or FSWT) devices were initially introduced into the hospital and orthopedic markets. FSWT devices are more precise (focused) in their application and penetrate up to 12cm in depth. Radial shockwave (or RSWT) devices have since been introduced providing the same technological effects as FSWT, but penetrating up to 6cm in depth. This lesser depth provides less risk for practitioners while providing the same effective relief as FSWT, for a fraction of the cost. Other advantages of RSWT include their ability to treat directly over hardware (replacement joint, pins, etc.),
as it is indicated to do so to help speed up the bonding process and for the removal of scar tissue buildup through osteoblastic activity.
For practitioners that do soft tissue work, RSWT can provide the same effects in a fraction of the time, while assisting in the longevity of the practitioner by replacing the toll that soft tissue work can take on the practitioner. Typical treatments times for RSWT is 3-7 minutes per treatment with most indications calling for between 6-12 treatments. A major benefit of RSWT is that most patients feel some initial relief directly following a treatment, making it easy for patients to comply with the treatment plan, eager for their next visit. The units are easy to use for clinicians and staff, with most units having built-in, preset programs, with very few contraindications.
Amazing patient results, along with increased affordability have contributed to this recent growth and popularity of shockwave therapy. Although it is an uncovered service with most major medical insurances, it does have its own billable HCPCS code (0101T) that is reimbursable through most PIP and work comp insurances, at rates between $400-$600 per treatment. *
With high quality RSWT units now being offered for as low as $6,500, can you really afford to not have RSWT in your practice? ■
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By Aaron Proulx, Esq.
This is the fifth article in a series that lights the way to success under Florida Tort Reform’s Section 768.0427. This article is a slight break in the flow of the series to issue what appears to be a necessary broad reminder to all personal injury attorneys in Florida: Tort Reform is NOT a general cap on damages.
While Subsection (2)(a) limits the amount the jury can award to the amount that was already at the time of trial paid to the provider to satisfy the bill, that subsection will seldom come into play because, by definition, that subsection applies only when the provider’s bills have already been paid. The heart of the statute is Subsection (2)(b), which applies to past medical bills that have not yet been satisfied. That subsection deals with evidence offered to prove the amount necessary to satisfy such bills. Please see Article #3 for detailed statutory analysis.
Here are two examples in the month of September alone wherein a personal injury attorney settled or was about to settle a case at a figure far below value because the attorney did not understand the distinction between Subsections (2)(a) and (2)(b). In all three of these cases, I learned of the mistake when my medical provider client called me to help avoid an interpleader between my client and the attorney.
First, an attorney settled a case based on Medicare rates even though the providers had opted out of Medicare. The fact of the opt out meant that the providers did not, and were not required to, submit the bills to Medicare. Because the providers did not submit the bills, Medicare did not pay. Because Medicare did not pay, Subsection (2)(b) – not Subsection (2)(a) -- applied. By the plain language of the statute, this meant that the jury could award any amount above Medicare that it found reasonable. The attorney had no reason to accept the claim representative’s offer to settle at the Medicare rate.
Second, an attorney settled a case based on an “approximation” of the health carrier’s reimbursement rate where the provider did have a contract with the carrier and did submit the bill to health insurance. The health carrier, however, denied the claim. The fact of the denial meant that the carrier did not pay. Because the carrier did not pay, Subsection (2)(b) – not
Subsection (2)(a) -- applied. By the plain language of the statute, this meant that the jury could award any amount above the “approximation” of the carrier’s reimbursement rate that it found reasonable. The attorney had no reason to accept the claim representative’s offer to settle based on the approximation.
Third, a provider performed a procedure that is not covered by Medicare. The attorney settled the case based on the Medicare rate of a “similar procedure” to the one performed. But the fact that the actual procedure was not covered meant that the provider did not, and was not required to, submit the bill to Medicare. Because the provider did not submit the bill, Medicare did not pay. Because Medicare did not pay, Subsection (2)(b) – not Subsection (2)(a) -- applied. By the plain language of the statute, this meant that the jury could award any amount above Medicare that it found reasonable. The attorney had no reason to accept the claim representatives offer to settle based at the Medicare rate.
It is critical that the personal injury attorneys and medical providers get on the same page. If an attorney settles a case at an amount based upon a non-applicable portion of the statute and the medical provider is aware of that mistake, the medical provider is not going to accept the attorney’s resulting request for an extreme reduction on the bill. The attorney will then have a difficult decision to make based upon his or her ethical obligations to the client/patient, which include the responsibility to protect the client from liens. ■
Aaron Proulx, Esq. THE DOCTOR’S LAWYER, PLLC.
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By George A. David, Esq
One of an insurance company’s favorite methods of wiggling out of coverage is a material misrepresentation defense. A material misrepresentation occurs when an insured misrepresents material facts that prejudices an insurance company. Material misrepresentations are in 2 categories: 1) a material misrepresentation made before claim arises and 2) material misrepresentations made after the claim arises. The second category is more difficult for an insurance company to prove than the first category. Many times lawyers and medical providers are afraid of material misrepresentation claims and will abandon a PIP claim or a personal injury claim once an insurance company raises a material misrepresentation defense to coverage. A knowledgeable attorney well-versed in coverage can definitely defeat an insurance company’s material misrepresentation defense in both categories.
One of the keys to defeating a material misrepresentation claim is proper preparation of an insured giving statements and examinations under oath. No statements and/or examinations under oath should be provided until the insurance company follows the strict letter of the law in requiring attendance to a statement or an examination under oath. Most insurance companies do not understand what triggers an insured’s appearance to an examination under oath or giving a statement. This provides an avenue for an experienced attorney to protect an insured from giving a statement and/or an examination under oath. Many attorneys practicing personal injury are great attorneys but unfortunately are not well-versed in coverage cases.
Insurance companies love to use policy provisions against an insured to try to prove a material misrepresentation. But why not use those same policy
provisions against an insurance company to defeat a material misrepresentation claim. This is what an experienced attorney well-versed in coverage cases does. Smart medical providers will make sure that they use experienced attorneys in coverage cases to stand in and represent the insured in cases where insurance companies ask an insured to appear to a statement or an examination under oath or in cases where an insurance company claims that the insured committed a material misrepresentation. So the next time a lawyer or a medical provider sees a material misrepresentation defense, do not be afraid just get someone well-versed in coverage to handle the claim. ■
GEORGE A. DAVID P.A
We are the law firm that is not afraid of difficult cases. We handle all cases, including the more difficult cases such as where insurance companies deny claims because:
◦ $10,000.00 policy limits are exhausted
◦ Material misrepresentation
◦ Fraud
◦ Invalid reductions in medical bills
◦ Failure to appear to examinations (EUOs) under oath or “independent” medical examinations (IMEs)
We work with medical providers in EUO and IME requests from insurance companies. We also will co-counsel with personal injury attorneys in making a special appearance in scheduling and appearing to EUOs and IMEs. We are available to answer any PIP questions. Just call or email us.
George David represented insurance companies from 1991 up until 2001. Since 2001 George David has been representing medical providers in PIP suits. We know all the insurance companies’ tricks. We handle cases throughout Florida and have suits filed in the Tampa, Tallahassee and South Florida areas. Our main office is in Coral Gables.
By Christopher M. Tuccitto, Esq.
As medical providers in Florida strive to comply with the complex landscape of billing Personal Injury Protection (PIP) insurance, the question of how much to bill for services lacking established reimbursement amounts under the Medicare Part or Workers’ Compensation fee schedules looms large. The intricacies of this issue are particularly relevant following a recent court decision that shed light on insurance company obligations to pay for unlisted services.
PIP insurance is a crucial component of Florida's no-fault insurance system, designed to cover medical expenses for individuals injured in automobile accidents, regardless of fault. According to Section 627.736, Florida Statutes, PIP insurers are expected to reimburse medical providers for “all reasonable expenses” incurred during treatment. This broad mandate raises significant questions when the services rendered do not align with pre-established reimbursement schedules. Florida law stipulates that when available, reimbursement amounts should adhere to existing fee schedules set forth by Medicare or Workers’ Compensation. However, the reality is that some medical services—especially specialized treatments—do not have corresponding amounts listed in these schedules.
In August 2023, the Fourth District Court of Appeal issued a pivotal ruling in the consolidated cases of Safeco Insurance Company of Illinois v. MD Now Medical Centers, Inc., LM General Insurance Company v. MD Now Medical Centers, Inc. a/a/o Lisa Lugo, and Liberty Mutual Insurance Company v. MD Now Medical Centers, Inc. These consolidated appeals raised important concerns regarding the obligations of PIP insurers to reimburse medical services without established reimbursement amounts under Medicare or Workers' Compensation.
The Court reiterated that while PIP reimbursement should reference these established fee schedules, when possible, it is not strictly bound to them. The ruling established that PIP insurers must have a methodology for determining reimbursement for an unscheduled service that is done by comparing the billed code(s) with clinically similar codes found in the Current Procedural Terminology (CPT) Manual or the Healthcare Common Procedure Coding System (HCPCS) Manual. This ruling is particularly significant because it clarifies that providers may seek reimbursement of their charges even if the charges do not have an established reimbursement amount.
Given the court's affirmation of reimbursement for unlisted services, medical providers must implement comprehensive strategies for billing PIP insurance when it comes to these unlisted services. The basis for this strategy should involve:
1. Assessment of Market Rates: Providers should research and document the standard fees for similar services within their region. Using industry benchmarks will help establish a fair and justifiable billing rate.
2. Documentation of Medical Necessity: Each service should be accompanied by thorough documentation demonstrating its necessity. Clear medical records can substantiate charges and enhance the provider's position during potential disputes with insurance companies.
3. Billing Procedures: Adopt transparent billing practices by breaking down services into detailed line items. This approach not only helps justify the total charges but also provides clarity for both the insurer and the patient.
4. Engagement with Insurers: Providers should be proactive in communicating with PIP insurers regarding their billing practices, especially when services do not fit neatly into existing reimbursement structures. Open dialogue can help prevent disputes and promote timely payment.
As Florida’s medical providers face the challenges associated with PIP billing for services without predetermined reimbursement amounts, the recent 4th DCA ruling provides ammunition for medical providers who are seeking reimbursement for unlisted services. By emphasizing reasonable billing practices, thoroughly documenting services, and being prepared to justify charges, providers will increase the likelihood of PIP reimbursement for these unlisted services. This not only ensures they receive fair compensation but also enhances the overall integrity of the healthcare system in Florida. ■
