On January 29, 2019, the New Jersey Appellate Division delivered opinions in the matters of New Jersey Manufacturers Insurance Company v. Specialty Surgical Center of North Brunswick a/s/o Claire Fiore and New Jersey Manufacturers Insurance Company v. Surgicare Surgical Associates of Fair Lawn a/s/o Martino Chizzoniti.
On January 29, 2019, the New Jersey Appellate Division delivered opinions in the matters of New Jersey Manufacturers Insurance Company v. Specialty Surgical Center of North Brunswick a/s/o Claire Fiore and Surgicare Surgical Associates of Fair Lawn a/s/o Martino Chizzoniti.
The Court considered the issue of whether an ambulatory surgery center could be paid by a no-fault insurer for surgical codes without a value listed in the ASC column of the Appendix to the fee schedule, Exhibit 1. From a jurisdictional standpoint, the Court noted "no published cases have addressed the issue before us; in light of the absence of needed precedent, public policy favors review of the instant matter".
On the critical issue, the Court endorsed NJM's argument:
“[W]hile an ASC may receive payment for hosting a spine surgery for a CMS/Medicare patient, these services are not payable to ASCs under New Jersey PIP. Stated another way, an ASC may host a procedure utilizing the "new" spine surgery codes[,] but it cannot be paid by a No-Fault insurer.”
As to codes adopted by Medicare but not on the PIP fee schedule, the Court found, including high value spine surgery hosting fees:
“The fact that Medicare now includes the CPT code 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. “