The Commonwealth Court has ruled in a case of first impression that chiropractors who treat workers' compensation claimants are not entitled to payment for routine office visits in addition to payment for procedures that are performed during those visits.

In Sedgwick Claims Management Services v. Bureau of Workers' Compensation, Fee Review Hearing Office (Piszel and Bucks County Pain Center), a three-judge panel of the court vacated an order of a Bureau of Workers' Compensation fee review hearing officer, which had required plaintiff Sedgwick Claims Management Services to pay chiropractor Michael Piszel for 39 office visit charges of $78 apiece in addition to charges for treatments provided at those visits.

The charges were incurred in the course of Piszel's treatment of workers' compensation claimant Robert Grivner, according to the Commonwealth Court's opinion. Sedgwick, as Grivner's employer's third-party workers' compensation insurance administrator, paid Piszel for shoulder and neck treatments he provided to Grivner during those visits but denied the claims for the additional office visit charges. Sedgwick argued that nothing was done during those appointments beyond routine examinations and evaluations related to the shoulder and neck treatments.

Sedgwick pointed to the Workers' Compensation Medical Cost Containment Regulation's mandate that payments for office visits on the same day that another procedure is performed are permitted “only when the office visit represents a significant and separately identifiable service performed in addition to the other procedure.”

The hearing officer sided with Piszel, finding that Sedgwick “did not offer proof, by affidavit or otherwise, explaining what is meant by the phrase 'significant and separately identifiable service' under the regulation” or “prove by a preponderance of the evidence that the procedures listed in provider's bills … include the value of the office visits.”

But the Commonwealth Court said the hearing officer erroneously treated the question of what constitutes a “significant and separately identifiable service” as a question of fact rather than a question of law.

Noting that the language in the state law was modeled after Medicare codes, the Commonwealth Court took guidance from federal Medicare case law and administrative decisions that have interpreted the same language. The appeals court said ”the language permitting payment for office visits 'only when the office visit represents a significant and separately identifiable service performed in addition to the other procedure,' shows a clear intent to make payment for same-day examinations the exception, not the rule.”

“We conclude, based on the language of the regulation and the interpretation of the identical Medicare terms that it incorporates, that an examination involving no new medical condition, change in medical condition, or other circumstances that require an examination and assessment above and beyond the usual examination and evaluation for the treatment performed on the same date does not constitute 'a significant and separately identifiable service' for which a chiropractor may be paid under Section 127.105(e),” Senior Judge James Gardner Colins wrote in the court's precedential opinion.

Colins, joined by Judges Patricia McCullough and Ellen Ceisler, said the hearing officer made no findings as to whether the examinations satisfied the requirements of Section 127.105(e).

The court remanded the case to the Bureau of Workers' Compensation Fee Review Hearing Office to determine whether the examinations for which Piszel sought office visit charges were for a new medical condition, change in medical condition or other special circumstances that went beyond the routine evaluations and examinations for the treatments performed on those dates.

Counsel for Sedgwick, Audrey Jacobsen Copeland of Marshall Dennehey Warner Coleman & Goggin in King of Prussia, declined to comment on the ruling.

Counsel for Piszel, Patrick Donan of Steiner, Segal, Muller and Donan in Dresher, could not be reached for comment.

(Copies of the 13-page opinion in Sedgwick Claims Management Services v. Bureau of Workers' Compensation, PICS No. 18-0462, are available at http://at.law.com/PICS.)