Peterson prevails before New Jersey Appellate Division on groundbreaking decision regarding ASC claims

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. “