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A routine office examination by a chiropractor does not constitute “a significant and separately identifiable service” for which a chiropractor may be paid under § 127.105(e) of the Medical Cost Containment Regulations.

July 1, 2018
Sedgwick Claims Management Services, Inc. v. Bureau of Workers’ Compensation, Fee Review Hearing Office (Piszel and Bucks County Pain Center); 1033 C.D. 2017; filed Apr. 11, 2018; Sr. Judge Colins

According to § 127.105(e) of the Medical Cost Containment Regulations, payment shall be made for an office visit provided on the same day as another procedure, only when the office visit represents “significant and separately identifiable services performed in addition to the other procedure.” The Commonwealth Court noted that the phrase “significant and separately identifiable service” was undefined and that this was a case of first impression. Citing federal Medicare case law and decisions, the court noted that an examination on the same date as a catheter placement or minor surgical procedure does not constitute a “significant and separately identifiable service,” unless it is above and beyond the usual evaluation performed in conjunction with that procedure or is unrelated to the procedure that was performed on the same day.

Therefore, the Commonwealth Court concluded 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 treatment performed on the same dates does not constitute “a significant and separately identifiable service” for which a chiropractor may be paid under § 127.105(e) of the Medical Cost Containment Regulations.

 

Case Law Alerts, 3rd Quarter, July 2018

Case Law Alerts is prepared by Marshall Dennehey Warner Coleman & Goggin to provide information on recent developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. Copyright © 2018 Marshall Dennehey Warner Coleman & Goggin, all rights reserved. This article may not be reprinted without the express written permission of our firm.

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