The Commonwealth Court of Pennsylvania has ruled in a case offirst impression that chiropractors who treat workers' compensation claimants are notentitled to payment for routine office visits in addition topayment 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 CountyPain Center), a three-judge panel of the court vacated anorder of a Bureau of Workers' Compensation fee review hearingofficer, which had required plaintiff Sedgwick Claims ManagementServices to pay chiropractor Michael Piszel for 39 officevisit charges of $78 each in addition to charges fortreatments provided at those visits.

The charges were incurred in the course of Piszel's treatment ofworkers' compensation claimant Robert Grivner, according to theCommonwealth Court's opinion. Sedgwick, as Grivner's employer'sthird-party workers' compensation insurance administrator, paidPiszel for shoulder and neck treatments he provided toGrivner during those visits but denied the claims for theadditional office visit charges. Sedgwick arguedthat nothing was done during those appointments beyond routineexaminations and evaluations related to the shoulder and necktreatments.

Sedgwick pointed to the Workers' Compensation Medical CostContainment Regulation's mandate that payments for office visits onthe same day that another procedure is performed are permitted“only when the office visit represents a significant and separatelyidentifiable service performed in addition to the otherprocedure.”

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

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A question of law, not fact

But the Commonwealth Court said the hearing officer erroneouslytreated the question of what constitutes a “significant andseparately identifiable service” as a question of fact rather thana question of law.

Noting that the language in the state law was modeled afterMedicare codes, the Commonwealth Court took guidance fromfederal Medicare case law and administrative decisions that haveinterpreted the same language. The appeals courtsaid, ”The language permitting payment for office visits 'onlywhen the office visit represents a significant and separatelyidentifiable service performed in addition to the other procedure,'shows a clear intent to make payment for same-day examinations theexception, not the rule.”

“We conclude, based on the language of the regulation and theinterpretation of the identical Medicare terms that itincorporates, that an examination involving no new medicalcondition, change in medical condition, or other circumstances thatrequire an examination and assessment above and beyond the usualexamination and evaluation for the treatment performed on the samedate does not constitute 'a significant and separately identifiableservice' for which a chiropractor may be paid under Section127.105(e),” Senior Judge James Gardner Colins wrote in the court'sprecedential opinion.

Colins, joined by Judges Patricia McCullough and Ellen Ceisler,said the hearing officer made no findings as to whether theexaminations 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 theexaminations for which Piszel sought office visit charges werefor a new medical condition, change in medical condition orother special circumstances that went beyond the routineevaluations and examinations for the treatments performed on thosedates.

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

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

(Copies of the 13-page opinion in Sedgwick ClaimsManagement Services v. Bureau of Workers' Compensation, PICSNo. 18-0462, are available at http://at.law.com/PICS.)

Zack Needles is Global Managing Editor, Regional Brands atALM. He is also the Managing Editor of The Legal Intelligencer,Pennsylvania Law Weekly, Delaware Business Court Insider andDelaware Law Weekly. Contact him at 215-557-2373 or [email protected]. OnTwitter: @ZackNeedlesTLI.

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