N.J.A.C. 11:3-29.4(e) limits an insurer's liability for a medical expense benefit not set forth in the fee schedules established by the New Jersey Department of Banking and Insurance to a reasonable amount considering the fee schedule amount for similar services. The regulation further states when a current procedural terminology (CPT) code for the service performed has been changed since the fee schedule was last amended, the provider shall bill the actual and correct code found in the most recent version of the CPT book, and the insurer shall pay the amount. The process of matching the current code with the most recent version of the fee schedule is referred to as "cross-walking." Where cross-walking is not possible because the fee schedule does not contain a reference to similar services, the insurer's liability for the medical expenses is limited to the usual, customary, and reasonable (UCR) fee.
Plaintiff treated a patient using electromyography and nerve conduction velocity (NCV) tests and received approval from defendant under CPT code 95913, which is defined as thirteen or more nerve studies. This code replaced CPT codes 95903, 95904, and 95934. Plaintiff conducted twenty separate NCV tests, billed defendant using CPT code 95913, but cross-walked the types of tests back to the prior codes, 95903, 95904, and 95934. Defendant reimbursed plaintiff using the more expensive prior CPT code, 95903, and capped the reimbursement at thirteen tests.
The parties arbitrated their dispute and a dispute resolution professional (DRP) ruled in favor of defendant. A majority of a DRP appellate panel affirmed. The trial court also affirmed the reimbursement, applying the UCR methodology.
On appeal, the court exercised its supervisory authority to resolve a split in the interpretation of CPT code 95913 among DRPs and conducted a de novo review of the parties' arguments interpreting N.J.A.C. 11:3-29.4(e). The court reversed the trial court's application of the UCR methodology, holding that under N.J.A.C. 11:3-29.4(e), the appropriate methodology, absent an updated fee schedule, for reimbursements sought under CPT code 95913, was to cross-walk the tests performed back to CPT codes 95903, 95904, and 95934.