Few CPT codes have sparked as much legal debate as CPT Code 97039, especially in the realm of personal injury protection (PIP) litigation. This code, representing miscellaneous therapeutic procedures not otherwise classified, continues to challenge Florida courts and insurance carriers alike.

The Turning Point: Lauderhill Medical Center and Chironex Enterprises

The 4th District Court of Appeal’s 2022 decisions in United Auto. Ins. Co. v. Lauderhill Medical Center and United Auto. Ins. Co. v. Chironex Enterprises, Inc. significantly altered how CPT Code 97039 claims are assessed.

In Lauderhill, the court held that it’s not the CPT code itself but the underlying service that determines reimbursement eligibility under Florida’s No-Fault Law. This precedent was reinforced in Chironex, where the court ruled that insurers must equate a non-billable CPT code to a general reimbursable CPT code to determine whether the underlying service is covered.

A New Development: Allstate Indemnity Co. v. Gady Abramson, D.C., P.A.

On December 4, 2024, the 3rd DCA weighed in with its opinion in Allstate Indemnity Co. v. Gady Abramson, D.C., P.A. Here, the court addressed whether aqua therapy billed under CPT Code 97039 was reimbursable. The Plaintiff argued it was analogous to CPT Code 97022 and could be reimbursed on a case-by-case basis under Medicare Part B.

The 3rd DCA disagreed, reversing the trial court’s ruling in favor of the provider. The court emphasized:

1. Statutory construction governs reimbursement: Reimbursement must align with specific fee schedules, not ad hoc case-by-case determinations.
2. Local custom doesn’t override statute: Statutory provisions under § 627.736(5)(a)(1)(f), Fla. Stat., require adherence to Medicare Part B rates or, alternatively, workers’ compensation rates if Medicare reimbursement is unavailable.
3. Avoiding statutory conflict: The court rejected interpretations that would render alternative statutory provisions meaningless.

The court also clarified that its opinion did not conflict with Lauderhill, as the facts were distinguishable. In Lauderhill, the service in question (vibe therapy) was explicitly reimbursable under Medicare Part B, making the workers’ compensation schedule inapplicable.

What’s Next?

While this opinion represents a win for carriers, it is unlikely to resolve the broader debate surrounding CPT Code 97039. With PIP litigation continuing to evolve, further judicial interpretations—or potentially conflicting opinions from other District Courts of Appeal—may lead to additional uncertainty until the Florida Supreme Court weighs in.

Key Takeaways for Carriers

• Review underlying services carefully: CPT Code 97039 often represents services without dedicated codes, which can complicate reimbursement decisions.
• Follow statutory fee schedules: Adhering strictly to the applicable fee schedules under Medicare Part B or workers’ compensation remains the safest approach.
• Stay informed: As case law continues to develop, carriers must monitor judicial opinions and legislative changes impacting CPT Code 97039 and PIP reimbursement practices.

For assistance navigating these complex issues, contact our team of experienced attorneys specializing in insurance defense and PIP litigation.