CPT Code 98960 is a patient self-management education and training code commonly billed for individualized instruction provided by a qualified nonphysician healthcare professional. In Florida PIP litigation, insurers have frequently argued that CPT 98960 is not reimbursable under the Medicare Part B Participating Physicians Fee Schedule because Medicare labels the code with a “Status B” indicator.
However, a recent Broward County ruling rejected that position and held that CPT 98960 must be reimbursed under the Medicare fee schedule methodology when the code contains Relative Value Units (“RVUs”) capable of generating a reimbursement amount under the Medicare Part B physician fee schedule formula.
In Clearcare LLC v. Security National Insurance Company, the court addressed whether insurers could bypass the Medicare Part B Participating Physicians Fee Schedule and instead reimburse CPT 98960 under workers’ compensation.
The court explained that section 627.736(5)(a)1.f., Florida Statutes, governs reimbursement for “all other medical services, supplies, and care” and specifically references “the participating physicians fee schedule of Medicare Part B.”
The insurer argued that although CPT 98960 has RVU values in the Medicare files, those RVUs were “not used for Medicare payment” because the code carries “Status B” under Medicare. Based on that position, the insurer attempted to skip Medicare reimbursement entirely and instead pay pursuant to the workers’ compensation fee schedule.
The court rejected that argument.
Relying heavily on the Fourth District Court of Appeal’s decision in Sunrise Chiropractic and Rehabilitation Center, Inc. v. Security National Ins. Co., the court explained that the Medicare Part B Participating Physicians Fee Schedule (“PPFS-MPB”) is calculated through RVU values, conversion factors, and geographic adjustments.
The court emphasized that CPT 98960 undisputedly contains RVU values within the Medicare RVU files, meaning a reimbursement value can be mathematically calculated under the PPFS-MPB methodology.
Importantly, the court found that the statutory language only permits an insurer to resort to workers’ compensation reimbursement if the service is “not reimbursable under Medicare Part B, as provided in this sub-subparagraph.”
According to the court, the insurer improperly relied on materials and Medicare concepts outside the actual statutory framework of section 627.736(5)(a)1.f. The court concluded that because CPT 98960 contains RVU values and can be calculated under the Medicare physician fee schedule formula, it is reimbursable under the Medicare Part B Participating Physicians Fee Schedule for Florida PIP purposes.
The ruling also rejected the insurer’s reliance on CMS lookup tools, finding those tools were “not authoritative for purposes of PIP reimbursements under Florida law.”
Ultimately, the court held that the insurer’s “skip” to the workers’ compensation fee schedule was incorrect and granted summary judgment in favor of the provider.
This decision is significant because it reinforces the argument that the existence of RVU values within the Medicare physician fee schedule framework may itself establish reimbursability under Florida’s PIP statute, even where insurers argue Medicare would not separately issue payment for the code under federal billing rules.
Source: Clearcare LLC v. Security National Insurance Company, Broward County Case No. COINX25010166
