CP# 2009-16548 (2010). Burn Surgeons of St. Barnabas, Petitioner vs. Shoprite, Respondent.

• Court: New Jersey

New Jersey Workers Compensation 2012. CP# 2009-16548 (2010). Burn Surgeons of St. Barnabas, Petitioner vs. Shoprite, Respondent CP# 2009-16548 Burn Surgeons of St. Barnabas L.L.P v. Shoprite State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation C.P# 2009-16548Burn Surgeons of St. Barnabas, Petitioner vs.Shoprite, RespondentRESERVED DECISION This is my decision in the matter of the Burn Surgeons of St. Barnabas vs. Shoprite, as insured by New Jersey Manufacturers Insurance Company (NJM). This is a dispute over medical bills, the manner in which they are paid and the amounts which were in fact paid. The worker, G.T. was a severely injured man who was injured in a compensable accident. Shoprite admitted liability and authorized the Burn Surgeons of St. Barnabas Hospital to treat the worker. G.T. has not yet filed a claim petition for his injuries. The issues to be decided in this case are: 1. Was it appropriate that the Burn Surgeons at St. Barnabas submit bills to NJM listing the two surgeons who performed surgery on the worker on the five dates as co-surgeons rather than as a primary surgeon and an assistant surgeon; 2. Did NJM apply the appropriate modifiers to the CPT codes and the multiple procedure reductions; 3. Did NJM pay the usual, customary and reasonable rate for the treatment rendered to the injured worker and finally 4. Does NJM owe any further money to the Burn Surgeons of St. Barnabas? N.J.S.A. 34:15-15 provides that the employer shall furnish to the injured worker such medical, surgical and other treatment as shall be necessary to cure and relieve the worker of the effects of the injury. These charges are to be reasonable and based upon the usual fees and charges which prevail in the same community for similar physicians, surgeons and hospital services. No detailed contract exists between NJM and the Burn Surgeons of St. Barnabas. Both parties place reliance on the interpretation of usual, customary and reasonable. At the outset of the worker's treatment, NJM sent a letter to the Burn Surgeons of St. Barnabas authorizing them to care for the worker and to bill at the usual, customary and reasonable rate. The surgeons involved in this action are individuals who treat burn victims. Their expertise is exclusively within the field of burn treatment. The Burn Surgeons of St. Barnabas have operating facilities at St. Barnabas Hospital; they receive burn victims from the northern part of New Jersey. Their geographic area encompasses all of New Jersey north of the Raritan River. Burn cases in need of treatment south of the Raritan are sent down to Crozier Chester Hospital Burn Center. In order to establish uniformity in billing for medical services nationwide, a coding system has been created by the American Medical Association for the benefit of doctors, insurers and patients. Medical procedures have been identified and reduced to single identifiable tasks and assigned specific codes. The codes are accumulated in the CPT Manual. CPT stands for Current Procedural Terminology. These codes, in number form, exist for every task and service that a doctor can perform on behalf of his patient. The manual is updated yearly by the American Medical Association. The Burn Surgeons at St. Barnabas Hospital use a relatively small number of codes in their daily practice. The surgeons herein have limited their claim for further payment to 6 CPT codes: 15000, 15001, 15100, 15101, 15120 and 15121. When any of the Burn Surgeons at St. Barnabas Hospital perform any of the above listed procedures, the code is listed on the billing form commonly known as a HCFA. The medical provider can set its own standard fee schedule for these codes. The payers however do not necessarily pay the provider's charge in full. The Burn Surgeons at St. Barnabas Hospital produced Dr. Michael Marano as its first witness. Dr. Marano is an attending surgeon employed at the Burn Surgeons and is Board Certified in general surgery and surgical critical care. He has had extensive training in the field of burn treatment. Dr. Marano qualified as an expert in general surgery and critical care surgery without objection from respondent. Dr. Marano testified about the specialized nature of his practice. The Burn Center at St. Barnabas is the only burn center in Northern New Jersey. He follows burn patients from admission through surgery, post-surgical therapy to discharge. Burn patients can have many complications in their treatment. Infection is a major cause of death. Organ failure is the second most cause of death in burn patients. Dr. Marano testified that these two complications warrant significant consideration and treatment plans developed for burn patients. In his opinion, the shortest period of time to excise the burns and to graft the wounds gives the patient the best chance of survival. Dr. Marano testified that the procedures used in conducting a grafting surgery from the removal of the old dressing and cleaning the wounds to the transport to the grafting theatre. He testified about the conditions in the theatres specifically that the room is maintained at 90 degrees for the protection of the patient. Patients without skin cannot maintain their own body temperatures. Surgeons wear cooling vests so they can work in the operating theatre. At the start of the surgery the patient is carefully positioned. There is an anesthesiologist present. In some cases, residents and medical students attend. Dr. Marano testified that in large burn cases two burn surgeons attend. Dr. Marano testified that the residents assist in positioning the patient but they cannot work independently. In the surgery there would be at least two operating room nurses, a scrub nurse in sterile garb who can assist in the procedures and a circulating nurse who can obtain necessary equipment and products such as blood. In regard to co-surgeons, Dr. Marano testified that the need for co-surgeons depending on the amount of surface area that needed to be addressed during that procedure. In his opinion, "the larger the surface area, the more blood lost, the more time it takes, the more complex the procedure is, the sicker the patient is." In these cases, Dr. Marano testified that the practice was "to have two experienced people working simultaneously, but sharing responsibility." Dr. Marano testified that there were many burn procedures that do not require two attending surgeons. These are cases that are smaller surface area and are often performed on patients who are not particularly ill in a step down unit, not an operating theatre. Dr. Marano testified that the shorter period of time in surgery, the better for the patient. He asserted that fewer trips to the operating room, fewer anesthetics, few hypothermic insults and fewer blood products benefit the patient. Another reason the burn surgeons utilize two attending surgeons would be the location on the body where the graft is to occur. A graft to the upper extremity would not require co-surgeons in his opinion. If a greater area was involved such as both arms, more can be accomplished than if just one surgeon was working. Burn surgery differs from other types of general surgery in that the task to be accomplished can be interrupted in the event that the patient's condition deteriorates during surgery. Surgeons measure the patient's status by observing blood pressure, pulse rate, temperature and urine output. Blood loss is also crucial. Dr. Marano described the manner in which the two surgeons work together. He made it clear that the patient is not divided in half (with one surgeon taking one side and the other surgeon taking the other). Dr. Marano described the procedures for grafting, wound cautery, utilization of temporary skin, splinting and post-surgical care. In obtaining graft material one surgeon excises skin, the other then steps forward to control blood loss. Blood loss is controlled through the use of topical thrombin material and cautery. In his opinion, it would not be a good idea for both surgeons to be excising at the same time. However, he testified that two surgeons work as co-equals in the operating room. Dr. Marano is familiar with the case of the worker, G.T. Mr. T suffered an injury consisting of 43% of total body surface with flame burns and severe smoke inhalation. Third degree burns involve the entire thickness of the skin and require surgery with excision and grafting. The worker was considered critically ill from the time of admission. He needed aggressive volume resuscitation with intravenous fluids. He needed a tracheostomy for stabilization of his airway. The worker also suffered from renal problems. Mr. T had his first surgery on December 27, 2004. He had a tracheostomy and excision and split thickness grafting for third degree burns of the left arm and hand. The two surgeons on these procedures were Doctors Petrone and Mansour. Dr. Marano testified that two surgeons were needed for the tracheostomy because of the damage to the worker's airway. Apparently this procedure was not billed for two co-surgeons. The first surgery had to be stopped because of blood loss. The operative note marked as P-6 noted that the petitioner tolerated the procedure well. The petitioner had a second surgery on January 3, 2005 for excision and split thickness skin grafting of third degree burns on the anterior torso, flanks and left shoulder. Dr. Marano felt that two...