The Evolution of Cross-Walking CPT Codes in PIP Claims

By: Kristina D. Forst and Siona R. Bieber 

At this year’s FIFEC conference, we dove into the ever-evolving world of Personal Injury Protection (PIP) claims and how the ways in which providers bill for services has undergone significant transformation – particularly through the use of cross-walked CPT codes. These coding substitutions have become the focus of increased legal scrutiny and case law development. Let’s explore the evolution of cross-walking CPT codes and the current legal landscape that shapes how insurers and medical providers navigate this complex reimbursement terrain. 

Understanding Cross-Walking in PIP Claims

“Cross-walking” is a term that has emerged through litigation, not statute and refers to the practice of billing for one service under a different CPT code. This is typically done to obtain reimbursement for services that may not be clearly reimbursable under Medicare Part B or Florida’s No-Fault Law (PIP statute). Essentially, it occurs when a service that’s billed under one CPT code is then shifted—or cross-walked—to another code that reimburses at a higher rate, even though the underlying service remains the same or similar. However, while there is no statutory definition of cross-walking, it has nonetheless become a routine and often controversial issue in PIP claims litigation and audits.

Why It Matters

Cross-walking has significant implications under Florida Statute 627.736, particularly: 

Fla. Stat. 627.736(5)(a)(1)(f) 

“…if such services, supplies, or care is not reimbursable under Medicare Part B… the insurer may limit reimbursement to 80 percent of the maximum reimbursable allowance under workers’ compensation… Services, supplies, or care that is not reimbursable under Medicare or workers’ compensation is not required to be reimbursed by the insurer.” 

This means insurers are not obligated to pay for services that fall outside both Medicare and workers’ compensation reimbursement schedules. 

Identifying cross-walked codes is essential for avoiding routine overpayment, misinterpretation of service types, and even potential violations under Fla. Stat. 627.736(5)(b)1.c, which addresses false or misleading statements in support of claims.

Common Cross-Walked Codes

Several CPT codes are frequently cross-walked in PIP billing: 

• 97014 → G0283 (and sometimes cross-walked back again) 
• 97039 → 97022 
• S8948 → 97039 

These substitutions often appear harmless but can carry significant implications for claim evaluation. Cross-walking is not just a billing tactic, but a legal and regulatory concern. Adjusters, attorneys, and medical providers alike must pay close attention to whether the service itself is reimbursable, not just whether a clever CPT code was used. In the context of Florida PIP, failing to do so can result in overpayments, legal challenges, and violations of statutory provisions. Staying informed and vigilant is key to navigating the ever-changing cross-walk code landscape in PIP claims.

Cross-walking through the 2000s: Case Studies and Legal Precedents 

2008: Where It All Began – CPT Code 97014 Cross-Walked to G0283

The conversation around cross-walked CPT codes in PIP claims began in 2008, when courts first tackled the issue of providers billing outdated codes, most notably CPT 97014 for unattended electrical stimulation, which Medicare replaced in 2003 with G0283. Though the services are functionally identical, only G0283 is Medicare-compliant. In Tri-County Spine Injury Center v. Progressive*, the court held that even valid services may not be reimbursable if billed under invalid codes, emphasizing that the nature of the service—not just the code—must guide reimbursement decisions. This case laid the foundation for how courts and insurers handle cross-walked code disputes under Florida PIP.

2013: CPT Code 99245 – A Turning Point in Reimbursement Interpretation 

The use of CPT 99245 (an office consultation code involving high-complexity decision making), marked a pivotal moment in how Florida courts view billing codes under the PIP statute. Though still valid, 99245 is no longer reimbursable under Medicare, only under Florida’s Workers’ Comp system. In Allstate v. Perez**, the court clarified that reimbursement depends on the nature of the medical service, not the CPT code alone. This ruling established a key legal standard: billing disputes must focus on what was provided, not just how it was coded.

2022: CPT Code 97039 and the Rise of Cross-Walked Modalities

In 2022, CPT 97039—a vague, unlisted modality code—became central to Florida PIP litigation. Because it can represent various services, providers must submit detailed documentation to justify reimbursement, including the procedure performed, duration, equipment used, and medical necessity. Although 97039 is not reimbursable under Medicare, it carries a set fee under Florida’s Workers’ Comp Fee Schedule. Under §627.736(5)(a)(1)(f), PIP carriers may apply that fee only if Medicare offers no guidance and the service is properly documented. 

In United Auto v. Lauderhill Medical***, the provider billed “vibe therapy” under 97039. The court held that insurers must look beyond the CPT code to determine whether the underlying service qualifies for payment under a recognized fee schedule. Similarly, in United Auto v. Chironex****, the court allowed cross-walking from S8948 (low-level laser therapy) to 97039, but only when records showed the service met the standards of 97039. These rulings confirmed that while billing flexibility exists, it requires precise documentation and a clear link between the code and the actual service rendered. 

2024: A Turning Point – Allstate Indemnity Co. v. Abramson and the Battle Over CPT Code 97039

In a key 2024 ruling, Allstate Indemnity Co. v. Gady Abramson*****, Florida’s Third DCA addressed the use of CPT 97039 in PIP claims. The provider billed aqua therapy using 97039, raising concerns it resembled non-reimbursable massage therapy, which is excluded under Fla. Stat. 627.736(1)(a)(5). Allstate argued that since 97039 lacks a Medicare price, payment must follow the Workers’ Comp Fee Schedule per Fla. Stat. 627.736(5)(a)(1)(f). 

The Third DCA agreed, reversing the trial court and holding that reimbursement must follow established schedules, not case-by-case analysis, when documentation is vague or the service resembles excluded care. The decision marks a shift toward strict statutory interpretation: if Medicare doesn’t price it and Workers’ Comp doesn’t apply, it’s not reimbursable. The ruling underscores the need for precise coding, clear documentation, and statutory compliance in PIP billing.

2025 Landscape: A Shift Toward Standardization—But with Some Throwbacks

In Lake Worth Physical Medicine, Inc. v. State Farm Mut. Auto. Ins. Co. ******, the court upheld State Farm’s use of Medicare code G0283 to reimburse CPT 97014, emphasizing that since 97014 isn’t reimbursable under Medicare, the Workers’ Comp Fee Schedule applies per the Abramson decision. This “backwards” cross-walking highlights the shift toward strict adherence to statutory fee schedules. As outdated codes like 97014 lose Medicare value, carriers and providers must rely on the Workers’ Comp Fee Schedule, solidifying Abramson’s lasting influence and the move away from subjective reimbursement. 

Best Practices for Handling Cross-Walked CPT Codes

Navigating unlisted or cross-walked CPT codes requires more than surface-level billing analysis. Therefore, both insurers and providers must take proactive steps to ensure accurate coding, maintain proper reimbursement, and achieve legal compliance.

Fla. Stat. § 627.736(6)(b) Requests

This statute allows insurers to request detailed provider documentation, including: 

• Treatment history, condition, dates, and costs 
• Medical necessity and reasonableness of charges 
• Sworn statement verifying services were tied to the injury 
• Timing matters: Requests must be sent within 30 days of receiving the bill, and if done correctly, the claim is not overdue until 10 days after the insurer receives the requested info. 
• Caution: Avoid vague or overbroad requests—abusing this tool may constitute an unfair trade practice. 

Depositions & Written Discovery

Use discovery to clarify what service was actually performed and what code it supports. Key questions may include: 

• What medical equipment was used? 
• What service does the procedure report reflect? 
• What CPT code is supported by the documentation?

Engage a Coding Expert

Whether pre-suit or post-suit, expert coders can: 

• Evaluate compliance with annual CPT code updates 
• Assess whether a more appropriate code applies 
• Tip: Consider using credentialed professionals like Jessica Schmor, RN, CPC, or others with medical coding expertise. 

These tools are critical for ensuring cross-walked codes are accurate, justified, and reimbursed under the correct fee schedule. 

Final Thoughts: Cross-Walked Codes in PIP and Where We Stand

Cross-walked CPT codes continue to play a pivotal role in PIP disputes, raising key questions about coding accuracy, lawful reimbursement, and compliance with Florida’s no-fault statute. Here’s a breakdown of the major impacts and legal considerations: 

Courts Say: “Service Controls, Not the CPT Code” 

• Florida courts consistently hold that what matters is the service rendered, not the CPT code used. This means cross-walked codes that do not reflect the actual service can undermine an entire claim—not just the individual charge. 

False & Misleading Charges = No Payment 

• Under Fla. Stat. § 627.736(5)(b)1.c., a claim based on false or misleading coding can be deemed entirely non-compensable. 
• Case Highlight: Chiropractic One v. State Farm******* – The court invalidated the entire claim due to improper coding, not just a single charge. 

Are These Rulings Undermining “Swift and Automatic Payment”? 

• The no-fault system aims for fast, predictable payouts. But when improper cross-walking leads to inflated or inaccurate charges, courts have allowed insurers to deny payment until proper compliance is met—slowing the process for all parties. 

Cross-Walked Codes and Deductibles 

• Improperly cross-walked charges may not be compensable—and therefore not deductible. 
• Progressive Select Ins. Co. v. Fla. Hosp. Med. Ctr. ******** clarified that deductibles apply to total charges, but only if those charges are lawful at the time rendered. 

Payment Issues Tied to Cross-Walking 

• Common concerns include: 
  • Routine overpayments 
  • Improper exhaustion of benefits 
  • Payment of non-compensable or inflated services 
  • Case to Watch: Elite Spine Grp., Inc. v. United Auto. Ins. Co. ********* explores overpayments tied to invalid cross-walked codes. 

Pre-Suit Demand Letters & Inflated Cross-Walked Charges 

• Including inflated or non-compensable services in a demand letter can violate Fla. Stat. § 627.736(10). 
• Case Example: Garrison Prop. & Cas. Ins. Co. v. Aventura Orthopedic Care Ctr. ********** – The court held the pre-suit demand was invalid because it sought payment for unbundled and unlawful services. 

Key Takeaways: Navigating the Coding Minefield 

As the legal landscape around cross-walked codes continues to evolve, both insurers and providers must remain vigilant to legislative changes and case law developments affecting PIP reimbursement. In particular, carriers should focus on the actual service rendered—not just the code billed—while, at the same time, providers must ensure their documentation clearly supports the treatment provided. Furthermore, by leveraging available investigatory tools, both pre- and post-suit, stakeholders can more effectively navigate these complex coding and reimbursement challenges.

 

Citations:

• * Tri-County Spine Injury Ctr., Inc. f/k/a Holistic Healthcare Clinic, Inc. a/a/o Judine Richard v. Progressive Am. Ins. Co., 15 Fla. L. Weekly Supp. 495b (Fla. Broward Cty. Ct. 2008) 

• ** Allstate v. Perez, 111 So. 3d 960 (Fla. 2d DCA 2013)  

• *** United Auto. Ins. Co. v. Lauderhill Med. Ctr., LLC, 350 So. 3d 754 (Fla. 4th DCA 2022) 

• **** United Auto. Ins. Co. v. Chironex Rx., 352 So. 3d 341 (Fla. 4th DCA 2022)  

• ***** Allstate Indem. Co. v. Gady Abramson, D.C., P.A., No. 3D23797 (Fla. 3d DCA 2024)  

• ****** Lake Worth Physical Med., Inc. v. State Farm Mut. Auto. Ins. Co., 33 Fla. L. Weekly Supp. 20b (Fla. Miami-Dade Cty. Ct. 2025)  

• ******* Chiropractic One, Inc. v. State Farm Mut. Auto. Ins. Co., 92 So. 3d 871, 874 (Fla. 5th DCA 2012)  

• ******** Progressive Select Ins. Co. v. Fla. Hosp. Med. Ctr., 260 So. 3d 219, 223–24 (Fla. 2018) 

• ********* Elite Spine Grp., Inc. v. United Auto. Ins. Co., No. CONO-19-013822 (Fla. Broward Cty. Ct. Apr. 5, 2022) (order by DeLuca, J.)  

• ********** Garrison Prop. & Cas. Ins. Co. v. Aventura Orthopedic Care Ctr., P.A., 46 Fla. L. Weekly D1550 (Fla. 4th DCA June 30, 2021)