DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.

ISSUES

A contested case hearing was held on June 15, 2011 to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of Medical Review that Petitioner is entitled to additional reimbursement in the total amount of $418.26 for date of service of August 13, 2010?

PARTIES PRESENT

Petitioner appeared and was represented by AF, layperson. Respondent/Carrier appeared and was represented by PP, attorney. Claimant did not wish to participate and did not appear.

BACKGROUND INFORMATION

Claimant sustained a compensable injury on (Date of Injury). Petitioner provided anesthesia services to Claimant. Petitioner billed Carrier $836.52, $418.26 under CPT code 01630 with modifier AD and $418.26 under CPT code 01630 with modifier QX, for date of service August 13, 2010. Carrier denied the bill, referring to “Medicare guidelines”.

Petitioner sought Medical Dispute Resolution. On April 5, 2011 a Medical Fee Dispute Resolution Findings and Decision (MFDRFD) was issued by a Medical Fee Dispute Resolution auditor. The issues before the auditor were:

1. Are the disputed CPT codes bundled into any other services rendered on the same day, and are the disputed CPT codes and appended modifiers billable by the provider of the service?
2. Is the requestor entitled to reimbursement?

The auditor’s findings were:

1. The requestor submitted a bill supporting that (IA), MD billed CPT code 01630 (anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint not otherwise specified) twice and appended modifiers “AD” (medical supervision by a physician, more than 4 concurrent anesthesia procedures) and “QX” (CRNA service, without medical direction by a physician). The insurance carrier denied these with reason code 97 (payment is included in the allowance for another service/procedure). The Medicare anesthesia guidelines support that modifier QX is a CRNA modifier and should not be reported if the provider of service is an anesthesiologist. The Division confirms through the Texas Medical Board that (IA), MD is an anesthesiologist. Therefore, reimbursement for CPT code 01630QX is not recommended. Pursuant to Rule 134.203(b)(1), for coding, billing, reporting, and reimbursement of professional medical services, including its coding, billing, correct coding initiatives (CCI) edits, modifiers, and other payment policies in effect on the date a service is provided with any additions or exceptions in the rules. Per the NCCI edits, CPT code 01630AD is not bundled into any other services the requestor billed on the same day. For this reason, reimbursement for CPT code 01630AD is recommended. Pursuant to Rule 134.203(c)(1), to determine the MAR for professional services system participants shall apply the Medicare payment policies with minimal modifications. For service categories of Evaluation & Management, General Medicine, Physical Medicine and Rehabilitation, Radiology, Pathology, Anesthesia, and Surgery when performed in a facility setting, the established conversion factor to be applied is $68.19 (for calendar year 2010). The MAR amount for CPT code 01630AD is $1,050.13.

The auditor concluded Petitioner had established that reimbursement was due in the amount of $418.26. Petitioner appealed the decision to a Medical Contested Case Hearing. The benefits at issue in this hearing were the $418.26 billed under CPT code 01630 with modifier QZ disallowed by MFDR.

Petitioner argued against but failed to rebut by the preponderance of the evidence the basis of the MFDRFD, that the applicable Medicare anesthesia guidelines indicate modifier QX, a CRNA (certified registered nurse anesthetist) modifier, is appropriate when the CRNA is not supervised by a physician, but should not be reported if the nurse anesthetist is supervised by a physician.

Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

1. The parties stipulated to the following facts:
   1. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
   2. On (Date of Injury), Claimant was the employee of (Employer).
   3. On (Date of Injury), Employer provided workers’ compensation insurance with Liberty Mutual Insurance Company, Carrier.
   4. On (Date of Injury), Claimant sustained a compensable injury.
   5. Medical Review determined that Petitioner was entitled to additional reimbursement in the amount of $418.26 for date of service of August 13, 2010.
2. Carrier delivered to Petitioner and Claimant a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
3. Petitioner submitted a bill under CPT code 01630 for anesthesia services provided by a doctor and a CRNA (certified registered nurse anesthetist) in connection with a surgical procedure, requesting two separate payments under two different modifiers: $418.26 under modifier AD (medical supervision by a physician, more than 4 concurrent anesthesia procedures) and $418.26 under modifier QX (CRNA service, without medical direction by a physician); Carrier denied both.
4. Applicable Medicare guidelines support payment under CPT code 01630 either with modifier AD (for the doctor’s services) or modifier QX (for the CRNA’s services, if not supervised by a doctor), not both.
5. Petitioner is entitled to reimbursement in the amount of $418.26 under CPT code 01630 with modifier AD for the services of the anesthesiologist, Dr. IA.
6. Petitioner is not entitled to reimbursement in the amount of $418.26 under CPT code 01630 with modifier QX for the services of the CRNA.
7. Medical Fee Dispute Resolution (MFDR) found Petitioner was entitled to $418.26 billed under CPT code 01630 with modifier AD but was not entitled to an additional $418.26 billed under CPT code 01630 with modifier QZ.
8. The benefits at issue in this hearing were the $418.26 billed under CPT code 01630 with modifier QZ disallowed by MFDR

CONCLUSIONS OF LAW

1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
2. Venue is proper in the (City) Field Office.
3. The preponderance of the evidence-based medical evidence is not contrary to the decision of the IRO that a chronic pain management program five days a week for two weeks is not healthcare reasonably required for the compensable injury of (Date of Injury).

DECISION

The preponderance of the evidence is not contrary to the decision of Medical Review that Petitioner is entitled to additional reimbursement in the amount of $418.26 for date of service of August 13, 2010.

ORDER

Carrier is not liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with Section 408.021 of the Act.

The true corporate name of the insurance carrier is OLD REPUBLIC INSURANCE COMPANY, and the name and address of its registered agent for service of process is

CORPORATION SERVICE COMPANY

211 EAST 7TH STREET, SUITE 620

AUSTIN, TEXAS 78701-3232

Signed this 15th day of June, 2011.

Thomas Hight
Hearing Officer