DECISION AND ORDER

Liberty Mutual Fire Insurance Company (Carrier) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (the Commission) ordering reimbursement to Total Care Medical Centers^[1] (Respondent) for medical services rendered to _______(Claimant).This decision holds that Carrier should reimburse Respondent$308.00 for massage therapy provided to Claimant under CPT Code 97124.

I. JURISDICTION AND NOTICE

There were no contested issues of jurisdiction or notice. Therefore, those issues are addressed in the findings of fact and conclusions of law.

II. PROCEDURAL HISTORY

The hearing in this matter convened October 25, 2001, in the Stephen F. Austin Building, 1700 North Congress Avenue, Austin, Texas. Administrative Law Judge (ALJ) Sharon Cloninger presided. Carrier was represented by Mahon B. Garry, Jr., attorney. Respondent appeared by telephone through Greg Howard, Jr., an employee in the billing department. The Commission did not appear. The record closed the same day.

III. BACKGROUND AND APPLICABLE LAW

A. Background

Claimant, age 20, incurred a compensable, job-related injury to his lower back on________. Claimant was Respondent’s patient at least from June 2, 2000, through July 19, 2000, during which time Respondent provided Claimant with massage therapy and myofascial release during 11 office visits. Carrier reimbursed Respondent for the myofascial release, billed under CPT Code 97250,^[2] but not for the massage therapy, billed under CPT Code 97124.^[3]Carrier denied Respondent’s request for reimbursement on the grounds that myofascial release is a global fee concept ^[4] and includes massage therapy.

On January 16, 2001, following Carrier’ denial of payment, Respondent submitted a request for dispute resolution to the MRD.The MRD’s Findings and Decision dated February 21, 2001, ordered Carrier to pay Respondent $308.00 plus interest.

The sole issue in this proceeding is whether Carrier should reimburse Respondent $308.00 plus interest for massage therapy rendered to Claimant during 11 office visits from June 2, 2000, through July 19, 2000, and billed under CPT Code 97124, when Carrier has already reimbursed Respondent for myofascial release provided to Claimant during those same visits, and billed under CPT Code 97250.

Carrier seeks a decision from the ALJ disallowing payment of the $308.00.

B. Applicable Law

Under the Texas Workers Compensation Act, an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that: (1) cures or relieves the effects naturally resulting from the compensable injury; (2) promotes recovery; or (3) enhances the ability of the employee to return to or retain employment.Tex. Labor Code Ann. § 408.21(a).

To assist health care providers and insurance carriers in determining the medical necessity of specific services and the maximum allowable reimbursement for those services, the Commission established Medical Fee Guidelines (MFG) in 1996, as authorized under Tex. Labor Code Ann. §413.011. The MFG is found at 28 Tex. Admin. Code (TAC) § 134.201.

Under the MFG, medical procedures are assigned CPT^[5] codes. In most instances, the MFG lists a maximum allowable reimbursement (MAR) for each CPT code. The insurance carrier is to reimburse the health care provider either the billed charge or the MAR, whichever is less.^[6]

The services at issue were billed using MFG CPT Code 97124, which is defined as “massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)” with an MAR of $28.00. Myofascial release is described separately under MFG CPT Code 97250 as “myofascial release/soft tissue mobilization, one or more regions” with an MAR of $43.00.

Under its General Instructions, the MFG states that “[t]he Texas Workers Compensation Medical Fee Guidelines (MFG) 1996, shall be effective for all medical services rendered by Health Care Providers (HCP) on or after April 1, 1996.”

IV. EVIDENCE AND ANALYSIS

A. Carrier’s Case

Carrier offered the certified record from the MRD hearing, which was admitted as Petitioner’s Exhibit 1, and a six-page document, which was admitted as Petitioner’s Exhibit 2.

Evidence

Carrier considers myofascial release to be a global procedure that includes massage therapy; the two procedures are not separately reimbursable. Petitioner’s Exhibit 2 is a document from First Health Group Corporation explaining that massage therapy is a component of myofascial release/soft tissue manipulation under the National Correct Coding Policy Manual (NCCPM). The document states in part:

Myofascial release can be defined as “. . . a very gently applied combination of passive range of motion massage with a central focus on stretching.” Soft tissue mobilization incorporates “. . . movement and joint position with the basic application of connective tissue massage techniques.” These definitions indicate that myofascial release and soft tissue mobilization are both techniques that incorporate massage. Myofascial release/soft tissue mobilization (97250) and massage therapy (97124) are both used to relax muscle and soft tissue to allow increased motion and decreased pain. Massage is one aspect of myofascial release therapy used to break up scar tissue. These codes then, would be considered overlapping.

. . . . The National Correct Coding Policy Manual Version 7.1 [NCCPM] states in its introduction: “This edition incorporates all code changes instituted by the Health Care Financing Administration (HCFA) through April 2001. . . It is the goal of HCFA to assist physicians in correctly coding their services for reimbursement. HCFA has developed these coding edits using coding conventions as defined in the AMA’s CPT manual, in national and local policies and edits, and in coding guidelines developed by national medical societies.”

NCCPM designated #97124 (massage therapy) as a component of #97250 (myofascial release/soft tissue manipulation) until its 1999 CPT replacement code #97140 became effective. The designation then showed #97124 as a component of the new code. This indicates massage is considered an integral part of the comprehensive service and not easily separated out as an individual charge. (Pet. Ex. 2).

Argument

Carrier’s position is that Respondent should receive no additional reimbursement for massage therapy because both massage therapy and myofascial release were used to release tension in Claimant’s back. The two procedures are so closely related that paying for both would amount to double payment. Carrier states it is not proper to bill for both procedures when they are performed on the same area of the body in the same physical therapy session. Carrier says CPT Code 97250 is a global fee which includes CPT Code 97124. Because Carrier has already reimbursed Respondent for CPT Code 97250, no further reimbursement for CPT Code 97124 is required.

B. Respondent’s Case

Respondent offered neither documentary evidence nor testimony.

Evidence

The disputed treatments are outlined in Petitioner’s Exhibit 1. During each of the following office visits, Respondent administered both massage therapy and myofascial release to Claimant.

On June 2, 2000, Respondent administered deep tissue massage to Claimant’s lower back to decrease muscle rigidity. Myofascial release was administered to the low back to restore functional mobility to the soft tissues by releasing myofascial adhesions.^[7] (Pet. Ex.1, p.11).

On June 5, 2000, Respondent gave Claimant tissue massage to the low back to relax the affected muscles while relieving hypertonicity.^[8] Myofascial release was performed to restore functional mobility to the soft tissues by releasing myofascial adhesions in the low back region. (Pet. Ex.1, p.12).

On June 7, 2000, Respondent gave Claimant deep tissue massage to the low back region to diminish hypertonicity, and myofascial release to the same area to reduce myofascial adhesions and improve soft tissue mobilization. (Pet. Ex. 1, p. 12).

On June 14, 2000, Claimant was given deep tissue massage to the low back to decrease muscle rigidity, and myofascial release to the lumbar area to restore functional mobility to the soft tissues by releasing myofascial adhesions. (Pet. Ex. 1, p. 27).

On June 19, 2000, Respondent gave Claimant deep tissue massage to the low back region to alleviate hypertonicity of the affected muscle tissue, and myofascial release to the same area to reduce myofascial adhesions and improve soft tissue mobilization. (Pet. Ex. 1, p. 13).

On June 21, 2000, Respondent gave Claimant deep tissue massage therapy to the lumbar spinal area, to abate muscle hypertonicity, and myofascial release to the low back to release congestion in the soft tissues and increase mobilization. (Pet. Ex.1, p. 14).

On June 30, 2000, Respondent gave Claimant tissue massage to the lumbar spinal area to diminish hypertonicity, and myofascial release to the lumbar area to release congestion in the soft tissues and increase mobilization. (Pet. Ex.1, p. 14).

On July 7, 2000, Respondent gave Claimant deep tissue massage in the lumbar spinal area to relax and reduce muscle hypertonicity, and myofascial release to the lumbar spine to restore functional mobility to the soft tissues by releasing myofascial adhesions. (Pet. Ex.1, p.15).

On July 14, 2000, Respondent gave Claimant tissue massage to the low back region to decrease muscle hypertonicity in the tissue, and myofascial release to the lumbar region to decrease myofascial adhesions of the soft tissue. (Pet. Ex.1, p.15).

On July 17, 2000, Respondent gave Claimant deep tissue massage to the low back region to decrease muscle hypertonicity in the tissue, and myofascial release to the low back to restore functional mobility of the soft tissues by releasing myofascial adhesions. (Pet. Ex.1, p. 16).

On July 19, 2000, Respondent gave Claimant tissue massage to the low back area to alleviate tightness and muscle rigidity, and myofascial release to the lumbar region to release congestion in the soft tissues and increase mobilization. (Pet. Ex.1, p. 16).

Argument

Respondent’s position is that massage therapy is not a component of myofascial release. Respondent argues that if the procedures were the same, the MFG would not list two separate CPT codes for them. Respondent said the procedures are distinct in that each procedure gives the patient a different benefit. The procedures performed under CPT Code 97124 for massage therapy are not a component of those performed under CPT Code 97250 for myofascial release, and should be separately reimbursed.

C. Analysisand conclusion

Carrier bears the burden of proof by a preponderance of the evidence on the question of whether the ALJ should deny payment for the disputed services. 28 Tex. Admin. Code (TAC) § 148.2(h). Carrier is limited on appeal to its reasons for denial of payment as set forth in the record admitted as Petitioner’s Exhibit 1.

Carrier declined to pay Respondent for the 11 massage therapies provided to Claimant from June 2, 2000, through July 19, 2000,on the grounds that massage therapy is global to the myofascial releases performed on the same dates, and for which Carrier reimbursed Respondent. The MFG Medicine Ground Rules, which apply to massage therapy and myofascial release, do not refer to a global concept, while the MFG Surgery Ground Rules do refer to a global fee concept, and indicate that starred (*) procedures are not subject to the global fee concept. When the Commission adopted the MFG, it could have also indicated whether therapeutic procedures are global, but it did not. The ALJ is persuaded that the MFG contains separate CPT codes for massage therapy and myofascial release because myofascial release is not a global procedure that includes massage therapy.

While Carrier argues that the NCCPM designates massage therapy to be a component of myofascial release, the Commission has not made a similar designation in the MFG. The MFG states in its General Instructions that the MFG “shall be effective for all medical services rendered by Health Care Providers (HCP) on or after April 1, 1996.”It is the ALJ’s determination that the MFG , and not the NCCPM, applies to the dispute in this case.Indeed, Carrier’s documentary evidence concedes that state guidelines are always the authoritative resource for bill payment, although nationally recognized references, such as the NCCPM, may be helpful in areas not addressed by the state guidelines.(Pet. Ex. 2, p. 3).

Because massage therapy and myofascial release are separate and distinct treatments, and myofascial release is not a global concept under the MFG, Carrier should reimburse Respondent $308.00 plus interest for providing Claimant with massage therapy.

V. FINDINGS OF FACT

1. On __________(Claimant) incurreda compensable injury under the Texas Workers’ Compensation Act, while working for an employer who had workers’ compensation insurance coverage with Liberty Mutual Fire Insurance Company (Carrier).
2. Total Care Medical Centers (Respondent) treated Claimant’s injury during 11 office visits from June 2, 2000, through July 19, 2000.
3. During each of the office visits referenced in Finding of Fact No. 2, Respondent treated Claimant’s low back using both myofascial release and massage therapy.
4. Massage therapy and myofascial release are separate and distinct procedures governed by the Medicine Ground Rules in the Commission’s Medical Fee Guidelines (MFG).
5. Massage therapy is not a component of myofascial release, and under the MFG the global fee concept does not apply to myofascial release.
6. Carrier reimbursed Respondent for the myofascial releases, but not for the massage therapies, on the grounds that the massage therapies were global to the myofascial releases, and not separately reimbursable.
7. On January 16, 2001, Respondent sought medical dispute resolution through the Texas Workers Compensation Commission (the Commission).
8. On February 21, 2001, the Commission’s Medical Review Division (MRD) issued a decision ordering Carrier to reimburse Respondent $308.00 plus interest for services rendered to Claimant between June 2, 2000, and June 19, 2000, under CPT Code 97124.
9. Carrier filed a timely appeal of the MRD decision on March 5, 2001, which culminated in a hearing before the State Office of Administrative Hearings on October 25, 2001.

VI. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act, Tex. Labor Code Ann. §413.031.
2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. §413.031(d), 28 Tex. Admin. Code (TAC) §145.3 and Tex. Gov’t Code Ann., Ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with 28 TAC § 148.4.
4. Carrier bears the burden of proof by a preponderance of the evidence on the question of whether the Administrative Law Judge should disallow additional payment for the disputed services. 28 Tex. Admin. Code (TAC) § 148.2(h)(i).
5. The ALJ is persuaded that the MFG contains separate CPT codes for massage therapy and myofascial release because myofascial release is not a global procedure that includes massage therapy.
6. Pursuant to Findings of Fact Nos. 4 and 5, Carrier failed to prove that additional reimbursement to Respondent should be disallowed because myofascial release is a global fee concept and massage therapy is a component of myofascial release.
7. Pursuant to the above findings of fact and conclusions of law, Carrier owes Respondent an additional reimbursement in the amount of $308.00 plus interest.

ORDER

IT IS, THEREFORE, ORDERED that the Liberty Mutual Fire Insurance Companyshall reimburseTotal Care Medical Center $308.00, plus interest.

Signed this 20^th day of December, 2001.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Total Care Medical Centers is now known as Accident & Injury Center, P. O. Box 23074, Beaumont, Texas 77720-3074. At the time of the disputed services, Total Care Medical Services was located at 1499 Lee Trevino, El Paso, Texas 79936.↑
2. CPT Code 97250 is defined as myofascial release, soft tissue mobilization, one or more regions. (TWCC Ex. 1, p. 10).↑
3. CPT Code 97124 is defined as massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion). (TWCC Ex. 1, p. 10). The MAR for this procedure is $28.00. ($28.00 x 11’$308.00).↑
4. Under the Medical Fee Guidelines (MFG), the global fee concept is described in the Surgery Ground Rules as follows: the concept of a global fee for surgical procedures is a long established concept under which a single fee is billed and paid for all necessary services normally performed by the surgeon before, during and afer the surgical procedure. The global reimbursement, as listed, includes the pre-operative care necessary for the specific surgical procedure, completion of the hospital records, initiation of treatment, local anesthesia. . ., the surgical procedure, post-operative care that normally follows the surgical procedure. Surgery Ground Rules I. A. 1. (Under Surgery Ground Rules I.A.3, starred (*) surgical procedures are not subject to the global fee concept.) Note that the MFG’s Medicine Ground Rules, which apply to the therapeutic procedures in this dispute, do not mention a global fee concept.↑
5. The Commission has incorporated usage of the American Medical Association’s 1995 Current Procedural Terminology (CPT) codes in its Medical Fee Guidelines. (See MFG, General Instructions, I.)↑
6. MFG General Instructions VI (Reimbursement).↑
7. Myofascial adhesions are adhesions (the abnormal union of surfaces normally separate by the formation of new fibrous tissue resulting from an inflammatory process) on the fascia ( a sheet of connective tissue covering or binding together body structures) of the muscles. Merriam Webster’s Medical Dictionary, Merriam-Webster Inc., 1995.↑
8. Hypertonicity is the state or quality of being hypertonic, which denotes a solution which when bathing body cells causes a net flow of water across the semipermeable cell membrane out of the cell. Dorland’s Illustrated Medical Dictionary, 28^th Edition, W. B. Saunders Company, 1994.↑