All Things Texas Workers' Compensation

Facebook Linkedin

Title: 

453-02-0249-m5

Date: 

October 18, 2002

Type: 

Retrospective Medical Necessity

453-02-0249-m5

DECISION AND ORDER

I. Summary

The Transcontinental Insurance Company (Carrier) sought review of a decision by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC or Commission) awarding Back and Joint Clinic (Provider) reimbursement for one-on-one physical therapy treatments for ____ (Claimant) on several dates of service in mid-1999, and for an established-patient office visit and supplies. Based on the evidence, the Provider is entitled to additional compensation in the amount of $369.00. This was the amount recommended by the MRD.

Administrative Law Judge (ALJ) Cassandra Church convened a hearing on these issues on August 13, 2002, and the record closed on August 19, 2002, to permit the parties to submit additional written argument. Scott Hilliard appeared on behalf of the Back and Joint Clinic; Kyle Hensley appeared for the Carrier.

II. Discussion

On each date of service at issue, the Provider had billed between eight and twelve units of physical therapy. A unit of physical therapy comprises 15 minutes of service. As the service is measured in time, it is referred to as a “timed code.” For each date of service at issue, the Carrier paid for between an hour and a quarter and an hour and one-half of therapy at the maximum allowable reimbursement (MAR) for one-on-one therapy. (CPT Code 97110). However, the Carrier denied payment for all additional units of physical therapy billed by the Provider on the basis that those amounts were in excess of the daily limit for timed codes.[1] The MRD ordered the Carrier to reimburse the Provider for two hours of physical therapy, but for only two hours, on each date of service. (June 1, 23, and July 9 and 23, 1999).[2] Further, the MRD declined to entertain the Carrier’s argument that reimbursement should be denied because the Provider had not demonstrated it had offered one-on-one therapy. The MRD officer termed that argument a documentation issue which was not before the MRD as the Carrier had not raised it when it initially denied part of the Provider’s claim for payment.

At hearing, the Carrier made two arguments. First, it argued that it should not be compelled to pay for units of physical therapy in addition to those it had already reimbursed. Second, the Carrier argued that it should not be required to pay for any one-on-one physical therapy, notwithstanding the fact that it had initially paid for some units of service. In essence, the Carrier was requesting a refund of amounts it had paid.

As to the latter argument, the position of the Carrier at hearing appeared to differ somewhat from the position it took before the MRD. There, the Carrier argued for refund of any amounts “inadvertently paid in excess of the Medical Fee Guideline,” and specifically referenced possible accumulations of units of group therapy (CPT Code 99213) and one-on-one therapy (CPT Code 97110) on the same date that might exceed the two-hour limit. (TWCC Exh. 1, Pp. 341-345). It did not request from the MRD a refund of its payment for the initial two hours of physical therapy.[3] The ALJ was unable to locate in the record of the MRD proceeding any claim by the Carrier for refund for amounts paid for the first two hours of physical theory. Further, the Carrier did not raise that issue in September of 2001 when it requested a hearing. Essentially, it offered a trial amendment of its pleadings, adding a claim for refund of the amounts it paid to its request for relief from the award made by the MRD. The Carrier provided no rationale for why is failed to present its refund claim to the MRD for consideration, and/or to plead it in its request for a contested case hearing. 1 Tex. Admin Code (TAC) §155.29. It provided no authority for the proposition that a party in a TWCC fee dispute can bring an entirely new claim for the first time in the contested case hearing. Further, even if a new claim can be raised here, since it was not raised when the hearing was requested, the Notice of Hearing issued by the Commission on September 26, 2001, did not provide notice to the Provider of this claim. 28 TAC § 148.4(b). Based on the scheme for contested-case review of medical fee disputes set forth in Tex. Labor Code Ann. § 413.031 and 28 TAC § 148.1, et. seq., the ALJ concludes that the Carrier did not properly and timely raise the issue of refund of amounts it paid for the initial two hours of physical therapy service. The ALJ cannot consider it in this contested case. 1 TAC §155.25(a). The only issue in this case will be the additional reimbursement ordered by the MRD.

In regard to the additional reimbursement, the ALJ is persuaded that the Provider is entitled to be reimbursed for up to two hours (8 units) of physical therapy on the four dates of service in issue. As discussed above, the only issue that the Carrier raised in regard to these dates was that the Provider’s billings were for more than two hours per day of physical therapy.[4] The ALJ agrees with the Carrier that the applicable portions of the MFG limit a provider of physical medicine to reimbursement for no more than two hours of service per day. The treatment notes fail to justify payment for additional hours, and the Carrier presented no evidence to show the MRD order obliged it to pay for more than two hours of service.

At hearing, the Carrier also reasserted the lack of Petitioner’s documentation as to one-on-one therapy. However, this new ground for denial cannot be considered here as the Carrier did not raise lack of documentation of the service the Provider provided during those two hours.

In sum, the evidence supports a conclusion that the Provider should be reimbursed in the amounts set forth below in the Findings of Fact.

In addition, the Carrier requested reconsideration of the reimbursement ordered for an office visit for an established patient conducted on February 11, 2000, and related supplies. (CPT Codes 99213 and 99070). The Carrier had denied the claim as a duplicate; the MRD determined the service had been provided. (TWCC Exh. 1, P. 109). The only evidence in the record regarding duplication is the Carrier’s explanation of benefits, which asserts the visit had already been evaluated by the Carrier. (TWCC Exh. 1, P. 338). As the Carrier failed to provide evidence of any previous consideration of the visit to support its claim, the Carrier did not sustain its burden of proof to show the bill was a duplicate. The Carrier must reimburse the Provider for the visit and supplies.

III. Findings of Fact

  1. On_______,____ (Claimant) suffered a compensable injury to his back and spine while at his employment as a dump truck driver.
  2. On_____, Claimant’s employer was covered by workers’ compensation insurance written by Transcontinental Insurance Company (Carrier).
  3. Claimant was diagnosed with lumbar disc displacement, sciatica, sprain of the neck, and cervicocranial syndrome
  4. Provider’s staff members performed physical therapy for Claimant’s benefit on the following dates: June 1 and 23, and July 9 and 23, 1999. The Provider billed the Carrier eight units of one-on-one physical therapy (CPT Code 97110) on June 1, for 11 units on June 23, for 12 units on July 9, and for 10 units on July 23, 1999. A unit of physical therapy service is 15 minutes of service.
  5. The Provider requested reimbursement of $35.00 for each unit of service. For the dates of service at issue, the maximum allowable reimbursement (MAR) for a unit of one-on-one physical therapy was $35.00 per unit.
  6. The Carrier paid for six units of physical therapy at the MAR level on June 1, for five units of therapy on June 23, and for six units of therapy on both July 9 and July 23, 1999. The Carrier denied payment for any additional units on the grounds the amounts billed exceed the two-hour-per-day time limits for physical therapy set in the Medical Fee Guideline, Medicine Ground Rules, Sec. I (A)(10)(a).
  7. Claimant was seen by Provider’s medical staff on February 11, 2000. This visit was billed at $50.00 as an office visit for an established patient (CPT Code 99213), utilizing additional supplies and materials (CPT 99070) valued at $6.00. The MAR for an office visit was $48.00.
  8. The Carrier denied payment for the office visit and supplies on the basis that the claim was a duplicate.
  9. There was no evidence that the billing in Finding of Fact No. 7 was a duplicate submission.
  10. The Provider timely sought review by the Commission of the Carrier’s determinations. On August 10, 2001, the Medical Review Division (MRD) of the Commission awarded reimbursement in the amount of $369.00 to the Provider for matters in dispute in this contested case.
  11. The MRD decision required the Carrier to reimburse the Provider $315.00 for nine additional units of physical therapy, distributed among dates of service as follows: June 1Btwo units; June 23Bthree units; July 9Btwo units, and July 23Btwo units. The award by the MRD had the effect of requiring the Carrier to pay for two hours of physical therapy on each day of service.
  12. The MRD decision required the Carrier to reimburse the Provider $315.00 for nine additional units of physical therapy, distributed among dates of service as follows: June 1Btwo units; June 23Bthree units; July 9Btwo units, and July 23Btwo units. The award by the MRD had the effect of requiring the Carrier to pay for two hours of physical therapy on each day of service.
  13. The MRD decision required the Carrier to reimburse the Provider $315.00 for nine additional units of physical therapy, distributed among dates of service as follows: June 1Btwo units; June 23Bthree units; July 9Btwo units, and July 23Btwo units. The award by the MRD had the effect of requiring the Carrier to pay for two hours of physical therapy on each day of service.
  14. The MRD decision required the Carrier to reimburse the Provider $315.00 for nine additional units of physical therapy, distributed among dates of service as follows: June 1Btwo units; June 23Bthree units; July 9Btwo units, and July 23Btwo units. The award by the MRD had the effect of requiring the Carrier to pay for two hours of physical therapy on each day of service.
  15. The Provider timely sought review by the Commission of the Carrier’s determinations. On August 10, 2001, the Medical Review Division (MRD) of the Commission awarded reimbursement in the amount of $369.00 to the Provider for matters in dispute in this contested case.
  16. The MRD decision required the Carrier to reimburse the Provider $315.00 for nine additional units of physical therapy, distributed among dates of service as follows: June 1Btwo units; June 23Bthree units; July 9Btwo units, and July 23Btwo units. The award by the MRD had the effect of requiring the Carrier to pay for two hours of physical therapy on each day of service.
  17. The Provider timely sought review by the Commission of the Carrier’s determinations. On August 10, 2001, the Medical Review Division (MRD) of the Commission awarded reimbursement in the amount of $369.00 to the Provider for matters in dispute in this contested case.
  18. The MRD decision required the Carrier to reimburse the Provider $315.00 for nine additional units of physical therapy, distributed among dates of service as follows: June 1Btwo units; June 23Bthree units; July 9Btwo units, and July 23Btwo units. The award by the MRD had the effect of requiring the Carrier to pay for two hours of physical therapy on each day of service.
  19. The MRD decision required the Carrier to reimburse the Provider $54.00 for an office visit on February 11, 2000, and related supplies.
  20. On September 21, 2001, the Carrier requested a hearing on the MRD decision.
  21. On September 26, 2001, the Commission issued a notice of hearing which included the date, time, and location of the hearing; and the applicable statutes under which the hearing would be conducted. On July 26, 2002, the Commission filed the statement of matters asserted.
  22. Administrative Law Judge Cassandra Church conducted a hearing on the merits of the case on August 13, 2002; the record closed on August 19, 2002, to permit the parties to submit additional written argument.

IV. Conclusions of Law

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §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 § 413.031 and Tex. Gov’t Code ch. 2003.
  3. Carrier timely requested a hearing, as specified in 28 Tex. Admin Code (TAC) § 148.3.
  4. Proper and timely notice of the hearing was effected on the parties in accordance with Tex. Gov’t Code ch. 2001 and 28 TAC §148.4(b).
  5. Carrier has the burden of proving by a preponderance of the evidence that it should prevail in this matter, pursuant to 28 TAC §148.21(h) and (i).
  6. Carrier failed to prove by a preponderance of the evidence that reimbursement to Provider at the MAR for an additional nine units of physical therapy on four dates of service in June and July 1999 failed to conform to agency fee guidelines, and was not fair and reasonable compensation, within the meaning of Tex. Labor Code § 413.011 and 28 TAC § 42.101, et. seq.
  7. Carrier is required to reimburse Back and Joint Clinic for the units of physical therapy described in Finding of Fact No. 11, pursuant to Tex. Labor Code §§413.011 and 413.015.
  8. Carrier failed to prove by a preponderance of the evidence that the bill for an office visit on February 11, 2000, and related supplies was an unreimbursable duplicate bill.
  9. Carrier is required to reimburse Back and Joint Clinic $54.00 for the office visit and related supplies on February 11, 2000.

ORDER

IT IS HEREBY ORDERED that the Transcontinental Insurance Companyreimburse Back and Joint Clinic $369.00 for physical therapy provided to Claimant on June 1 and 23, and July 9 and 23, 1999, and for an office visit and supplies on February 11, 2000.

Signed October 18, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CASSANDRA J. CHURCH
Administrative Law Judge

  1. The applicable portion of the Medicine Ground Rules, Sec. I(A)(10)(a), P. 32, in the Medical Fee Guideline (MFG) 28 Tex. Admin. Code (TAC) §’134.201, reads as follows: 10.Additional Ground Rules a.A physical medicine session is defined as any combination of four modalities (97010-97039), procedures (97110-97150) and/or physical medicine activities and training (97220-97541). The maximum amount of time allowed per session is two hours.↑
  2. Although the MRD denied on other grounds substantial portions of the Provider’s total claim for reimbursement for one-on-one physical therapy, the Provider did not seek relief from those portions of the MRD decision adverse to it. Thus they are not at issue here. 28 TAC§148.3(a).↑
  3. The ALJ notes that the Carrier also argued that other physical medicine modalities such as myofascial release (CPT Code 97250) and joint mobilization (CPT Code 97265) should be counted toward the two-hour service maximum. However, the MRD held that since those two procedures were not timed codes, they did not count toward the total service hours. The Carrier did not pursue that argument further.↑
  4. For example, the Carrier denied payment for more than one and one-half hours of physical therapy on July 9, 1999 in the following language, “ADJUSTMENT CODES [Code] 765 Maximum occurrence for this physical therapy procedure has been exceeded as specified in the fee schedule. (Refer to TWCC Code Exception F).” (TWCC Exh. 1, P. 133).↑