DECISION AND ORDER

The Petitioner, Liberty Mutual Fire Insurance Company (Carrier), appealed the Findings and Decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) in MRD Docket No. M5-01-2524-01. The MRD found that Respondent Central Dallas Rehab (Provider) was entitled to reimbursement for certain medical services performed by Provider on behalf of ___(Claimant). The MRD granted reimbursement because it found that the treatments billed by Provider were in fact provided to Claimant, and that such treatments were necessary on those occasions on which medical necessity was disputed. This decision finds that Carrier’s appeal should be granted and that no further reimbursements are necessary.

I. PROCEDURAL HISTORY, JURISDICTION, AND NOTICE

Notice and jurisdiction were not contested and are discussed only in the Findings of Fact and Conclusions of Law.

The hearing was held on June 6 and 26, 2002, at the William P. Clements Building, 300 West 15^th , Austin, Texas. The Carrier was represented by Attorney Mahon B. Garry, Jr., and Attorney Scott Hilliard represented the Provider. The record closed on July 9, 2002, with the receipt of a draft order from Carrier pursuant to the ALJ’s request.

II. DISCUSSION

The case originated in Carrier’s appeal of those portions of the decision of the MRD favorable to Provider. Portions of the MRD decision favorable to Carrier were not appealed by Provider.

This is a workers’ compensation medical fee dispute regarding treatment of Claimant for one of two injuries that he received in the course of his employment. On or about_________, Claimant injured his left foot while at work. Later, on our about_________, Claimant injured his back, also while at work. It is undisputed that both injuries were compensable. The same Provider was the treating physician for both injuries. During the period in which the disputed services were provided, Provider was providing services for both injuries.

The disputes in this case involve payment for treatment of Claimant’s foot injury. Carrier’s denial of the payments in dispute was based on the theory that the payments in question were duplicate payments for the same service provided in connection with Provider’s treatment of Claimant’s back injury.

III. ANALYSIS

A. OFFICE VISITS

There are ten dates of service in dispute-September 18 and 20, and October 3, 9, 11, 12, 18, 19, 23, and 25-on which Provider billed Carrier for an intermediate office visit (CPT code 99213) for Claimant’s back injury and also billed Carrier for a 99213 intermediate office visit for Claimant’s foot injury. For each date, Carrier paid the MAR ($48.00) for the office visit for Claimant’s back injury but denied the office visit for the foot injury as a duplicate charge. Doctor Olsea Kamath testified that, at each visit, he would see Claimant regarding his back injury. Claimant would then go to physical therapy, and, on his return, Doctor Kamath would see him again regarding his foot injury.

The ALJ finds that Carrier is not obligated to pay for two 99213 office visits on a given date for this set of facts. The descriptor for CPT code 99213 reads as follows:

“Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components; an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity.”

“Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.”

“Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.”

The ALJ finds that only one visit per day is justified for this patient at this level of care. Since the undisputed evidence establishes that Carrier had paid provider for a 99213 visit for treatment of the back injury for each date in dispute, the Carrier is not obligated to make any additional payment.

B. MYOFASCIAL RELEASE

There are seven dates of service in dispute-September 13, 18, and 20, and October 11, 19, 23, and 25-on which Provider billed Carrier for myofascial release (CPT code 97250) for Claimant’s back injury and also billed Carrier for myofascial release for Claimant’s foot injury. For each date, Carrier paid the MAR ($43.00) for the treatment for Claimant’s back injury but denied the treatment for the foot injury as a duplicate charge. It is undisputed that Provider performed myofascial release on the back and on the foot.

The ALJ finds that Carrier is not obligated to pay for two 97250 myofascial releases on a given date. The descriptor for CPT code 97250 reads as follows:

“Myofascial release/soft tissue mobilization, one or more regions.”

The ALJ finds that only one myofascial release per day may be charged for any one patient. The descriptor for myofascial releases says that the code covers one or more regions. Since the undisputed evidence establishes that Carrier had paid provider for a 97250 myofascial release for treatment of the back injury for each date in dispute, the Carrier is not obligated to make any additional payment.

C. JOINT MOBILIZATION

There are nine dates of service in dispute-September 13, 18, and 20, and October 5, 11, 18, 19, 23, and 25-on which Provider billed Carrier for joint mobilization (CPT code 97265) for Claimant’s back injury and also billed Carrier for joint mobilization for Claimant’s foot injury. For each date, Carrier paid the MAR ($43.00) for the treatment for Claimant’s back injury but denied the treatment for the foot injury as a duplicate charge. It is undisputed that Provider performed joint mobilization on the back and on the foot.

The ALJ finds that Carrier is not obligated to pay for two 97265 joint mobilizations on a given date. The descriptor for CPT code 97250 reads as follows:

“Joint mobilization, one or more areas (peripheral or spinal).”

The ALJ finds that only one joint mobilization per day should have been charged for this patient in these circumstances. The descriptor for joint mobilization says that the code covers one or more areas. Since the undisputed evidence establishes that Carrier had paid provider for a 97265 joint mobilization for treatment of the back injury for each date in dispute, the Carrier is not obligated to make any additional payment in this case.

D. CONCLUSION

Based on the evidence in this matter, the ALJ concludes that Carrier is not obligated to make any additional payments to Provider for disputed treatments on the dates in dispute.

IV. FINDINGS OF FACT

1. On__________, Claimant suffered a compensable injury in the course and scope of his employment with Employer.
2. At the time of Claimant’s injury Carrier was the workers’ compensation carrier for Employer.
3. At all relevant times, Doctor Olsea Kamath was the treating physician for Claimant and was an employee of Provider. All treatment by Provider was pursuant to the direction of Doctor Kamath.
4. On September 18 and 20 and October 3, 9, 11, 12, 18, 19, 23, and 25, Provider billed Carrier for an intermediate office visit (CPT code 99213) for Claimant’s back injury and also billed Carrier for a 99213 intermediate office visit for Claimant’s foot injury.
5. For the visits of September 18 and 20 and October 3, 9, 11, 12, 18, 19, 23, and 25, Carrier paid the MAR ($48.00) for the office visit for Claimant’s back injury but denied the office visit for the foot injury as a duplicate charge.
6. Only one 99213 office visit per day is justified for Claimant on the dates in dispute.
7. Carrier had paid Provider for a 99213 visit for treatment of the back injury for each date in dispute.
8. Carrier is not obligated to make any additional payment for 99213 office visits on September 18 and 20, and October 3, 9, 11, 12, 18, 19, 23, and 25.
9. On September 13, 18, and 20 and October 11, 19, 23, and 25, Provider billed Carrier for myofascial release (CPT code 97250) for Claimant’s back injury, and also billed Carrier for myofascial release for Claimant’s foot injury.
10. For the myofascial release treatments of September 13, 18, and 20, and October 11, 19, 23, and 25, Carrier paid the MAR ($43.00) for the treatment for Claimant’s back injury but denied the treatment for the foot injury as a duplicate charge.
11. Only one myofascial release per day may be charged for this patient in these circumstances, because the descriptor for myofascial releases says that the code covers one or more regions and more than one charge form this same provider is duplicative.
12. Carrier had paid Provider for a 97250 myofascial release for treatment of the back injury for each date in dispute.
13. Carrier is not obligated to make any additional payment for 97250 myofascial release on September 13, 18, and 20 and October 11, 19, 23, and 25
14. On September 13, 18, and 20 and October 5, 11, 18, 19, 23, and 25, Provider billed Carrier for joint mobilization (CPT code 97265) for Claimant’s back injury and also billed Carrier for joint mobilization for Claimant’s foot injury.
15. For the joint mobilization treatments of September 13, 18, and 20, and October 5, 11, 18, 19, and 25, Carrier paid the MAR ($43.00) for the treatment for Claimant’s back injury but denied the treatment for the foot injury as a duplicate charge.
16. Only one joint mobilization charge per day is justified in for these facts, because the descriptor for joint mobilization says that the code covers one or more areas and more than one charge would be duplicative and excessive.
17. Carrier had paid Provider for a 97265 joint mobilization for treatment of the back injury for each date in dispute.
18. Carrier is not obligated to make any additional payment for 97265 joint mobilization on September 13, 18, and 20 and October 5, 11, 18, 19, 23, and 25.

V. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401, et seq.
2. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order pursuant to the Act§413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
3. Petitioner had the burden of proving by a preponderance of the evidence that it should prevail in this matter. 28 TAC § 134.1001 (e)(3)(E).
4. Based on Findings of Fact 4, 5, 6, 7, and 8, Provider is not entitled to additional reimbursement for office visits (CPT 99213) of September 18 and 20 and October 3, 9, 11, 12, 18, 19, 23, and 25, 2000.
5. Based on Findings of Fact 9, 10, 11, 12, and 13, Provider is not entitled to additional reimbursement for myofascial release (CPT 97250) on September 13, 18, and 20 and October 11, 19, 23, and 25, 2000.
6. Based on Findings of Fact 14, 15, 16, 17, and 18, Provider is not entitled to additional reimbursement for joint mobilization (CPT 97265) on September 13, 18, and 20 and October 5, 11, 18, 19, 23, and 25, 2000.

ORDER

IT IS, THEREFORE, ORDERED that Provider is not entitled to additional reimbursement from Carrier for services provided on the dates in dispute in this case.

Signed this 15th day of August 2002.

Bill Zukauckas
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS