DECISION AND ORDER

This case is a dispute about whether Back & Joint Clinic, Ltd. (BJC) should receive additional reimbursement from American Casualty Co. of PA, (carrier or American Casualty) for range of motion testing performed on a workers’ compensation claimant during an office visit and whether the muscle testing performed on the claimant should be reimbursed by body area or in 15 increments of time. On the first issue, The Medical Review Division (MRD) ordered an additional payment to the provider in the amount of $72.00. On the second issue, the provider billed $553.00 and the carrier paid $129.00 for those services. The MRD denied further reimbursement for the muscle testing.

The provider, BJC, seeks additional payment in the amount of $424.00. The carrier, American Casualty, cross-appealed asking for relief from the finding that it owes provider an additional $72.00.

The ALJ finds that American Casualty should pay BJC an additional $244.00 plus appropriate interest.

I. Discussion

BJC performed various disputed medical services for the Claimant from July 19, 2001, through September 11, 2001. In a decision issued March 13, 2002, the MRD of the Texas Workers’ Compensation Commission (the Commission) ordered additional reimbursement of $72.00. American Casualty disputes having to pay that amount. The remaining dispute is over muscle testing performed on July 19, 2001, August 27, 2001, and September 11, 2001.

The range of motion issue is simply whether those charges were included within the office visit billing code that was submitted for those dates. The charges should be paid because the Commission’s 1996 Medical Fee Guideline Provides that range of motion testing is not global to the office visit in circumstances such as those in this case. Medical Ground Rule (IV)(A)(1).

The muscle testing dispute is more difficult:

Regarding muscle testing, the Commission’s 1996 Medical Fee Guideline (MFG), states:

Muscle testing (97750-MT) requires a report identifying the service provided, results, and interpretation of the test and shall be reimbursed per body area (see section (I)(D)(1) of the ground rules for this section). If two or more contiguous areas are injured and if testing requires no additional tasks, then reimbursement shall be allowed for only one body area. Muscle testing shall not be reimbursed in addition to a functional capacity evaluation (FCE). Muscle testing may be used to replace any six components of the functional abilities test and shall be reimbursed (by time required) as a component of the FCE, not exceeding the MAR for an FCE.

1996 MFG, page 35.

The MFG describes CPT code 97750 as “physical performance test or measurement” e.g. musculoskeletal, functional capacity) with written report, each 15 minutes. . . .

1996 MFG, page 60.

BJC performed isometric muscle tests on the Claimant’s spine. The question is how much reimbursement the MFG allows for that testing. BJC seeks reimbursement for each 15-minute unit, at $43.00 per unit. The carrier has reimbursed BJC for $43.00 for each session, claiming provider only gets reimbursed for testing on one body part.

The MFG’s verbiage is not very clear. However, the logical starting point is the definition of muscle testing found on page 35, which requires reimbursement “per body area.” That restriction prevents a provider from attempting to be reimbursed for each muscle tested within a body area

The MAR level allows 15-minute increments of testing, as long as those tests are otherwise reasonable and necessary. In this case, there is no dispute about the reasonableness of the tests. Therefore, the provider is allowed to charge for each 15-minute unit of testing within the body area. In this instance, SCD should be reimbursed the additional $244.00, along with interest as required.

The $244.00 amount is determined by subtracting the $129.00 already paid for muscle testing from $301.00 (seven 15-minute units of muscle testing at $43.00 per unit) leaving $172.00 and adding the $72.00 reimbursement for range of motion testing.

II. Findings of Fact

1. The Claimant sustained a compensable back injury on____________, and sought treatment from Back & Joint Clinic, Ltd. (BJC).
2. BJC performed various disputed medical services for the Claimant from January 31, 2001, through March 2, 2001.
3. In a decision issued March 13, 2002, the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission) ordered additional reimbursement of $72.00. The MRD declined to order additional reimbursement for muscle testing.
4. BJC and American Casualty Co. of PA each filed a timely appeal of the MRD decision.
5. Notice of the hearing was sent April 12, 2002.
6. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
7. The hearing was held July 11, 2002, with Administrative Law Judge Nancy N. Lynch presiding and representatives of BJC and American Casualty (carrier) participating. The hearing was adjourned the same day.
8. BJC performed range of motion tests on claimant on July 19, 2001 and September 11, 2001, that were billed as charges separate from office visit charges.
9. BJC performed 30 minutes of Dynatron lumbar spine muscle testing on July 19, 2001; 45 minutes of Delorme Muscle Testing on August 27, 2001, and on the 30 minutes of Dynatron muscle testing on September 11, 2001.
10. The total muscle testing time for the relevant dates was 105 minutes for a total of 7 units of muscle testing.
11. The Carrier reimbursed BJC $129.00 for muscle testing, leaving $172.00 not paid for muscle testing.

III. Conclusions of Law

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq.
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann.§§413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
4. Petitioner and cross-petitioner each have the burden of proof regarding its own claim in this matter. 28 Tex. Admin. Code §148.21(h). Petitioner BJC met its burden of proof; cross-petitioner American Casualty Co. did not.
5. The Commission’s 1996 Medical Fee Guideline provides that range of motion testing is not global to the office visit in circumstances such as those in this case. Medical Ground Rule (IV)(A)(1).
6. The Commission’s 1996 Medical Fee Guideline allows a health care provider to charge for each 15-minute unit of muscle testing within each body area.
7. BJC should be reimbursed the additional amount of $244.00 along with interest as required.

ORDER

IT IS, THEREFORE, ORDERED that American Casualty Company of PA shall reimburse Back & Joint Clinic, Ltd. $244.00 for range of motion testing conducted on Claimant on July 19, 2001, and September 11, 2001, and muscle testing conducted on the Claimant on July 19, 2001, August 27, 2001; and September 11, 2001, plus applicable interest.

Signed September 11, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Nancy N. Lynch
Administrative Law Judge