DECISION AND ORDER

John A. Sazy, M.D. (Petitioner) seeks reimbursement of an additional $23.00 from the State Office of Risk Management (SORM) for an office visit provided to injured worker ___ (Claimant). The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) conducted medical dispute resolution and issued an order denying reimbursement. Petitioner has requested a hearing on MRD’s decision. After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Petitioner has proven by a preponderance of the evidence that the documentation for the office visits supports the level of service billed. Therefore, the ALJ grants the request for reimbursement.

I. DISCUSSION

The sole issue in this case is whether the documentation supports reimbursement for services billed under CPT Code 99214. Petitioner saw Claimant for an office visit on July 3, 2002 in relation to her compensable injury. Petitioner billed the office visit under CPT Code 99214, which is the code for moderately complex office visits involving at least two of the following components: a detailed history, a detailed examination, and medical decision-making of moderate complexity. SORM denied payment, arguing that the documentation submitted by Petitioner to support the office visit was partially illegible and did not establish the required components for a moderately complex office visit billed under CPT Code 99214.

The ALJ finds that the documentation, as explained at the hearing by Dr. Sazy, meets the requirements for reimbursement under CPT Code 99214. Dr. Sazy’s documentation shows that he took a detailed history of the Claimant, who had undergone a failed cervical fusion operation and also suffered from carpel tunnel syndrome. Dr. Sazy also performed a somewhat detailed examination of the Claimant, taking her weight and height, examining her range of motion and the stability of her upper extremities, and assessing her muscle strength in her upper and lower extremities. The medical decision making was also at least of moderate complexity. Dr. Sazy had to assess whether the failed fusion operation should be redone and how the Claimant’s carpal tunnel syndrome fit into the picture. He spent at least twenty-five minutes face-to-face with the Claimant as he helped her to make informed decisions on these issues. He also ordered that the Claimant’s medications be continued and that she continue to wear a splint for her carpal tunnel syndrome.

Finally, while Dr. Sazy’s writing is not a model of good penmanship, it was reasonably legible and the abbreviations and acronyms he used were standard and widely understood within the medical community. Accordingly, the ALJ concludes that Dr. Sazy properly used CPT Code 99214 and should recover the full MAR of $71 for the office visit in dispute. Because SORM has already reimbursed him $48 for the visit, it should be ordered to reimburse Dr. Sazy an additional $23.

II. FINDINGS OF FACT

1. Claimant ___. suffered a compensable, work-related injury on ___.
2. The State Office of Risk Management (SORM) is the provider of workers’ compensation insurance covering Petitioner for her compensable injury.
3. On July 3, 2002, Claimant saw John A. Sazy, M.D. (Petitioner) for treatment of her injury.
4. Petitioner billed SORM for the office visit under CPT Code 99214.
5. CPT Code 99214 reflects a billing of a medical examination of moderate complexity.
6. The maximum allowable reimbursement for office visits billed under CPT Code 99214 is $71.00; SORM reimbursed the Petitioner $48 for the visit, leaving $23 in dispute.
7. SORM denied reimbursement of the additional $23 on the basis that the documentation for the office visit did not support the level of service billed.
8. Petitioner requested medical dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD).
9. After conducting medical dispute resolution, MRD issued an order on November 25, 2003, declining to order additional reimbursement.
10. On December 22, 2003, Petitioner requested a hearing, and the case was referred to the State Office of Administrative Hearings (SOAH).
11. Notice of the hearing was sent on January 5, 2004.
12. The notice contained a statement of the time, place, and nature of the hearing, and the legal authority and jurisdiction under which the hearing was to be held; a reference to the sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
13. On April 12, 2004, ALJ Kerry D. Sullivan convened a hearing in this case. Petitioner appeared and represented himself. SORM appeared and was represented by its attorney, Stephen Vollbrecht. The hearing concluded and the record closed that same day.
14. For the office visit in dispute, Petitioner documented that he took a detailed history of the Claimant, who had undergone a failed cervical fusion operation and also suffered from carpel tunnel syndrome.
15. The medical decision making required during the July 3, 2002 office visit was at least of moderate complexity. The Petitioner had to assess whether the failed fusion operation should be redone and how the Claimant’s carpal tunnel syndrome impacted the assessment. The Petitioner also ordered that the Claimant’s medications be continued and that she continue to wear a splint for her carpal tunnel syndrome.
16. The Petitioner spent at least twenty-five minutes face-to-face with the Claimant during the physical examination and as he helped her to make informed decisions regarding her course of treatment.

III. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers’ Compensation Act (the Act), specifically Tex. Labor Code Ann. § 413.031(k), and Tex. Gov’t Code Ann. ch. 2003.
2. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
3. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code § 148.3.
4. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann.§§2001.051 and 2001.052.
5. Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
6. Under 28 Tex. Admin. Code § 133.1(a)(3)(D)-(E), a medical provider is required to submit documentation supporting and substantiating the care given for which the medical provider is seeking reimbursement.
7. Petitioner established by a preponderance of the evidence that the documentation for the July 3, 2002 office visit supports and substantiates the level of service billed on that date.
8. Petitioner’s request for reimbursement should be granted.

ORDER

IT IS ORDERED that the State Office of Risk Management is required to reimburse Petitioner an additional $23 for the services billed under CPT Code 99214 for the office visit provided to Claimant on July 3, 2002.

Signed June 10, 2004.

KERRY D. SULLIVAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS