DECISION AND ORDER

John A. Sazy, M.D. (Petitioner) seeks reimbursement of $98.10 from the American Home Assurance Company (Carrier) 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 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 visit 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 the office visit billed under CPT Code 99214 (an office visit of moderate complexity). Petitioner saw Claimant for an office visit on August 18, 2003, in relation to her compensable injury (a ligament tear). Petitioner billed the office visit under CPT Code 99214, which is the code for an office visit for an established patient involving at least two of the following components: a detailed history, a detailed examination, and medical decision-making of moderate complexity. Carrier denied payment, arguing that the documentation submitted by Petitioner did not support an 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. Because Claimant was an established patient, it was not necessary to take a detailed history of the patient.^[1] Therefore, Dr. Sazy’s documentation does not show a detailed history of Claimant, but it does meet the other two requirements necessary for billing under CPT Code 99214. Dr. Sazy’s documentation shows that he performed a detailed examination of the Claimant, examining her range of motion and stability of her upper and lower extremities, and assessing her muscle strength in her upper and lower extremities. Dr. Sazy reviewed the diagnostic tests and discussed them with Claimant. In addition, the medical decision making was of moderate complexity.^[2] Dr. Sazy explained the risks and benefits of the ACL reconstructive surgery. He also discussed post-surgery recovery and the physical therapy that would be required. He spent more than thirty minutes face-to-face with the Claimant as he helped her to

make an informed decision about the surgery. After his presentation of the risks and benefits, Dr. Sazy answered questions and obtained Claimant’s consent to perform the surgery.

While Dr. Sazy could have provided more detail in his report, the documentation supports use of CPT Code 99214. Accordingly, the ALJ concludes that Dr. Sazy properly used CPT Code 99214 and should recover the full maximum allowable reimbursement of $98.10 for the office visit in dispute.

II. FINDINGS OF FACT

1. Claimant ___. suffered a compensable, work-related injury.
2. American Home Assurance Company (Carrier) is the carrier of workers= compensation insurance covering Claimant’s compensable injury.
3. On August 18, 2003, Claimant saw John A. Sazy, M.D. (Petitioner) to discuss her ACL reconstructive surgery.
4. Petitioner billed Carrier 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 this office visit billed under CPT Code 99214 was $98.10.
7. Carrier denied reimbursement 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. MRD issued an order on August 27, 2004, declining reimbursement for the office visit.
10. On September 24, 2004, 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 October 8, 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 June 20, 2005, Administrative Law Judge Michael J. O=Malley convened a hearing in this case. Petitioner appeared and represented himself. Carrier appeared and was represented by its attorney, Jeffrey Federspiel. The hearing concluded and the record closed that same day.
14. For the office visit in dispute, Petitioner documented that he conducted a detailed examination of the Claimant, who was to undergo ACL reconstructive surgery.
15. Dr. Sazy checked Claimant’s range of motion and stability of her upper and lower extremities, and assessed her muscle strength in her upper and lower extremities.
16. Dr. Sazy reviewed the diagnostic tests and discussed them with Claimant.
17. The medical decision making was of moderate complexity.
18. Dr. Sazy explained the risks and benefits of the ACL reconstructive surgery.
19. Dr. Sazy discussed post-surgery recovery and the physical therapy that would be required.
20. Dr. Sazy spent more than thirty minutes face-to-face with Claimant as he helped her to make an informed decision about the surgery.
21. After his presentation of the risks and benefits, Dr. Sazy answered questions and obtained Claimant’s consent to perform the surgery.

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 August 18, 2003 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 American Home Assurance Company is required to reimburse Petitioner $98.10 for the services billed under CPT Code 99214 for the office visit provided to Claimant on August 18, 2003.

Signed June 29, 2005.

MICHAEL J. O=MALLEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Dr. Sazy had seen Claimant two or three times before this office visit.↑
2. Claimant had to decide whether the ACL reconstructive surgery was the best option for her.↑