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At a Glance:
Title:
08065
Date:
May 19, 2008
Status:
Medical Fees

08065

May 19, 2008

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.

ISSUE

A contested case hearing was held on May 19, 2008 to decide the following disputed issue:

Is (Provider) entitled to $48.80 plus interest under CPT Code 97750-FC for a service performed on April 21, 2004?

PARTIES PRESENT

Carrier appeared and was represented by JS, attorney. Respondent appeared and was represented by TN, lay representative.Claimant did not appear, and his attendance was waived.

BACKGROUND EVIDENCE

On April 21, 2004, (Provider) performed an FCE. The Provider submitted a bill for $500.00 for 5 units under CPT code 97750-FC for the service performed on April 21, 2004. The parties stipulated that the Carrier paid $500.00 for the service performed on April 21, 2004. The Provider submitted a bill for reconsideration with a note of "corrected claim" also under CPT code 97750-FC for the FCE performed on April 21, 2004; However, this bill was for $686.00 for 20 units. Medical Dispute issued an order on March 18, 2008 approving an additional amount of $48.80 which the Carrier has disputed claiming that the reconsideration was improperly submitted.

Carrier argued that the rule in effect at the time of the reconsideration was Rule 133.304(k) (1) (b) which under the Medicare fee guidelines is now Rule 133.250. Pursuant to Rule 133. 250(d), the request for reconsideration shall:(1) reference the original bill and include the same billing codes, date(s) of service, and dollar amounts as the original bill; (2) include a copy of the original explanation of benefits, if received, or documentation that a request for an explanation of benefits was submitted to the insurance carrier; (3) include any necessary and related documentation not submitted with the original medical bill to support the health care provider's position; and (4) include a bill-specific, substantive explanation in accordance with §133.3 of this chapter (relating to Communication Between Health Care Providers and Insurance Carriers) that provides a rational basis to modify the previous denial or payment. Strictly interpreting the rule, the Provider did not properly submit their request for reconsideration. The Provider included 15 extra units with an additional cost of $186.00 for the same FCE that was previously billed for April 21, 2004.

The greater weight of the evidence is contrary to the findings of Medical Review and the Petitioner (Carrier) is not liable for the additional $48.80 plus applicable accrued interest for the FCE performed on April 21, 2004 billed under CPT Code 97750-FC.

Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

  1. The parties stipulated to the following facts:

A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers' Compensation.

B.On ___, Claimant was the employee of (employer) when he sustained a compensable injury.

C.The Carrier paid the Provider $500.00 for the FCE performed on April 21, 2004.

  • Carrier delivered to Claimant and Health Care Provider a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • The preponderance of the evidence is contrary to the decision of Medical Review rendered on March 18, 2008 that Respondent (Provider) is entitled to reimbursement for an additional $48.80 under CPT Code 97750-FC for services rendered on April 21, 2004 and the Petitioner (Carrier) is not liable for the additional $48.80 plus applicable accrued interest.
  • CONCLUSIONS OF LAW

    1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
    2. Venue is proper in the (City) Field Office.
    3. (Provider) is not entitled to $48.80 plus interest under CPT Code 97750-FC for a service performed on April 21, 2004.

    DECISION

    (Provider) is not entitled to $48.80 plus interest under CPT Code 97750-FC for a service performed on April 21, 2004.

    ORDER

    The health care provider has been paid in full and Carrier is not liable to the health care provider for any additional payment for services rendered on April 21, 2004 under CPT code 97750-FC.

    The true corporate name of the insurance carrier is TRANSPORATION INSURANCE COMPANY and the name and address of its registered agent for service of process is

    CT CORPORATION SYSTEM
    350 NORTH ST. PAUL STREET
    DALLAS, TEXAS 75201

    Signed this 19th day of May, 2008.

    Carol A. Fougerat
    Hearing Officer

    End of Document
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