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.
A benefit contested case hearing was held on May 15, 2008, to decide the following disputed issue:
Is the Provider entitled to reimbursement in the amount of $649.86 plus applicable accrued interest under CPT Code 90806 for services rendered from February 27, 2007 through July 6, 2007?
Carrier (self-insured) appeared and was represented by CA, attorney. Provider appeared and was represented by KM, attorney. The Employer representative was CS. Also present were Dr. RF and RR. Claimant did not appear; and her appearance was waived.
The parties stipulated that the Claimant sustained a compensable knee injury on ______________. The Claimant received psychotherapy sessions from February 27, 2007 through July 6, 2007 and the Provider billed for these services using the ICD-9 code of 717.9 (internal derangement of the knee). The Provider representative, Dr. M, testified that the psychotherapy was recommended in order to assess the Claimant's psycho-social component related to the compensable injury for referral for work-hardening, as well as, address her adjustment disorder. Dr. M testified that the Claimant was referred to their facility as a result of her knee injury and that all psychotherapy was a direct result of the compensable injury. Dr. M testified that they are instructed to give the primary diagnosis, in this case internal derangement of the knee, when submitting their bills pursuant to the Medicare guidelines which refer to the ICD-9 codes and that any secondary codes, such as adjustment disorder, were not required. The Carrier argued that the Claimant's compensable injury did not include depression or psychological disorders and that the correct ICD-9 code should have been 309.0 for adjustment disorder. The Carrier argued that the Provider was being deceitful by attempting to get the bill paid using the compensable injury code of 717.9 as opposed to 309. 0. It should be noted Carrier had disputed extent of injury to include depression and that the DWC-24 agreement that the injury did not include depression was entered into in March 2008.
Pursuant to Rule 134.202, for coding, billing, reporting, and reimbursement of professional medical services, Texas Workers' Compensation system participants shall apply the Medicare program reimbursement methodologies, models, and values or weights including its coding, billing, and reporting payment policies in effect on the date a service is provided with any additions or exceptions in this section. Medicare utilizes the ICD-9 codes. In this case, the Carrier pre-authorized the psychotherapy treatment for the knee diagnosis (ICD-9 code 717.9) and the health care provider billed under this diagnosis. The psychotherapy sessions were recommended for treatment of the compensable injury and the proper ICD-9 code is the primary diagnosis of internal derangement of the knee. The greater weight of the evidence is not contrary to the findings of Medical Review and the health care provider is entitled to $649.86 plus interest under CPT Code 90806 for services rendered from February 27, 2007 through July 6, 2007.
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
- 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 she sustained a compensable right knee injury.
C.The compensable injury of ______________ does not extend to include depression or psychological condition.
D.The Provider was paid $649.86 for six sessions of psychotherapy for the period from February 27, 2007 through July 6, 2007.
CONCLUSIONS OF LAW
- The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
- Venue is proper in the (City) Field Office.
- The Provider is entitled to reimbursement in the amount of $649.86 plus applicable accrued interest under CPT Code 90806 for services rendered from February 27, 2007 through July 6, 2007.
The Provider is entitled to reimbursement in the amount of $649.86 plus applicable accrued interest under CPT Code 90806 for services rendered from February 27, 2007 through July 6, 2007.
Carrier is liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.
The true corporate name of the insurance carrier is (SELF-INSURED) and the name and address of its registered agent for service of process is:
(CITY), TX (ZIP CODE)
Signed this 17th day of June 2008.
Carol A. Fougerat