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At a Glance:
Title:
08108
Date:
July 30, 2008
Status:
Medical Fees

08108

July 30, 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 July 28, 2008, to decide the following disputed issue:

  1. Whether the health care provider is not entitled to reimbursement in the amount of $369.00 plus interest for services rendered to Claimant on May 8, 2003, and June 12, and 26, 2003?

PARTIES PRESENT

Petitioner/Carrier appeared and was represented by SG, attorney. Respondent/ Subclaimant appeared and was represented by PJ, lay representative.

BACKGROUND INFORMATION

On May 8, 2003, and June 12, and 26, 2003, the health care provider (the HCP) provided services to Claimant in the form of testing and individual psychotherapy. Prior to rendering the services, the HCP obtained preauthorization for the services as part of work hardening and/or multidisciplinary pain management for a right shoulder/arm injury. The Medical Fee Dispute Resolution Findings and Decision rendered on May 29, 2008, ordered Carrier to pay $369.00 plus interest for the services on the service dates above. Billing for the services was coded in accordance with treatment for an injury to the shoulder region.

Carrier now denies liability for the subject services on that basis that the injury does not extend to and include depression and psychological conditions. Carrier further agues that the HCP intentionally miscoded the treatment for the shoulder region when it should have coded treatment for the psychological components. The HCP asserts that it had proper and correct preauthorization for multidisciplinary pain management and that the services performed were "situational" to the right shoulder injury.

Carrier's argument is incorrect. Health care providers are instructed by the Division of Workers' Compensation (and its predecessor the Texas Workers' Compensation Commission) to give the primary diagnosis, in this case "the shoulder region", when submitting their bills pursuant to the Medicare guidelines which refer to the ICD-9 codes; and that any secondary codes, such as 90830 for "psychological testing" or 90900 for "biofeedback training", are not required.

Carrier failed to meet its burden of proof. The HCP is entitled to reimbursement in the amount of $369.00 plus interest for services rendered to Claimant on May 8, 2003, and June 12, and 26, 2003.

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 she sustained a compensable injury.

  • Carrier delivered to Claimant 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.
  • Medical Fee Dispute Resolution Findings and Decision rendered on May 29, 2008, that the health care provider is entitled to reimbursement in the amount of $369.00 plus interest for services rendered to Claimant on May 8, 2003, and June 12, and 26, 2003.

    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. The health care provider is entitled to reimbursement in the amount of $369.00 plus interest for services rendered to Claimant on May 8, 2003, and June 12, and 26, 2003.

    DECISION

    The health care provider is entitled to reimbursement in the amount of $369.00 plus interest for services rendered to Claimant on May 8, 2003, and June 12, and 26, 2003.

    ORDER

    Carrier is ordered to pay benefits in accordance with this decision, the Texas Workers’ Compensation Act, and the Commissioner’s Rules. Accrued but unpaid income benefits, if any, shall be paid in a lump sum together with interest as provided by law.

    The true corporate name of the insurance carrier is AMERICAN CASUALTY COMPANY OF READING, PENNSYLVANIA and the name and address of its registered agent for service of process is

    CT CORPORATION SYSTEM

    350 N. ST. PAUL STREET

    DALLAS, TEXAS 75201

    Signed this 30th day of July, 2008.

    Charles T. Cole
    Hearing Officer

    End of Document
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