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At a Glance:
Title:
09014-m4r
Date:
August 25, 2008

09014-m4r

August 25, 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 7, 2008 to decide the following disputed issue:

Is (Healthcare Provider) entitled to additional payment of $150.00 plus interest for an impairment rating evaluation performed on April 24, 2007?

PARTIES PRESENT

(Healthcare Provider), Petitioner, appeared in person by and through their lay representatives KR and CM. Carrier appeared by phone and was represented by RJ, attorney. Claimant did not appear, and his attendance was waived.

BACKGROUND EVIDENCE

On April 24, 2007, (Healthcare Provider) performed an impairment rating evaluation for the claimant herein. The doctor provided ratings for the lumbar spine, using the DRE model; and, the right and left knees, left ankle, right elbow and left hip, all using the range of motion model.

The Provider billed a total of $670.04 for the April 24, 2007 impairment rating evaluation as follows:

First body area using range of motion $300.00

V3 modifier for level of visit (99213) 70.04

Two additional body areas at $150.00/ea 300.00

Total Bil $670.04

The Medical Fee Dispute Resolution Officer found that per Rule 134.202(c)(1) and Rule 134.202(e)(6)(d)(iii)(II)(a) and (b)(2) reimbursement was due as follows: $70.04 for applicable established patient office visit level associated with examination (V3), which corresponded with the applicable office visit and total of $450.00 ($150.00 x 3 body areas) for a total of $520.04.

Carrier had paid $520.04, therefore, no additional reimbursement was ordered by Medical Fee Dispute Resolution.

Rule 134.202(e)(6) sets out the billing and reimbursement rules for MMI/IR examinations. Under the rules, an examining doctor, who performs an MMI/IR evaluation, may bill for a maximum of three musculoskeletal body areas. The rule defines musculoskeletal body areas and sets out the MAR (Maximum Allowable Reimbursement) for musculoskeletal body areas as follows:

“(II) The MAR for musculoskeletal body areas shall be as follows.

(-a-) $150 for each body area if the Diagnosis Related Estimates (DRE) method found in the AMA Guides 4th edition is used.

(-b-) If full physical evaluation, with range of motion, is performed:

(-1-) $300 for the first musculoskeletal body area; and,

(-2-) $150 for each additional musculoskeletal body area.”

In the instant case, under a plain reading of the applicable rule, the preponderance of the evidence is contrary to the findings of Medical Review and the Petitioner (Provider) is entitled to reimbursement of the entire amount billed.

The Rule provides that where the DRE method is use in rating the body areas during an impairment rating examination, the provider may bill $150.00 per body area, with a maximum of three body areas allowable for each examination. The Rule also provides that where the provider uses the range of motion model in evaluating the impairment rating, the provider is entitled to bill $300.00 for the first body area and $150.00 for each additional body area.

Rule 134.202(e)(6)(D)(iii)(I)(a) and (b) clearly contemplates that a doctor is entitled to bill more for the full physical examination required to perform range of motion testing as opposed to the assignment of a category under the DRE method. In the instant case, the provider used both the DRE and ROM methods in evaluating the injured employee’s impairment. As the range of motion method was used in performing a portion of the evaluation herein, the Provider was entitled to bill for that full physical evaluation as provided by the rules and is entitled to reimbursement for the $150.00 requested herein.

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.

  • On _____________, Claimant was the employee of (Employer) when he sustained a compensable injury.
  • 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.
  • Provider billed $670.04 for the an impairment rating evaluation performed on April 24, 2007, which included 70.04 for the V3 modifier for the level of office visit; $300.00 for rating the first body area using the range of motion method; and, $150.00 each for evaluation of two additional body areas.
  • The Carrier paid the Provider $520.04 for an impairment rating examination performed on April 24, 2007.
  • Provider appealed to Medical Review and Medical Review upheld the Carrier’s reimbursement calculation.
  • The preponderance of the evidence is contrary to the decision of Medical Review rendered on November 14, 2007 that Petitioner (Provider) is not entitled to reimbursement for an additional $150.00 under CPT Code 99455-V3-WP for services rendered on April 24, 2007 and the Respondent (Carrier) is not liable for the additional $150.00 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. (Healthcare Provider) is entitled to additional payment of $150.00 plus interest for an impairment rating evaluation performed on April 24, 2007.

    DECISION

    (Healthcare Provider) is entitled to additional payment of $150.00 plus interest for an impairment rating evaluation performed on April 24, 2007.

    ORDER

    Carrier is ordered to pay benefits in accordance with this decision, the Texas Workers’ Compensation Act, and the Commissioner’s Rules.

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

    CORPORATION SERVICE COMPANY

    701 BRAZOS, SUITE 1050

    AUSTIN, TEXAS 78701

    Signed this 25th day of August, 2008.

    Erika Copeland
    Hearing Officer

    End of Document
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