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At a Glance:
Title:
09148
Date:
April 20, 2009
Status:
Medical Fees

09148

April 20, 2009

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 March 10, 2009, with the record closing on April 15, 2009 to decide the following disputed issue:

Whether the preponderance of the evidence is contrary to the decision of Medical Fee Dispute Resolution that (Healthcare Provider) is entitled to receive $117.99 plus interest under CPT Code 99214 for services performed on April 17, 2008.

PARTIES PRESENT

Carrier appeared and was represented by TPR. attorney. Respondent appeared and was represented by SL, claims specialist.Claimant appeared; however, she chose not to participate and was excused.

BACKGROUND INFORMATION

On April 17, 2008, the Claimant was seen at (Healthcare Provider) (HCP) for a follow-up office visit, complaining of back pain. The Carrier was billed $124.00 for CPT Code 99214. Carrier denied payment, initially citing two reasons: 1) The documentation provided did not support the nature of the presenting problems as moderate to high severity; and 2) The treatment provided required preauthorization. The HCP submitted a request for reconsideration to the Carrier. This was subsequently denied. The HCP requested Medical Fee Dispute Resolution on January 6, 2009. The parties submitted documentation to Medical Fee Dispute Resolution (MFDR). Carrier relied solely on the first reason for denial, choosing to drop the argument that preauthorization was required prior to the service. In a decision dated January 29, 2009, a Medical Fee Dispute Resolution reviewer found in favor of (Healthcare Provider) and ordered the Carrier to remit to (Healthcare Provider) $117.99 plus accrued interest, for reimbursement of the disputed services. Carrier appealed the decision, requesting a Contested Case Hearing.

According to the Medical Fee Dispute Findings and Decision, per Rule 134.203(b), the description of CPT code 99214 is: “Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.” The MFDR reviewer found that two of the three components, a detailed history and a detailed examination, were present in the documentation submitted by (Healthcare Provider).

Carrier argued at the hearing that the documentation of the office visit on April 17, 2008, including a detailed medical history and a detailed examination, were nearly identical to one or two prior office visits and that therefore the HCP should not receive the requested reimbursement. Without more, the Carrier's argument isnot persuasive.

The greater weight of the evidence is not contrary to the findings of Medical Review and the Carrier is liable for the additional $117.99 plus applicable accrued interest for the service performed on April 17, 2008 and billed under CPT Code 99214.

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 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.
  • On January 29, 2009, Medical Fee Dispute Resolution issued a decision that (Healthcare Provider) was entitled to an additional $117.99 under CPT Code 99214 for services performed on April 17, 2008.
  • The clinic note submitted by (Healthcare Provider) for the office visit of April 17, 2008, contained a detailed history and detailed examination of the Claimant.
  • 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 preponderance of the evidence is not contrary to the decision of Medical Fee Dispute Resolution, rendered on January 29, 2009, that (Healthcare Provider) is entitled to an additional $117.99 under CPT Code 99214 for services performed on April 17, 2008 and the Carrier is liable for the additional $117.99 plus applicable accrued interest.

    DECISION

    (Healthcare Provider) is entitled to $117.99 plus interest under CPT Code 99214 for services performed on April 17, 2008.

    ORDER

    Carrier is liable to the health care provider for reimbursement at issue in this hearing. Claimant remains entitled to medical benefits for the ______________ compensable injury, in accordance with Texas Labor Code Ann. §408.021.

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

    RUSSELL OLIVER, PRESIDENT

    TEXAS MUTUAL INSURANCE COMPANY

    6210 EAST HIGHWAY 290

    AUSTIN, TEXAS 78723

    Signed this 20th day of April, 2009.

    Carolyn Cheu
    Hearing Officer

    End of Document
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