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At a Glance:
Title:
10031-m4r
Date:
September 21, 2009

10031-m4r

September 21, 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 September 17, 2009, to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the decision of Medical Fee Dispute Resolution Findings and Decision that Dr. R, MD is not entitled to receive $187.90 as reimbursement for health care services rendered on January 16, 2009 under CPT code 99215?

PARTIES PRESENT

In attendance on behalf of Petitioner was Dr. R. Claimant did not appear. Respondent/Carrier appeared and was represented by JB, adjuster.

BACKGROUND INFORMATION

Claimant sustained a compensable injury on ______________ while he was carrying a heavy piece of rebar. He injured his right upper extremity. Claimant received extensive treatment and reached MMI on June 2, 2005. After a three and a half year gap of no treatment Claimant saw Dr. R on January 16, 2009 with complaints of pain. Dr. R billed Carrier for the January 16, 2009 office visit, listed the American Medical Association (AMA) Physician's Current Procedural Terminology (CPT) code as 99215, and submitted documentation for payment. In accordance with the Division's Medical Fee Guideline and Division Rule 134.201 Dr. R would be entitled to a reimbursement in the sum of $187.90 based on the maximum allowable reimbursements (MARs) under Division Rule 134.202(c), and subject to submittal of the supporting documentation to Carrier for payment.

Carrier denied Dr. R’s bill due to the lack of information and documentation to support the level of service being billed in accordance with the CPT code 99215, and having an inconsistent diagnosis code for the procedure. In its denial, Carrier specifically noted that Dr. R submitted documentation for a level of service indicating that the nature of Claimant's presenting problems were of high complexity in accordance with the CPT code 99215, but the documentation as submitted by Dr. R did not support that level of service. Dr. R requested reconsideration which Carrier denied. Dr. R timely requested Medical Dispute Resolution (MDR) in accordance with Division Rule 133.307(c).

On June 11, 2009, the Medical Fee Dispute Resolution Findings and Decision (MFDRFD) were rendered by a MDR reviewer. The MFDRFD determined that based on the documentation submitted by the parties, and in accordance with Texas Labor Code §413.031, Dr. R was not entitled to reimbursements of $187.90 for an office visit, under CPT code 99215 for date of service of January 16, 2009 for the compensable injury of ______________.

Under CPT code 99215 for a lumbar injury, the Official Disability Guidelines (ODG) states:

"Doctor's visit for the evaluation of an established patient for a detailed history, examination, and a medical decision of high complexity.Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family."

According to the MFDRFD, the CPT code 99215 requires a detailed history, detailed examination, and medical decision making of high complexity, and the physician typically spending 40 minutes face-to-face with the patient and or family. The MDR reviewer correctly determined that the documentation submitted by Dr. R lacked the required information to bill for CPT code 99215. Even if the administrative mistake as to the inconsistent diagnosis code with the procedure is overlooked, the MDR reviewer correctly determined that Dr. R failed to make a medical decision of high complexity that involved a number of diagnosis and/or management options, the amount and/or complexity of the data to be reviewed, and the risks of complication, morbidity, and or mortality. Also as stated in the April 6, 2009 peer review report, there was no documentation of circumstances accounting for treatment beyond the recommended parameters as recommended by the ODG.

The preponderance of the evidence is not contrary to the decision of MFDRFD that Dr. R is not entitled to reimbursement of $187.90 under CPT code 99215 for date of service of January 16, 2009 for the compensable injury of ______________.

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).

C.Claimant sustained a compensable injury on ______________.

  • Carrier delivered to Petitioner 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 June 11, 2009, the Medical Fee Dispute Resolution Findings and Decision determined that Dr. Dr. R was not entitled to a reimbursement of $187.90 under CPT code 99215 for dates of service of January 16, 2009 for the compensable injury of ______________.
  • Dr. R, MD, Petitioner, did not provide a report of medical decision making of high complexity, as required under CPT code 99215 when he submitted the documentation for reimbursement of $187.90 under CPT Code 99215 for date of service of January 16, 2009.
  • CONCLUSIONS OF LAW

    1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
    1. Venue is proper in the (City) Field Office.
    2. The preponderance of the evidence is not contrary to the decision of Medical Fee Dispute Resolution Findings and Decision that Dr. R, MD, Petitioner, is not entitled to receive $187.90 as reimbursement for health care services rendered on January 16, 2009 under CPT code 99215 for the compensable injury of ______________.

    DECISION

    Dr. R, MD is not entitled to receive $187.90 as reimbursement for health care services rendered on January 16, 2009 under CPT code 99215 for the compensable injury of ______________.

    ORDER

    Carrier is not liable for the benefits 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 COMMERCE & INDUSTRY INSURACE, and the name and address of its registered agent for service of process is

    CORPORATION SERVICE COMPANY

    701 BRAZOS STREET, SUITE 1050

    AUSTIN, TEXAS 78701-3232

    Signed this 21st day of September, 2009.

    Judy L. Ney
    Hearing Officer

    End of Document
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