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At a Glance:
Title:
10032-m4r
Date:
September 10, 2009

10032-m4r

September 10, 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 2, 2009, to decide the following disputed issue in Docket Number (DWC Docket No. 1), MDR Number M4-09-2395-01:

  1. Is the preponderance of the evidence contrary to the decision of Medical Fee Dispute Resolution Findings and Decision that Petitioner, is not entitled to receive $235.48 as reimbursement for health care services rendered on October 24, 2008 and November 21, 2008 under CPT code 99214?

and the following disputed issue in Docket Number (DWC Docket No. 2), MDR Number M4-09-8440-01:

  1. Is the preponderance of the evidence contrary to the decision of Medical Fee Dispute Resolution Findings and Decision that Petitioner, is not entitled to receive $117.74 as reimbursement for health care services rendered on September 26, 2008 under CPT code 99214?

PARTIES PRESENT

In attendance on behalf of Petitioner was Dr. R. Claimant did not appear and his appearance was waived by the parties. Respondent/Carrier appeared and was represented by GS, attorney.

BACKGROUND INFORMATION

Claimant sustained a compensable injury on ____________ while he was carrying a heavy piece of rebar. He injured his lower back. From the medical history outlined in a peer review report by Dr. C, D.C. Claimant began treating with Dr. A, D.C. in July 2007, was provided chiropractic therapy, and referred to Dr. K, at (Healthcare Provider). According to the medical records, Dr. K examined Claimant on September 26, 2008, October 24, 2008, and November 21, 2008, and refilled medications. (Healthcare Provider) billed Carrier for three office visits, listed the American Medical Association (AMA) Physician's Current Procedural Terminology (CPT) code as 99214, and submitted documentation for payment. In accordance with the Division's Medical Fee Guideline, Division Rule 134.201, Dr. K would be entitled to a reimbursement in the sum of $117.74 based on the maximum allowable reimbursements (MARs) under Division Rule 134.202(c), and subject to Dr. K submitting the supporting documentation to Carrier for payment.

Carrier denied Dr. K’s bills due to the lack of information and documentation to support the level of service being billed in accordance with the CPT code 99214, having an invalid diagnosis code, and not listing a referring doctor. Petitioner contended that previous bills had been paid where the diagnosis code 235.48, sacroiliac joint disorder, was identified and the same services rendered. In its denial, Carrier specifically noted that Dr. K had submitted documentation for a level of service indicating that the nature of Claimant's presenting problems were of moderate to high severity in accordance with the CPT code 99214, but the documentation as submitted by Dr. K did not support that level of service. (Healthcare Provider) requested reconsideration which Carrier denied. (Healthcare Provider) timely requested Medical Dispute Resolution (MDR) in accordance with Division Rule 133.307(c).

On June 24, 2009, Medical Fee Dispute Resolution Findings and Decisions (MFDRFD) were rendered by MDR reviewers. The MFDRFDs determined that based on the documentation submitted by the parties, and in accordance with Texas Labor Code §413.031, (Healthcare Provider) was not entitled to reimbursements of $117.74 per office visit conducted by Dr. K, under CPT code 99214 for dates of service of September 26, 2008, October 24, 2008 and November 21, 2008 for the compensable injury of ____________.

Under CPT code 99214 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 moderate 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 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."

According to the MFDRFD, the CPT code 99214 requires a detailed history, detailed examination, and medical decision making of moderate complexity, and the physician typically spending 25 minutes face-to-face with the patient and or family. The MDR reviewer correctly determined that the documentation submitted by Dr. K was a template for past visits, and lacked the required information to bill for CPT code 99214. Even if the administrative mistakes as to the invalid diagnosis code and lack of name of the referring doctor are overlooked, the MDR reviewer correctly determined that Dr. K failed to conduct a detailed examination of Claimant that included an extended examination of the affected body area, and other symptomatic or related symptoms; and correctly determined that Dr. K failed to make a medical decision of moderate 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.

The preponderance of the evidence is not contrary to the decision of MFDRFD that Dr. K is not entitled to reimbursement of $117.74 and $235.48 under CPT code 99214 for dates of service of September 26, 2008, October 24, 2008 and November 21, 2008 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 24, 2009, the Medical Fee Dispute Resolution Findings and Decision, in Docket Number (DWC Docket No. 1), MFDR Number M4-09-8437-01 determined that Dr. K, from (Healthcare Provider), was not entitled to a reimbursement of $235.48 under CPT code 99214 for dates of service of October 24, 2008 and November 21, 2008, for the compensable injury of ____________.
  • Dr. K, M.D., Provider, from (Healthcare Provider), Petitioner, did not provide a report of a detailed history, detailed examination, and medical decision making of moderate complexity, for each visit, as required under CPT code 99214 when he submitted the documentation for reimbursement of $235.48 under CPT Code 99214 for dates of service of October 24, 2008 and November 21, 2008 for the compensable injury of ____________.
    1. On June 24, 2009, the Medical Fee Dispute Resolution Findings and Decision, in Docket Number (DWC Docket No. 2), MFDR Number M4-09-8440-01 determined that Dr. K, from (Healthcare Provider), was not entitled to a reimbursement of $117.74 under CPT code 99214 for date of service of September 26, 2008 for the compensable injury of ____________.

    6.Dr. K, M.D., Provider, from (Healthcare Provider), Petitioner, did not provide a report of a detailed history, detailed examination, and medical decision making of moderate complexity as required under CPT code 99214 when he submitted the documentation for reimbursement of $117.74 under CPT code 99214 for date of service of September 26, 2008, for the compensable injury of ____________

    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.

      3.For Docket Number (DWC Docket No. 1), MDR Number M4-09-8437-01:

    2. The preponderance of the evidence is not contrary to the decision of Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider), Petitioner, is not entitled to receive $235.48 as reimbursement for health care services rendered on October 24, 2008 and November 21, 2008 under CPT code 99214 for the compensable injury of ____________.

    4.For Docket Number (DWC Docket No. 2), MDR Number M4-09-8440-01:

    The preponderance of the evidence is not contrary to the decision of Medical Fee Dispute Resolution Findings and Decision that (Healthcare Provider), Petitioner, is not entitled to receive $117.74 as reimbursement for health care services rendered on September 26, 2008 under CPT code 99214 for the compensable injury of ____________.

    DECISION

    For Docket Number (DWC Docket No. 1), MDR Number M4-09-8437-01:

    (Healthcare Provider), Petitioner, is not entitled to receive $235.48 as reimbursement for health care services rendered on October 24, 2008 and November 21, 2008 under CPT code 99214 for the compensable injury of ____________.

    For Docket Number (DWC Docket No. 2), MDR Number M4-09-8440-01:

    (Healthcare Provider), Petitioner, is not entitled to receive $117.74 as reimbursement for health care services rendered on September 26, 2008 under CPT code 99214 for the compensable injury of ____________.

    ORDER

    For Docket Number (DWC Docket No. 1), MDR Number M4-09-8437-01:

    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.

    For Docket Number (DWC Docket No. 2), MDR Number M4-09-8440-01:

    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 ZURICH AMERICAN INSURANCE COMPANY, 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 10th day of September, 2009.

    Judy L. Ney
    Hearing Officer

    End of Document
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