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.

ISSUES

A contested case hearing was held on February 18, 2010 to decide the following disputed issue:

1. Is the preponderance of the evidence contrary to the findings of Medical Fee Dispute Resolution that the health care provider is not entitled to $1154.15 for dates of service March 17, 2009 and April 14, 2009 for the compensable injury of _______________?

PARTIES PRESENT

Petitioner/Provider appeared and was represented by Dr. R.

Respondent/Carrier appeared and was represented by SC, attorney.

Claimant did not appear and his appearance was waived by the parties.

BACKGROUND INFORMATION

On March 17, 2009 and April 14, 2009, Dr. K performed radiofrequency ablation with destruction of neuromas below the left knee stump for the Claimant’s compensable injury. Dr. K also took x-rays following both of the procedures. The procedures were performed at the Petitioner’s facility and he seeks reimbursement in the total amount of $1154.15 for both dates of service. Payment for the dates of service was denied by the Respondent/Carrier because the services billed did not match the diagnosis code. Claimant’s diagnosis is an amputation of the leg below the knee and the operative reports submitted were for destruction of neuromas below the left knee stump. The Provider billed for neurolytic destruction of nerves in the lumbar spine. The Petitioner/Provider filed a request for Medical Fee Dispute Resolution and on November 5, 2009, the Dispute Resolution Officer issued a finding that the Petitioner was not entitled to reimbursement.

The Dispute Resolution Officer cited several reasons for her denial of the fees. Specifically, she states that it is unclear why the Provider billed for services related to the spine when the services were actually performed on the lower extremity, the medical documentation submitted was not signed by the Provider as required by Medicare, and there was no documentation of the Carrier’s pre-authorization submitted for her review. The Petitioner did enter a copy of the pre-authorization approval into evidence at the Medical Contested Case Hearing.

Rule 133.20(c) required that a health care provider submit a bill with the correct billing code. Dr. R did not submit any documentary evidence to show that the bill was ever submitted with the correct billing codes. Dr. R also did not provide any explanation for why the bill was submitted with billing codes for the lumbar spine instead of the left lower extremity. Based upon the evidence presented in this hearing, the Petitioner has not shown entitlement to reimbursement for the requested services.

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 _______________.

D.The medical fee dispute resolution officer determined that the Provider is not entitled to reimbursement in the amount of $1152.15 for dates of service March 17, 2009 to April 14, 2009.

Carrier delivered toSubclaimant 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.

Petitioner’s claim for $1152.15 was not properly submitted to the carrier for reimbursement in accordance with Rule 133.20(c).

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 findings of the Medical Fee Dispute Resolution Officer that the health care provider is not entitled to $1152.15 for dates of service March 17, 2009 and April 14, 2009 for the compensable injury of _______________.

DECISION

Petitioner, (Health Care Provider), is not entitled to reimbursement in the amount of $1152.15 for dates of service March 17, 2009 and April 14, 2009 for the compensable injury of _______________.

ORDER

Respondent/Carrier is not liable for the medical benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

The true corporate name of the insurance carrier is TRAVELERS INDEMNITY COMPANY OF CONNECTICUT and the name and address of its registered agent for service of process is:

CORPORATION SERVICE COMPANY d/b/a

CSC-LAWYERS INCORPORATING SERVICE COMPANY

211 EAST 7TH STREET, STE. 620

AUSTIN, TX 78701-3218

Signed this 23rd day of February, 2010.

Jacquelyn Coleman
Hearing Officer