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 June 1, 2010 to decide the following disputed issue:

Is the preponderance of the evidence is contrary to the decision of Medical Fee Dispute Resolution that (Healthcare Provider) is entitled to $113.00 plus interest for CPT Code 99361 rendered on on ________________?

PARTIES PRESENT

Petitioner appeared and was represented by TR, attorney.Respondent appeared and was represented by EM, office manager.Claimant did not appear, but was represented by KG, attorney.

BACKGROUND INFORMATION

It is undisputed that the Claimant sustained a compensable injury on _______________ and was subsequently treated by (Healthcare Provider 1) and (Healthcare Provider 2). On ________________, Dr. C met with AZ, a counselor with (Healthcare Provider 2), for the purpose of case management. (Healthcare Provider) submitted a bill to the carrier under CPT Code 99361 for Case Management/Medical Team Conference. Carrier denied reimbursement because the only persons present for the team conference were Dr. C and Ms. AZ and, according to documentation, a minimum of three health care professionals is required for a team conference. Further, documentation did not address how the conference addressed the injured worker’s ability to return to work.

(Healthcare Provider) appealed to Medical Fee Dispute Resolution (MFDR). On April 15, 2010, MFDR found that (Healthcare Provider) was entitled to $113.00 for reimbursement of services involved in the dispute. The medical fee dispute resolution officer indicated that the participants were adequately identified in the documentation and that there was coordination of patient care, the alternative to coordination of the injured employee’s return to work. There was no mention of the number of professionals present for the conference.

According to CPT 2007, a codebook published by the American Medical Association, CPT Code 99361 is defined under the heading of Team Conference as “Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care.” The carrier argues that this definition implies that there should be a physician and more than one other health professional involved in a medical conference. Thus, a minimum of three professionals should be present for the team conference.

Rule 134.204(e) (3) states that contact with one or more members of the interdisciplinary team more often than once every 30 days shall be limited to the following:

1. (A) coordinating with the employer, employee, or an assigned medical or vocational case manager to determine return to work options.
2. (A) developing or revising a treatment plan, including any treatment plans required by Division rules;
3. (B) altering or clarifying previous instructions; or
4. (C) coordinating the care of employees with catastrophic or multiple injuries requiring multiple specialties.

Because the rule allows the treating doctor to have met with one member of the team, for the aforementioned purposes, and no alternate CPT Code exists for appropriate reimbursement, the greater weight of the evidence is not contrary to the findings of Medical Fee Dispute Resolution and the Carrier is liable for the additional $113.00 plus applicable accrued interest for the services rendered on ________________.

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.

1. B.On _______________, Claimant sustained a compensable injury.
2. C.On April 15, 2010, Medical Fee Dispute Resolution determined that the health care provider was entitled to $113.00 for the services provided on behalf of the claimant on ________________.

2.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.

The preponderance of the evidence is not contrary to the decision of Medical Review rendered on April 15, 2010 that the Health Care Provider is entitled to $113.00 for services provided on ________________.

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 $113.00 plus interest for services performed on ________________.

DECISION

(Healthcare Provider) is entitled to $113.00 plus interest under CPT Code 99361 for services performed on ________________.

ORDER

Carrier is liable to (Healthcare Provider) for payment of $113.00 plus interest under CPT Code 99361 for services performed on ________________.

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:

RON WRIGHT, PRESIDENT

TEXAS MUTUAL INSURANCE COMPANY

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723

Signed this 7th day of June, 2010.

Carolyn Cheu
Hearing Officer