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At a Glance:
Title:
10221
Date:
September 1, 2010
Status:
Medical Fees

10221

September 1, 2010

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 August 31, 2010, 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. K, MD is not entitled to receive in excess of $350.00 as reimbursement for health care services rendered on June 24, 2009 under CPT code 99456-SP?

PARTIES PRESENT

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

BACKGROUND INFORMATION

Claimant sustained a compensable injury on ______________. Dr. K was requested to provide the MMI/IR examination. Dr. K utilized the results of an auditory test, previously performed by Dr. C, on February 26, 2009, in determining Claimant’s IR. Dr. K billed Carrier $400.00 ($350 for assigning MMI, and $50 for incorporating a specialist’s report) using the CPT code 99456-SP. Initially the carrier made a payment of $50.00 only toward the medical bill of $400.00. Subsequently the carrier made an additional reimbursement of $300.00 for a total of $350.00. When Carrier denied the $50 referral fee, Dr. K requested reconsideration, which was also denied. Dr. K timely requested Medical Dispute Resolution (MDR) in accordance with Division Rule 133.307(c). On June 14, 2010, the Medical Fee Dispute Resolution Findings and Decision (MFDRFD) determined that based on lack of information and documentation to support that Claimant was referred to a specialist for use in an impairment rating assignment, Dr. K was not entitled to reimbursements in excess of $350.00 under CPT code 99456-SP for date of service of June 24, 2009 for the compensable injury of ______________.

Pursuant to Rule 134.204(j)(4)(D)(iii)(I), when the examining doctor refers testing for a non-musculoskeletal body area to a specialist, the examining doctor (e.g. the referring doctor) shall bill using the appropriate CPT code with modifier “SP”. Reimbursement shall be $50 for incorporating one or more specialists’ report(s) information into the final assignment of IR. Dr. K’s June 24, 2009 certifying report was in evidence. Carrier specifically noted that the results of the February 26, 2009 audiometric test were utilized by Dr. K. There was no documentation to support that Dr. K referred Claimant to a specialist. Dr. K only reviewed and incorporated an existing medical report. The preponderance of the evidence supports that Dr. K is not entitled to the additional reimbursement of $50.00 under Rule 134.204(j)(4)(D)(iii)(I).

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 ______________.

2.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.

3. Dr. K did not refer Claimant to a specialist to determine Claimant’s impairment rating.

4. The preponderance of the evidence is not contrary to the decision of Medical Fee Dispute Resolution Findings and Decision rendered on June 14, 2010 that Petitioner/Provider is not entitled to receive in excess of $350.00 as reimbursement for health care services rendered on June 24, 2009 under CPT code 99456-SP and the Respondent/Carrier is not liable for additional payment.

CONCLUSIONS OF LAW

1.The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.

  1. 2.Venue is proper in the (City) Field Office.
  2. 3.Dr. Dr. K, is not entitled to receive in excess of $350.00 as reimbursement for health care services rendered on June 24, 2009, under CPT code 99456-SP for the compensable injury of ______________.

DECISION

Dr. Dr. K, is not entitled to receive in excess of $350.00 as reimbursement for health care services rendered on June 24, 2009 under CPT code 99456-SP for the compensable injury of ______________.

ORDER

Respondent/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 WAUSAU UNDERWRITERS
INSURANCE COMPANY, and the name and address of its registered agent for service of process is

CT CORPORATION SYSTEM

1021 MAIN STREET, SUITE 1150

HOUSTON, TEXAS 77002

Signed this 1st day of September, 2010.

Judy L. Ney

Hearing Officer

End of Document
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