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April 5, 2002
Medical Fees


April 5, 2002




Dr. Cesar A. Sevilla sought reimbursement using CPT Code 99205 for an injured worker’s office visit, but the (Petitioner) decided the medical records did not justify the billing level used and paid Dr. Sevilla at a reduced rate. Subsequently, the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission ordered Petitioner to pay an additional $31 plus accrued interest. Petitioner requested a hearing to challenge the order. The Administrative Law Judge (ALJ) finds Petitioner failed to meet its burden of proof and orders payment of $31 plus accrued interest.

On February 25, 2002, ALJ Georgie B. Cunningham convened the hearing at the Stephen F. Austin Building, 1700 North Congress Avenue, Austin, Texas. Assistant Attorney General Bradley D. McClellan represented Petitioner. Sue Sanders, Dr. Sevilla’s office manager, appeared via telephone on behalf of Dr. Sevilla. The Commission’s staff was not represented. The parties did not contest notice or jurisdiction.[1] After evidence was presented, the ALJ closed the hearing on February 25, 2002.



On________, ____ (the Claimant) sustained a job-related injury to his lower back. The Claimant, who reported having an acute onset of pain from his neck to his lower back, consulted Dr. Sevilla, an orthopedic surgeon, on September 22, 1998, for an evaluation. The Claimant had received intermittent treatment from several doctors for five job-related injuries since 1986.

Dr. Sevilla examined the Claimant and submitted a claim for $260 under CPT Code 99205. Petitioner decided that the documentation did not justify reimbursement under CPT Code 99205 and reimbursed Dr. Sevilla $106 based on CPT Code 99204. Because the maximum allowable reimbursement under CPT Code 99205 is $137, the matter to be determined is whether the medical records submitted met the documentation requirements for an additional reimbursement of $31 under CPT Code 99205.[2]

A certified copy of the MRD record was introduced at the hearing. Although Ms. Sanders testified, she did not have personal knowledge about this Claimant. She knew, however, that Dr. Sevilla typically spends an hour evaluating a new patient and schedules no more than one new patient with a back problem every morning and one every afternoon to allow adequate time for the evaluations. Ms. Sanders pointed to a letter from another staff member who wrote that Dr. Sevilla spent over an hour with the Claimant. Because no other evidence was presented, the ALJ had to rely on the MRD record.

CPT Code 99205 requires three key components: (a) a comprehensive history; (b) a comprehensive examination; and (c) medical decision making of high complexity. The MRD record shows that Dr. Sevilla took the Claimant’s medical history, performed numerous tests, evaluated the Claimant’s condition, and made a preliminary diagnosis. Dr. Sevilla referred the Claimant for an MRI of the lumbar spine, ordered physical therapy and home exercises, and prescribed medication.

In contrast, the nurse who reviewed the claim wrote that the Claimant had been evaluated two days post injury by another orthopedic surgeon who submitted a claim at a lower reimbursement level. She also wrote that CPT Code 99205 should be used for 60-minute high-complexity examinations for claimants with moderate to high severity problems. The nurse-reviewer added that the records failed to show Dr. Sevilla requested previous medical records and x-rays and diagnosed the problem as back strain and backache.

The nurse’s two page letter was insufficient evidence to establish that the documentation was inadequate for CPT Code 99205. The letter was conclusory without any indication of her actual knowledge of the time spent with the Claimant or her knowledge of the amount of time orthopedic surgeons typically spent in performing similar examinations. Moreover, the nurse failed to explain how the lack of documentation regarding whether prior medical records had been requested affected her decision to reduce the reimbursement. Simply put, the nurse’s letter lacked the probative force of Dr. Sevilla’s medical report. Of even more importance, Petitioner did not introduce evidence addressing the third prong of what constitutes medical decision making of high complexity.

Although its position may be meritorious, Petitioner simply failed to present sufficient evidence to show the use of the billing code was incorrect. The facts and reasoning in support of this decision are set forth in the findings of fact, and the legal conclusions derived from those facts appear in the conclusions of law.



  1. On_________, ____ (the Claimant) sustained a job-related injury to his lower back.
  2. The Claimant was employed in a shipping department for the _____________(Petitioner), which provided workers’ compensation coverage.
  3. On September 22, 1998, the Claimant consulted Dr. Cesar A. Sevilla, an orthopedic surgeon, for an evaluation of his symptoms.
  4. Dr. Sevilla submitted an insurance claim of $260 under CPT Code 99205 for the office visit.
  5. Petitioner decided the documentation did not support the level of service billed and reimbursed Dr. Sevilla $106 based on CPT Code 99204.
  6. On August 9, 1999, Dr. Sevilla requested dispute resolution services from the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission).
  7. On September 15, 2000, MRD issued its decision ordering Petitioner to remit $31 plus accrued interest to Dr. Sevilla.
  8. The MRD decision concluded that the documentation met the required components of CPT Code 99205 related to a detailed examination, comprehensive history, and medical decision making of high complexity.
  9. On September 27, 2000, Petitioner filed a request for a hearing to contest the MRD order.
  10. The Commission sent notice of the hearing to the parties on October 19, 2000, and a statement of matters asserted on January 5, 2001. The hearing notice and the statement of matters asserted informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
  11. The Claimant has incurred five job-related lower-back injuries since____ .
  12. The Claimant had chronic backache, recurring symptoms, decreased strength, and the inability to hold his 31-pound child.
  13. Dr. Sevilla reviewed the Claimant’s medical history with the Claimant and recorded details of his current injury.
  14. Dr. Sevilla examined the Claimant’s back in the standing, sitting, and supine positions.
  15. Dr. Sevilla performed various tests on the Claimant including four gait tests, scoliometer screening, range-of-motion tests, straight leg lifting, knee reflexes, pinprick, Patrick test, and Kernig test.
  16. Dr. Sevilla manually checked the Claimant’s ankle, knee, hips, and related muscles for strength, weakness, and flexion; checked hip motion; and measured leg size and length for discrepancies.
  17. Dr. Sevilla performed a vascular examination of the lower extremities.
  18. Dr. Sevilla reviewed x-rays of Claimant’s lumbar spine and pelvis.
  19. Dr. Sevilla’s preliminary diagnosis was back strain and backache.
  20. Dr. Sevilla referred the Claimant for an MRI of the lumbar spine and physical therapy, provided educational materials regarding back conditioning exercises and lifting techniques, prescribed medication, and advised the Claimant about the risks of the medication prescribed.
  21. Dr. Sevilla spent over an hour with the Claimant.



  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented, pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 413.031.
  2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §§402.073 and 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. Petitioner timely filed notice of appeal, as specified in 28 Tex. Admin. Code (TAC) §148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code Ann. ch. 2001 and 28 TAC § 148.4(b).
  5. Petitioner had the burden of proving the case by a preponderance of the evidence, pursuant to 28 TAC § 148.21(h) and (i).
  6. As provided in 28 TAC § 134.201, the Commission adopted a Medical Fee Guideline, specifying the maximum allowable payment for medical services rendered an injured employee using the physician’s current procedural technology codes (CPT).
  7. CPT Codes 99201 - 99205 may be used for submitting a claim for the evaluation and treatment of a doctor’s new patient.
  8. CPT Code 99205 requires three key components: (a) a comprehensive history; (b) a comprehensive examination; and (c) medical decision making of high complexity.
  9. Physicians billing at the CPT Code 99205 level typically spend 60 minutes face-to-face with the patient or family and usually are treating problems of a moderate to high severity.
  10. Based on the foregoing findings of fact and conclusions of law, Petitioner failed to meet its burden of proving that Dr. Sevilla was not entitled to be compensated on the basis of the Maximum Allowable Reimbursement provided for CPT Code 99205, as specified in the Medical Fee Guideline, 28 TAC § 134.201.


It is hereby ordered that the Petitioner shall reimburse Dr. Sevilla an additional $31 plus accrued interest as ordered by the Medical Review Division on September 15, 2000.

This decision is final on the date when the party is notified of the decision according to 28 Tex. Admin. Code §148.22(h). If the decision is mailed, a party or the party’s representative is presumed to have been notified on the date on which the notice was sent.

Signed this 5th day of April, 2002.

Administrative Law Judge
State Office of Administrative Hearing

  1. Petitioner stated it would not pursue its argument in this case as it has in related cases that Dr. Sevilla had the burden of proof; however, Petitioner remained convinced that the burden of proof was misplaced.
  2. The MRD decision also found that Petitioner changed the billing code without complying with 28 Tex. Admin. Code§133.301(b). Neither party addressed that issue at the hearing. It is not necessary to reach a decision about changing the code because the ALJ is ruling against Petitioner on the documentation issue.
End of Document