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April 5, 2002
Medical Fees


April 5, 2002




Dr. Cesar A. Sevilla sought reimbursement for an injured worker’s office visit using CPT Code 99205, but the (Petitioner) decided the medical records did not show he spent sufficient time with ______ (the Claimant) to justify the billing level used and paid him 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 it to pay Dr. Sevilla $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. MRD 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 her right shoulder and back. The Claimant consulted Dr. Sevilla, an orthopedic surgeon, on April 20, 1999, for an evaluation following her initial visits to an emergency room and the employees’ health clinic. Dr. Sevilla submitted a claim for $260 under CPT Code 99205. Petitioner decided that the documentation did not show Dr. Sevilla had spent at least 60 minutes with the Claimant to justify reimbursement under that code and reimbursed him $106 based on CPT Code 99204. Because the maximum allowable reimbursement under CPT Code 99205 is $137, the issue to be determined is whether the medical records submitted met the documentation requirements for reimbursement of an additional $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. Because no other evidence was presented, the ALJ had to rely on the MRD record.

Typically CPT Code 99205 requires that the physician spend 60 minutes face-to-face with the patient. The adjustor decided the documentation did not show Dr. Sevilla spent 60 minutes with the Claimant. The adjustor responded to inquiries from Dr. Sevilla’s office and from MRD staff only that Petitioner “stood behind its original audit,” but provided no reason for the decision. Although its position may be meritorious, Petitioner simply failed to present evidence to establish that Dr. Sevilla did not spend 60 minutes with the Claimant. 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 her right shoulder and back.
  2. The Claimant was employed as a nurse for the _____________ (Petitioner), which provided workers’ compensation coverage.
  3. On April 20, 1999, the Claimant consulted Dr. Cesar A. Sevilla, an orthopedic surgeon, for an evaluation of the problems arising from her work-related injury.
  4. Dr. Sevilla submitted an insurance claim of $260 under CPT Code 99205 for the office visit.
  5. Petitioner decided the documentation did not show that Dr. Sevilla spent at least 60 minutes with the Claimant and reimbursed him $106 based on CPT Code 99204.
  6. On September 8, 1999, Dr. Sevilla requested dispute resolution services from the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission).
  7. On October 6, 2000, MRD issued its decision ordering Petitioner to remit $31 plus accrued interest to Dr. Sevilla.
  8. The MRD decision concluded that the documentation supported the billing level.
  9. On October 18, 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 November 14, 2000. The hearing notice informed the parties of the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
  11. The Claimant twisted her upper body while she was trying to prevent a 210 pound patient from falling.
  12. The Claimant had constant pain in her right shoulder and lower back and numbness and tingling in her right arm.
  13. Dr. Sevilla reviewed the Claimant’s medical history with the Claimant and recorded details of her current injury.
  14. Dr. Sevilla examined the Claimant’s right shoulder and thoracic back.
  15. Dr. Sevilla performed neurologic and vascular examinations.
  16. Dr. Sevilla reviewed x-rays of the Claimant’s right shoulder.
  17. Dr. Sevilla did not order back x-rays because her symptoms were mostly soft tissue symptoms.
  18. Dr. Sevilla’s preliminary diagnosis was right shoulder impingement and myofacial pain syndrome, thoracic.
  19. Dr. Sevilla discussed alternatives to treatment with the Claimant, referred her for physical therapy, prescribed medication, and advised the Claimant about the risks of the medication prescribed.
  20. Dr. Sevilla typically spends an hour evaluating a new patient.



  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. Physicians billing at the CPT Code 99205 level typically spend 60 minutes face-to-face with the patient or family.
  9. Based on the findings of fact, Dr. Sevilla spent an hour in his initial examination of the Claimant.
  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 October 6, 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 based on a lack of evidence.
End of Document