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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 University of Texas System (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 establish the documentation was insufficient for the billing code used 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. 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 his lower back. The Claimant consulted Dr. Sevilla, an orthopedic surgeon, on April 21, 1999, for an evaluation. After Dr. Sevilla submitted a claim for $260, Petitioner determined that the documentation did not justify reimbursement under CPT Code 99205 and reimbursed him $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 reimbursement of an additional $31 under CPT Code 99205.[2]

A certified copy of the MRD record was introduced at the hearing. Although ______ 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.

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 ordered physical therapy, prescribed medication, and discussed possible side effects of the medication.

On June 14, 1999, the djustor who reviewed the claim wrote that the examination was Ano more than a 60-minute examination of moderate complexity. On September 22, 1999, the adjustor noted that the Claimant had not sought treatment for four days post injury and that Dr. Sevilla had not documented decision making of high complexity. On September 9, 1999, another adjustor wrote a more detailed letter citing the Spine Treatment Guideline, Medical Fee Guideline, and a report from another orthopedic surgeon who examined the Claimant.[3]

The adjustors’ letters were insufficient evidence to establish that the documentation was inadequate for billing using CPT Code 99205. The letters were conclusory without indication the adjustors had actual knowledge of the time Dr. Sevilla spent with the Claimant or knowledge of the amount of time orthopedic surgeons typically spent in performing similar examinations. The excerpt from the Spine Treatment Guideline related to the level of care without any showing of how it related to billing. Moreover, Petitioner did not address 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 by the University of Texas System (Petitioner), which provided workers’ compensation coverage.
  3. On April 21, 1999, 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 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 3, 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 October 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 November 21, 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 sustained the injury to his lower back while unloading a truck. A 500-pound supply cart fell off a lift pulling the Claimant down in the fall.
  12. The Claimant went to the employee health clinic where he was diagnosed with muscle sprain and possible ruptured disc.
  13. The Claimant was reassigned to light duty work in the animal research center, which he had difficulty performing because of the need to bend, wash, and pull animals around.
  14. The Claimant had pain radiating from his lumbar spine to his thoracic spine and intermittent numbness in his legs.
  15. Dr. Sevilla reviewed the Claimant’s medical history with the Claimant and recorded details of his current injury.
  16. Dr. Sevilla examined the Claimant’s back in the standing, sitting, and supine positions.
  17. Dr. Sevilla performed neurologic, motor, and vascular examinations.
  18. Dr. Sevilla performed various tests on the Claimant.
  19. Dr. Sevilla reviewed x-rays of Claimant’s lumbar spine.
  20. Dr. Sevilla’s preliminary diagnosis was back strain and backache with degenerative changes of the lumbar spine and lower segment of the thoracic spine. Dr. Sevilla did not find indications of lumbar radiculopathy, spondylolysis, or spondylolisthesis.
  21. Dr. Sevilla discussed treatment alternatives with the Claimant and referred him to physical therapy, prescribed medication, and advised the Claimant about the risks of the medication prescribed.
  22. 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. 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 University of Texas System shall reimburse Dr. Sevilla an additional $31 plus accrued interest as ordered by the Medical Review Division on October 3, 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 (TAC) §133.301(b). Neither party addressed that issue; however, it is not necessary to reach a decision on changing the code because the ALJ is ruling against Petitioner based on a lack of evidence.
  3. 28 TAC § 134.1001(g)(6)(A).
End of Document