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At a Glance:
Title:
453-01-1188-m5
Date:
April 3, 2002
Status:
Retrospective Medical Necessity

453-01-1188-m5

April 3, 2002

DECISION AND ORDER

The issue in this proceeding is whether Texas Mutual Insurance Company (Texas Mutual) correctly denied payment for physical therapy billed by David Olson, D.C. Texas Mutual contends that Dr. Olson inappropriately used current procedural terminology (CPT)[1] code 97110 to bill for two hours of physical therapy provided to _____(the Claimant) because Dr. Olson did not provide exclusive one-on-one patient contact and because the patient’s injury did not warrant one-on-one contact. Dr. Olson contends that the care he provided met the criteria for CPT code 97110. The Administrative Law Judge (ALJ) finds that Dr. Olson failed to provide sufficient evidence of exclusive one-on-one therapy, and therefore, was entitled to bill for only one 15-minute unit of physical therapy pursuant to CPT code 97110. CPT code 97150 applies to the remaining therapy provided to the Claimant.

I. JURISDICTION AND NOTICE

There were no contested issues of jurisdiction or notice. Therefore, those issues are addressed in the findings of fact and conclusions of law without further discussion here.

II. PROCEDURAL HISTORY

The hearing on the merits was conducted by ALJ Katherine Smith on January 31, 2002. Texas Mutual was represented by Christopher Trickey, an attorney. Dr. Olson represented himself. The Texas Workers’ Compensation Commission (Commission) did not participate. The record closed on February 7, 2002, with the filing of a closing brief by Texas Mutual.

III. BACKGROUND

Claimant suffered a compensable workers’ compensation injury on_________. Dr. Olson provided Claimant with physical therapy treatment two hours a day for 12 days, from October 27 to December 10, 1999. Using CPT code 97110, Dr. Olson billed $280.00 per day for eight 15‑minute units of one-on-one therapy at $35.00 per unit. Texas Mutual determined that Dr. Olson had provided about 15 minutes of direct one-on-one treatment during each two-hour treatment session. Texas Mutual paid Dr. Olson $35.00 for 15 minutes of one-on-one therapy and $27.00 pursuant to CPT code 97150,[2] which compensates for therapeutic procedures for a group of two or more persons, for the remainder of the treatment session, for a total of $62.00 per day. The Commission’s Medical Review Division (MRD) determined that Dr. Olson was entitled to reimbursement for eight units of therapy per treatment session pursuant to CPT code 97110, for a total of $3,360.00. Noting that Dr. Olson had been paid $744.00, it ordered Texas Mutual to pay Dr. Olson $2,616.00 more. Texas Mutual appealed the MRD’s decision.

IV. ANALYSIS

Relying on Medicine Ground Rules I.A.9.b & d of the Medical Fee Guideline, 28 Tex. Admin. Code § 134.201, Dr. Olson contends that he appropriately billed using CPT code 97110 because he treated the Claimant in an individualized setting with direct visual and verbal contact at scheduled intervals.[3] Relying on clarification received from the AMA[4] and Medicine Ground Rules I.A.9.b and I.C.9,[5] Texas Mutual asserts that Dr. Olson was entitled to limited reimbursement pursuant to CPT code 97110, because use of CPT code 97110 requires direct one-on-one patient contact during each 15-minute unit of treatment.

According to Texas Mutual witness Dr. William DeFoyd, a practicing chiropractor, although CPT codes 97110 and 97150 both require supervised treatment, use of CPT code 97110 requires the health care provider to work exclusively and directly one-on-one with the patient. If the health care provider is dividing his or her time between two or three patients, checking each at intervals, the proper billing code is 97150. Group billing applies even if the patients are performing individualized tasks. Dr. DeFoyd testified that the physical therapy records in this case do not indicate that exclusive one-on-one therapy was provided for two hours of treatment. Dr. DeFoyd testified further that the therapy Claimant was receiving did not require Dr. Olson’s constant attendance. The only patients needing one-on-one treatment for two hours would be stroke patients or those learning to walk or having significant neurological problems. Claimant had an ankle injury and was working full time at the time of the treatment. Moreover, the physical therapy that Claimant received could have been provided at a health club or been performed at home if Claimant had the right equipment. Dr. DeFoyd testified that it would have been appropriate to bill for one 15-minute unit of one-on-one supervision over the two-hour session and to bill using CPT code 97150 for the balance of the time.

Dr. Olson’s medical notes do not indicate that one-on-one physical therapy was provided for two hours. Although he testified at the hearing that he spent 80 to 90% of his time with the Claimant and that frequently Claimant was the only patient at the end of the day, his previously-given deposition contradicts his testimony. In his deposition he admitted that he would watch the Claimant, monitor him, and leave to work with other patients or do other tasks. He stated that he did not need to be with the Claimant the entire time. Texas Mutual Ex. 13 at 26. He stated further that he would give the Claimant enough work for a period of time so that he was able to work on another patient, that he would return to the Claimant to test him, that he would visually observe the Claimant, and that he would bounce back and forth between the patients. Id. at 29.

A number of recent SOAH decisions have interpreted CPT code 97110. One ALJ concluded that CPT code 97110 applies when the doctor or therapist works only one-on-one with that patient’s therapy. If two or more patients are performing the same or different therapeutic exercises in the same setting under the supervision of a doctor or health care provider, CPT code 97110 would not apply because one-on-one contact would be lacking; instead, CPT code 97150 would apply.[6] To qualify for reimbursement under CPT code 97110 beyond one unit per session, the provider must prove that the units of physical therapy were conducted exclusively on a one-on-one basis.[7]

The issue then becomes, therefore, how much one-on-one therapy was provided and should be compensated. Claimant generally performed a 15-minute cardiovascular work-out, 45 minutes of stretching, and one hour of strengthening. Dr. Olson stated in his deposition that Claimant would work 15 to 30 minutes on his own on stretching and that Dr. Olson would spend “between five minutes to 10, 15, sometimes 20 minutes” with the Claimant during the strengthening period. Id. at 33, 37. Dr. Olson appears to have provided at least 20 minutes of one-on-one supervision to Claimant. Unfortunately, no details exist beyond that minimum. Better note-taking at the time the treatment was given would have buttressed Dr. Olson’s claim that he spent more one-on-one time with the Claimant. His testimony that he spent 80-90% individual time with the Claimant is belied by his deposition statements and his belief that he did not need to provide exclusive one-on-one contact to qualify for payment pursuant to CPT code 97110.

Dr. Olson also argues that reimbursement according to CPT code 97110 is more appropriate because Claimant was frequently the only patient in the facility at the end of the day. But as Texas Mutual suggested in its closing brief, CPT code 97110 is not a default code, even if the patient is the only person performing therapeutic procedures in a rehab area. CPT code 97110 is billed only when the health care provider works exclusively one-on-one with the patient for a full 15 minutes. Although Dr. Olson may not have had other patients to supervise, according to his deposition he would do other tasks.

The ALJ, therefore, finds that Dr. Olson is entitled to reimbursement of $35.00 for one 15‑minute period of one-on-one therapy pursuant to CPT code 97110 for each day of Claimant’s treatment. Dr. Olson is entitled to an additional $27.00, pursuant to CPT code 97150, for the remainder of each two-hour session during which the Claimant participated in a group setting. Having already reimbursed Dr. Olson $62.00 for each two-hour treatment session provided the Claimant, Texas Mutual is not required to reimburse Dr. Olson any additional fees.

V. FINDINGS OF FACT

  1. On_____________, ____ (the Claimant) suffered a compensable workers’ compensation injury.
  2. David Olson, D.C., provided treatment to the Claimant, consisting of therapeutic exercises two hours a day for 12 days between October 27 to December 10, 1999.
  3. For each of the 12 treatment sessions, Dr. Olson billed Texas Mutual Insurance Company (Texas Mutual) for eight 15-minute units of therapy using CPT code 97110.
  4. For each of the 12 treatment sessions, Texas Mutual paid $35 for one unit of one-on-one therapy under CPT code 97110 and $27.00 for one untimed unit of group therapy under CPT code 97150.
  5. Dr. Olson requested medical dispute resolution by the Texas Workers’ Compensation Commission (Commission).
  6. The Commission’s Medical Review Division (MRD) issued a decision and order on October 24, 2000, ordering Texas Mutual to pay additional fees to reimburse Dr. Olson for eight, 15-minute units pursuant to CPT code 97110 for each of the 12 treatment sessions.
  7. On November 13, 2000, Texas Mutual filed its request for a hearing.
  8. The Commission provided adequate and timely notice of this proceeding on December 6, 2000.
  9. The Claimant participated in physical therapy with Dr. Olson 12 days for two hours each day.
  10. Dr. Olson did not provide Claimant with one-on-one physical therapy during the two-hour treatment session.
  11. Dr. Olson would instruct the Claimant, monitor him, and leave to work with other patients or to do other tasks.
  12. The Claimant received approximately 20 minutes of direct, one-on-one attention from Dr. Olson during his daily treatments.
  13. During the remainder of the two-hour treatment session, Claimant performed therapeutic exercises on his own in a group setting.

VI. CONCLUSIONS OF LAW

  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. §413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
  4. Texas Mutual had the burden of proving by a preponderance of the evidence that it should prevail in this matter pursuant to Tex. Lab Code Ann. §413.031.
  5. CPT code 97110 applies when the health care provider works directly one-on-one with a patient on that patient’s therapy only. Medicine Ground Rules I.A.9.b, 28 Tex. Admin. Code § 134.201.
  6. Supervision by a health care provider of a patient performing therapeutic exercises on his own in a group setting is to be reimbursed according to CPT code 97150. Medicine Ground Rules I.A.9.b and I.C.9.
  7. Based on the findings of fact and conclusions of law, Texas Mutual has correctly reimbursed Dr. Olson for the 12 sessions of therapy provided the Claimant.

ORDER

IT IS, THEREFORE, ORDERED that Texas Mutual Insurance Company is not required to reimburse Dr. Olson for any additional therapy billed under CPT code 97110.

Issued April 3, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

KATHERINE L. SMITH
Administrative Law Judge

  1. CPT codes are five-digit codes obtained from the Physicians’ Current Procedural Terminology, Fourth Edition, Copyright 1994 by the American Medical Association, which lists descriptive terms and numeric identifying codes for reporting medical services and procedures performed by physicians. Texas Mutual Ex. 2.
  2. CPT code 97150 may be billed only once per session; it is not a timed code as is 97110, which may be billed for every 15 minutes of treatment. See SOAH Docket No. 453-99-1216.M5 at 5 (ALJ Landeros, March 2000) citing the Commission’s comment published in 21 Tex. Reg. 2380 (March 22, 1996).
  3. According to I.A.9.b, the use of the following physical therapy codes require, “Procedures (Supervision by the doctor or [health care provider], in either a group (97150) or one-to-one (97110-97139) setting).” I.A.9.d defines supervision “as the on-site presence of the licensed [health care provider] . . . and direct visual and verbal contact with the patient at scheduled intervals during the period of time for which treatment is being provided at that site.”
  4. Texas Mutual Ex. 7, CPT Assistant, Vol. 9, No. 12 (Dec. 1999); Texas Mutual Ex. 10, a letter dated July 22, 1999, from the AMA’s CPT Information Services.
  5. According to I.C.9, “If any of the procedures (97110-97139) are performed with two or more individuals, then 97150 is reported.”
  6. See SOAH Docket No. 453-00-2051.M4 at 4 (ALJ O’Malley, Dec. 1, 2000).
  7. See SOAH Docket No. 453-00-1219.M5 at 9 (ALJ Church, Sept. 27, 2000).
End of Document
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