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At a Glance:
Title:
453-01-1961-m5
Date:
October 15, 2001
Status:
Retrospective Medical Necessity

453-01-1961-m5

October 15, 2001

DECISION AND ORDER

This case involves an appeal by the State Office of Risk Management (Petitioner) from Findings and Decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) allowing Respondent Daniel Burdin, M. D. to recover reimbursement in the amount of $3,492.00 for services rendered to _________(Claimant) during the period from February 17, 1999, through June 28, 1999. This decision affirms the MRD decision in all respects.

JURISDICTION & HEARING

The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), TEX. LABOR CODE ANN. Ch. 401 et seq. (Vernon 2000). 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. LABOR CODE ANN. §413.031(d) and TEX. GOVT. CODE ANN. Ch. 2003. (Vernon 2000). No party challenged subject matter jurisdiction or contested the adequacy of notice of the hearing.

On August 29, 2001, Ernest Fortenberry, Administrative Law Judge (ALJ), convened the hearing in Suite 1100 of the Stephen F. Austin building, 1700 North Congress Avenue, Austin, Texas. Attorney Jonathan Bow appeared and represented the State Office of Risk Management.

Petitioner offered in evidence the Certified Record of the proceedings before the MRD and offered in evidence additional copies of Health Insurance Claim Forms (Form HCFA 1500) pertaining to the claim to supplement the record. The evidence was received without objection. Petitioner also offered the testimony of Ms. Teresa Peterson, an employee with Petitioner’s Medical Bill Audit Division. Dr. Daniel Burdin (Respondent) appeared and testified telephonically. After extensive argument based on the evidence, the hearing was adjourned, and the record was closed.

THE EVIDENCE

The evidence is undisputed. The Claimant suffered a crush injury to her right hand while working at the Texas Department of Criminal Justice when an inmate slammed a drawer closed on her hand. She received treatment by Dr. Daniel Burdin for this hand injury, which was listed as Plantar Fascial Fibromatosis, ICD9 Code 728.71, and on all line items of the doctor’s bills (HCFA 1500s) submitted by him. It was stipulated by the parties that the diagnosis Code 728.71 is properly defined as referring to treatment of a foot condition. It is unclear why Dr. Burdin’s bills made reference to an incorrect treatment code, but it is undisputed (and clear beyond any question on all of the medical bills and reports) that all of the treatment was for the compensable injury to the hand. Apparently it was a simple clerical error.

Petitioner objected to reimbursement of Dr. Burdin stating: Carrier respectfully denies any all liability for treatment and/or disability relating to left hand, right shoulder cervical and right brachial plexus as these are not compensable parts nor are they causally related to injury on _____ to right hand.

ANALYSIS & CONCLUSION

Petitioner argues that it cannot be ordered to make reimbursement until such time as it receives a correct bill. Although Petitioner admits that it was never in doubt as to whether the treatments administered by Dr. Burdin, and billed by him, were for the compensable injury to the hand, it argues that it should not be required to pay the bills when they were submitted with the incorrect code.

Petitioner relies largely on Section 133.301 of the Commission’s Rules, 28 Texas Administrative Code(TAC) §133.301, Subsection (a) of which provides that the insurance carrier shall review all medical bills, including in its examination a review for accuracy of coding in relation to the medical record and reports. Subsection (b) of the same Rule states, Neither the insurance carrier nor the carrier’s agent shall change a billing code on a medical bill or reimburse treatment(s) and/or service(s) at another billing code’s value unless the insurance carrier contacts the sender of the bill and the sender agrees to the change. Petitioner argues that it contacted Dr. Burdin’s office and gave adequate notice of the incorrect billing, and Petitioner further contends that it had no authority under the specific language of Rule 133.301 to change the billing code on Dr. Burdin’s bills.

Petitioner’s argument might have some validity but for the fact that none of the parties concerned had the slightest doubt as to what treatments were administered and what treatments were the subject of the bills in question. The whole purpose of the billing procedure is to have accurate communication between the medical provider and the insurance carrier. That purpose was fully achieved here.

Petitioner argues that the MRD decision presumes, or intuits, an error by the Provider which the Provider has not yet acknowledged. Dr. Burdin acknowledged in his testimony at the hearing that Code 728.71 has reference to treatment of a foot condition, rather than treatment of a hand, but Dr. Burdin went on to point out that it was crystal clear on the face of every single bill and report he submitted that he was treating the hand and billing for those treatments. Under the circumstances it is clear that the MRD decision presumed nothing. Instead it simply recognized the obvious fact that a clerical error had been made in the billings, which were clear and correct in meaning from even a casual reading, and it ordered reimbursement accordingly.

The Medical Review Division’s decision was correct, and it should be affirmed.

FINDINGS OF FACT

  1. Daniel Burdin, M. D. (Respondent) sought reimbursement for medical services provided to __________ (Claimant) from February 17, 1999, through June 28, 1999, for a hand injury
  2. The State Office of Risk Management (Petitioner) objected to Dr. Burdin’s request for reimbursement.
  3. All of the bills submitted by Respondent, Dr. Burdin, made it clear that the medical services provided were to the hand; however, the diagnosis code on the bills referenced a foot injury.
  4. All of the parties stipulated that none of them was, at any time, in doubt as to whether the treatments rendered and billed for by Dr. Burdin were for treatment of the hand condition.

CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (the Commission) has jurisdiction to decide the issue presented pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), TEX. LABOR CODE ANN. Ch. 401 et seq. (Vernon 2000).
  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 an order, pursuant to TEX. LABOR CODE ANN. §413.031(D) and TEX. GOVT. CODE ANN. Ch. 2003 (Vernon 2000).
  3. The Petitioner bears the burden of proof by a preponderance of the evidence on the question of whether the Administrative Law Judge should order a reversal of the Medical Review Division’s decision, pursuant to 28 TEX. ADMIN. CODE §148.21(h).
  4. There is nothing in the Rules of the Texas Workers’ Compensation Commission requiring that reimbursement for medical services be denied merely because of a clerical error in the coding of a Provider’s bill where the nature of the services rendered and billed for is clear.

ORDER

IT IS, THEREFORE, ORDERED that the Findings and Decision of the Medical Review Division are in all respects affirmed.

As set forth in the commission’s Rules at 28 TEX. ADMIN. CODE §148.22(h) this decision is final on the date the party is notified of the decision. 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 mailed.

As set forth in 28 TEX. ADMIN. CODE §148.22(i), no motion for rehearing of this decision will be entertained. A party dissatisfied with the decision may seek judicial review by filing a petition in a District Court of Travis County, Texas, no later than the 30th day after the date the decision is final, as provided by the Administrative Procedure Act, §§2001.171 et seq., TEX. GOV’T CODE ANN.

Signed this 15th day of October, 2001.

ERNEST FORTENBERRY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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