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At a Glance:
Title:
453-01-2006-m5
Date:
September 24, 2002

453-01-2006-m5

September 24, 2002

DECISION AND ORDER

Texas Workers’ Compensation Insurance Fund (Carrier) appealed the findings of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD), which found that Curtis Adams, D.C. (Provider) should be reimbursed $2,858.00 for physical therapy and chiropractic services rendered between November 10, 1999 and May 24, 2000.[1] The Administrative Law Judge disagrees with the MRD and finds that the Carrier is required to reimburse the Provider $62.

I. PROCEDURAL HISTORY AND NOTICE

The hearing convened before Janet R. Dewey, Administrative Law Judge (ALJ) with the State Office of Administrative Hearings (SOAH), on June 17, 2002, 300 West 15th Street, Fourth Floor, Austin, Texas. Katie Kidd appeared on behalf of the Carrier. The Provider appeared via telephone and was represented by Andrew Dunlap. After the parties had additional time to submit written closing statements, the record closed July 26, 2002.

This case was consolidated with SOAH Docket No. 453-01-2600.M5; T.W.C.I.F. v. Texas Workers’ Compensation Insurance Commission and Curtis Adams, D.C., because the matters contained similar issues for consideration and the parties are the same.The cases were heard together, but the ALJ issues separate decisions.

II. FACTUAL BACKGROUND

The injured worker, ____, sustained a compensable workers’ compensation injury to his left wrist on ___________to his left wrist. For most of the dates of service in question, the patient usually performed therapeutic exercises at Dr. Adams’ clinic for approximately two hours per visit several times a week for several months. For each visit, Dr. Adams typically billed eight fifteen minute units split evenly between two different CPT codes: 97110 (therapeutic procedure) and 97530 (therapeutic activity). Both are physical therapy codes. For the most of the relevant dates of service, the Carrier reimbursed the Provider for one unit of CPT code 97110, one unit of CPT code 97530, and at least one unit of group physical therapy under CPT code 97150.[2] The Provider requested medical dispute resolution before the MRD, which found that the Provider was entitled to reimbursement because the services were preauthorized.

III. DISCUSSION

The ALJ finds that the Carrier is required to reimburse the Provider $62 for services billed

underCPT codes 97110 and 97530.

  1. “One-on-one” Therapy
  2. Carrier’s Position

The Carrier contends that the Provider inappropriately charged for “one-on-one” therapy when the Provider actually supervises more than one patient at a time. The Carrier also argues that the documentation does not substantiate that “one-on-one” therapy was provided. Further, the Carrier maintains that the disputed services were not medically necessary.

The Carrier contends that one-on-one CPT codes require a therapist to devote his or her exclusive attention to a patient during the time for which one-on-one CPT codes are billed. If the therapist supervises more than one patient and divides his or her attention between the patients, then CPT code 97150 for group exercise should be used. The Carrier relies upon previous SOAH decisions, the American Medical Association’s (AMA’s) definition of CPT code 97110 as a one-on-one code, and the 1996 Medical Fee Guideline, as well as the testimony of its witnesses.

The Provider argues that it is not necessary for the health care provider to be “alone” with the patient and that it is permissible for several people to be receiving “one-on-one” therapy at the same time under the supervision of the therapist. The Provider also argues that the Carrier has not demonstrated that there was more than one patient receiving therapy on any given date of service. The Provider relies upon the individualized records kept for each phase of treatment. The Provider disputes the Carrier’s contention that one-on-one therapy was not medically necessary, relying on the preauthorizations provided by the Carrier for physical therapy.

Provider’s Position

The Provider argues that it is not necessary for the health care provider to be “alone” with the patient, and that it is permissible for several people to be receiving “one-on-one” therapy at the same time under the supervision of the therapist. The Provider also argues that the Carrier has not demonstrated that there was more than one patient receiving therapy on any given date of service. The Provider relies upon the individualized records kept for each phase of treatment. The Provider disputes the Carrier’s contention that one-on-one therapy was not medically necessary, relying on the preauthorizations provided by the Carrier for physical therapy.

ALJ Analysis

The ALJ found the Carrier’s arguments on this issue persuasive. First, the 1996 Medical Fee Guideline[3] (MFG) provides that CPT code 97150 (group therapy) should be reported if any of the procedures provided through CPT code 97110-97139 are performed with two or more individuals.[4] The Provider billed four units of CPT code 97110 (therapeutic procedures) and four units of CPT code 97530 (therapeutic activities) for most of the dates of service in question. The Provider’s deposition testimony reflects that the therapist may be working with anywhere from one to five patients while they are receiving physical therapy.[5] The Provider’s documentation, however, fails to indicate if the therapist was working with only the injured worker or was dividing his or her attention among as many as five individuals.[6]

The MFG provides: “If any of the procedures (97110-97139) are performed with two or more individuals, then 97150 is reported.”[7] While the MFG seems clear on its face, the Carrier also provided evidence demonstrating that the American Medical Association defines CPT code 97110 as a one-on-one code: “CPT code 97110 is to be reported when the therapist is providing therapy to only one patient. When the therapist is working with several patients at the same time, then CPT code 97150 should be reported.”[8] The MFG also clearly states: “Therapeutic activities (97530) is defined as direct (one-on-one) patient contact by the provider with the use of dynamic activities to improve functional performance.”[9] Therefore, the ALJ finds that both CPT codes 97530 and 97110 require one-on-one contact between the patient and the therapist, with the therapist providing therapy to only one patient during the time for which a one-on-one code is billed.

The Provider contends that the physical therapy was preauthorized without limitation; therefore, the Carrier is required to pay for all of the one-on-one therapy billed. Even assuming the Carrier preauthorized all of the one-on-one therapy billed by the Provider, it is still incumbent upon the Provider to document that the service was actually provided. In the case of CPT codes 97110 and 97530, an intrinsic component of the service is that it is provided one-on-one under the definitions provided by the MFG. The MFG requires that the provider document the “exact description of procedure or service provided.”[10] This is especially true based upon the Provider’s own representation that sometimes the therapist may work with as many as five patients at a time. The Provider’s documentation does not demonstrate that the therapist worked exclusively with the injured worker for any period of time for which the Provider billed the Carrier using CPT codes 97530 or 97110.

For each date of service from November 16, 1999 through April 13, 2002, for which the Provider billed the Carrier under CPT codes 97530 and 97110, the Carrier reimbursed the Provider for one unit ($35) for each one-on-one code billed (fifteen minutes of 97530 and fifteen minutes of 97110) and at least one unit ($27) of the group code, CPT code 97150. In light of the lack of documentation that any of these services were provided on a one-on-one basis, these payments seem reasonable.

On November 10, 1999, however, the record demonstrates that the Carrier did not reimburse the Provider for any physical therapy provided. The relevant preauthorization letter approved one unit of “therapeutic exercise” (CPT code 97110) and one unit of “kinetic activity” (CPT code 97530) per session. Because the Provider cannot confirm that these services were provided on a one-on-one basis, the ALJ approves a payment of one unit of group activity under CPT code 97150 ($27) and one unit of kinetic activity under CPT code 97530 ($35) for a total of $62.

The ALJ, therefore, concludes that the Provider is entitled to additional reimbursement in the amount of $62 for its billing under CPT code 97110 and 97530 for the period from November 10, 1999 through April 13, 2000.

Myofascial Release

The Provider billed the Carrier for CPT code 97250 (myofascial release/soft tissue mobilization) for the November 10, 1999 date of service. The Carrier contends, however, that the preauthorization letter of October 15, 1999 only approved kinetic activity. CPT code 97250 is a passive modality, not a kinetic activity and preauthorization was not obtained for it. The Provider did not provide any argument or evidence in response to the Carrier. The ALJ agrees with the Provider that this service was not preauthorized and the Carrier is not required to reimburse the Provider.

Joint Mobilization

The Provider billed the Carrier for CPT code 97265 (joint mobilization) for the November 29, 1999 date of service. The Carrier did not reimburse this service because it contends that it reimbursed the Provider for a joint manipulation performed on the same body part on the same day. The Carrier provided expert testimony to explain that in order for a chiropractor to perform a manipulation on a certain body part; he must first “mobilize” that body part. The ALJ agrees with the Carrier. Therefore, it is not reasonable for the Provider to charge for a mobilization necessarily performed as part of a joint manipulation for which the Provider has been compensated.

Work Hardening

The Provider billed the Carrier for CPT code 97545-wc for work hardening/conditioning. The Carrier contends that the Provider’s documentation was insufficient to support reimbursement for this service. The Provider’s notes fail to reflect that the injured worker was involved in a work conditioning program, other than to say that the therapist had him perform exercises that simulated his job activities. Nor is the time element spent on work conditioning clearly documented. Further, the documentation does not reflect that the injured worker is likely to benefit from the program or that his current level of functioning due to illness or injury interferes with his ability to carry out specific identifiable tasks required in the work place, as is required by the MFG.[11] The ALJ agrees with the Carrier, and finds that the documentation provided by the Provider was insufficient to warrant reimbursement for any work conditioning.

Conclusion

The ALJ finds that the Carrier is required to reimburse the Provider for $62 for services billed under CPT codes 97110 and 97530. The ALJ finds that the Carrier is not required to reimburse the Provider for the joint mobilization, the myofascial release or the work conditioning.

IV. FINDINGS OF FACT

  1. The injured worker suffered a compensable injury on_________.
  2. On January 4, 2001, the Medical Review Division of the Texas Workers’ Compensation Commission issued a decision finding the Texas Workers’ Compensation Insurance Fund (Carrier) was required to pay Curtis Adams, D.C. (Provider) $2,858.00.
  3. The Carrier filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  4. The original notice of hearing was sent April 12, 2001.
  5. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  6. The Carrier provided workers’ compensation insurance coverage to the injured worker’s employer on the date of the injury.

One-on-One Therapy

  1. For eighteen dates of service occurring between November 10, 1999 and April 13, 2000, the Provider billed the Carrier for CPT codes 97110 and 97530.
  2. For most of the dates of service, the patient usually performed therapeutic exercises at Dr. Adams’ clinic for approximately two hours per visit several times a week for several months. For each visit, Dr. Adams typically billed eight fifteen minute units split evenly between two different CPT codes: 97110 (therapeutic procedure) and 97530 (therapeutic activity). Both are physical therapy codes.
  3. For the dates the Provider billed the Carrier under CPT codes 97150 and 97530, the therapist may have been working with up to five people depending on how many patients were present.
  4. The Provider’s documentation does not demonstrate that the therapist worked exclusively with the injured worker for any period of time for which the Provider billed the Carrier using the one-on-one CPT codes 97530 and 97110.
  5. For each date of service from November 16, 1999 through April 13, 2002, in which the Provider billed the Carrier under CPT codes 97530 and 97110, the Carrier reimbursed the Provider for one unit ($35) for each one-on-one code billed (fifteen minutes of 97530 and fifteen minutes of 97110) and at least one unit ($27) of the group code, CPT code 97150. In light of the lack of documentation that any of these services were provided on a one-on-one basis, these payments are reasonable.
  6. On November 10, 1999 the Carrier did not reimburse the Provider for any physical therapy provided. The relevant preauthorization letter approved one unit of “therapeutic exercise” (CPT code 97110) and one unit of “kinetic activity” (CPT code 97530) per session. A payment of one unit of group activity under CPT code 97150 ($27) and one unit of kinetic activity under CPT code 97530 ($35) for a total of $62 is reasonable in light of the lack of documentation that these services were provided on a one-on-one basis.

Myofascial Release

  1. The Provider billed the Carrier for CPT code 97250 (myofascial release/soft tissue mobilization) for the November 10, 1999 date of service.
  2. The preauthorization letter of October 15, 1999 only approved kinetic activity. Myofascial release/soft tissue mobilization is not a kinetic activity.
  3. CPT code 97250 was not preauthorized for the November 10, 1999 date of service.

Joint Mobilization

  1. The Provider billed the Carrier under CPT code 97265 (joint mobilization) for the November 29, 1999 date of service. The Carrier reimbursed the Provider for a joint manipulation for the same date of service for the same body part.
  2. When a chiropractor performs a manipulation on a certain body part, it is necessary to first perform a mobilization on that body part.
  3. The treatment notes show that a manipulation was performed on the same body part for which the Provider also billed for a joint mobilization on the same date of service.
  4. It is not reasonable for the Provider to receive reimbursement for a joint mobilization performed as part of a joint manipulation to the same body part when the Provider has been compensated for the manipulation.

Work Conditioning

  1. The Provider billed the Carrier under CPT code 97545-wc for work hardening/conditioning provided on April 18, 2000.
  2. The Provider failed to demonstrate that the injured worker was involved in a formal work conditioning program.
  3. The documentation provided by the Provider is insufficient to warrant reimbursement for any work conditioning.

V. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction over this matter pursuant to section 413.031 of the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq.
  2. SOAH has jurisdiction over 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. §§2001.051 and 2001.052.
  4. The Carrier has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) § 148.21(h).
  5. CPT code 97110 (therapeutic procedure) applies only when the doctor or therapist works directly, one-on-one with a patient on that patient’s therapy only. If two or more patients are performing the same or different therapeutic exercises in the same setting under the supervision of the therapist or doctor, one-on-one contact does not exist; the group code, CPT code 97150, would apply in this situation. Medical Fee Guideline (MFG), Medicine Ground Rule, I.A.9.b. and I.C.9.
  6. CPT code 97530 (therapeutic activities) applies when the doctor or therapist works directly, one-on-one with a patient on that patient’s therapy with the use of dynamic activities to improve functional performance. MFG, Medicine Ground Rule, I.A.11.A.
  7. Section III, of the General Instructions of the MFG requires that the provider document the “exact description of procedure or service provided.”
  8. For the period of November 16, 1999 through April 13, 2000, the reimbursement Carrier has already paid to the Provider itemized in Exhibit A to this order for services billed under one-on-one codes is reasonable.
  9. For physical therapy services provided on November 10, 1999, a payment of one unit of group activity under CPT code 97150 ($27) and one unit of kinetic activity under CPT code 97530 ($35) for a total of $62 is reasonable.
  10. The Carrier is not required to reimburse the Provider for the amount billed under CPT code 97250 (myofascial release) for November 11, 1999, because the Provider failed to obtain preauthorization for this service as is required by 28 TAC § 134.600.
  11. The amount billed for a joint mobilization on November 29, 2002 is not reasonable under Tex. Lab. Code Ann. § 401.011 (19)(A).
  12. The amount billed for work hardening/conditioning under CPT code 97545-wc was not documented as required by MFG, Physical Medicine Ground Rule, II.D.
  13. The Provider is entitled to $62 additional reimbursement in this matter.

Order

IT IS, THEREFORE, ORDERED that the Texas Workers’ Compensation Insurance Fund’s appeal is granted, and it required to pay Curtis Adams, D.C., $62.

Signed this 24th day of September, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

JANET R. DEWEY
Administrative Law Judge

  1. The parties subsequently narrowed their dispute as is reflected in Exhibit “A.”
  2. CPT code 97150 is an untimed code that provides a flat reimbursement fee for group therapy. CPT codes 97110 and 97530 are billed in fifteen minute increments.
  3. Adopted pursuant to 28 Tex. Admin. Code § 134.201.
  4. MFG, Medicine Ground Rule, I.C.9.
  5. “I am working with the patient, I perform the stretches, I observe, I supervise, I help the patient out with the stretches. If he’s the only one in there, then that’s the only patient I work with at the time. If there’s three patients in there, I work with all three patients at the same time.” Ex. 7, Deposition of Marilyn Ndam at 32, line 9; Ex. 6, Deposition of Curtis Adams, D.C., at 65, line 8.
  6. Ex. 6 at 65.
  7. MFG, Physical Medical Ground Rules, I.C.9.
  8. Cpt Assistant, Vol. 9, Issue 12, Dec. 1999.
  9. MFG, Medicine Ground Rules, I.A.11.a.
  10. MFG, General Instructions, III.
  11. MFG, Physical Medicine Ground Rule, II.D.
End of Document
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