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At a Glance:
December 3, 2001
Medical Fees


December 3, 2001


This case is a dispute over whether an office consultation should have been billed under CPT Code 99245 or CPT code 99244. The amount in controversy is $53.00.

The Administrative Law Judge (ALJ) concludes the Petitioner did not meet his burden of proving CPT code 99245 was correct. Therefore he denies additional reimbursement.

Findings of Fact

  1. The patient suffered a compensable injury_________________.
  2. The patient was referred to the Petitioner, Cesar A. Sevilla, M.D., who examined her on December 21, 1998, at his office.
  3. Dr. Sevilla diagnosed the patient as suffering from lumbar radiculitis on the right side, backache, and right lower leg pain.
  4. Dr. Sevilla billed the Respondent, the University of Texas System (the U.T. System), for $350.00 using CPT Code 99245.
  5. The Maximum Allowable Reimbursement (MAR) for CPT code 99245 is $201.00
  6. The U.T. System paid Dr. Sevilla $148.00, which is the MAR for CPT code 99244.
  7. Dr. Sevilla filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking additional reimbursement of $53.00.
  8. On October 9, 2000, the Commission’s Medical Review Division (MRD) denied the request for additional reimbursement.
  9. Dr. Sevilla filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  10. Notice of the hearing was sent February 26, 2001.
  11. 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.
  12. The hearing was held October 25, 2001, with ALJ Henry D. Card presiding and representatives of the U.T. System and Dr. Sevilla participating. The hearing was adjourned the same day.
  13. Under the Commission’s Medical Fee Guidelines, CPT Code 99244 is to be used for “medical decision making of moderate complexity,” during which physicians
    “typically spend 60 minutes face-to-face with the patient and/or family.”
  14. Under the Commission’s Medical Fee Guidelines, CPT Code 99245 is to be used for “medical decision making of high complexity,” during which physicians “typically spend 80 minutes face-to-face with the patient and/or family.”
  15. Although patients with radiculitis are typically more complicated than the average patient, the evidence did not show that this particular patient required medical decision-making of high complexity.
  16. Dr. Sevilla did not keep track of, and the evidence did not show, the amount of time the office consultation required.

Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the 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. '2001.052.
  4. The Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code '148.21(h).
  5. Dr. Sevilla has not met his burden of proving he was entitled to additional reimbursement.
  6. Dr. Sevilla’s request for additional reimbursement should be denied.


IT IS, THEREFORE, ORDERED that Cesar A. Sevilla, M.D.’s request for additional reimbursement of $53.00 from the University of Texas System for a December 21, 1998, office consultation is denied.

Signed December 3, 2001.


Henry D. Card
Administrative Law Judge

End of Document