DECISION AND ORDER
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
- The patient suffered a compensable injury_________________.
- The patient was referred to the Petitioner, Cesar A. Sevilla, M.D., who examined her on December 21, 1998, at his office.
- Dr. Sevilla diagnosed the patient as suffering from lumbar radiculitis on the right side, backache, and right lower leg pain.
- Dr. Sevilla billed the Respondent, the University of Texas System (the U.T. System), for $350.00 using CPT Code 99245.
- The Maximum Allowable Reimbursement (MAR) for CPT code 99245 is $201.00
- The U.T. System paid Dr. Sevilla $148.00, which is the MAR for CPT code 99244.
- Dr. Sevilla filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking additional reimbursement of $53.00.
- On October 9, 2000, the Commission’s Medical Review Division (MRD) denied the request for additional reimbursement.
- Dr. Sevilla filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
- Notice of the hearing was sent February 26, 2001.
- 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.
- 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.
- 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.”
- 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.”
- 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.
- Dr. Sevilla did not keep track of, and the evidence did not show, the amount of time the office consultation required.
Conclusions of Law
- 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.
- 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.
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. '2001.052.
- The Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code '148.21(h).
- Dr. Sevilla has not met his burden of proving he was entitled to additional reimbursement.
- 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.
STATE OFFICE OF ADMINISTRATIVE HEARINGS
Henry D. Card
Administrative Law Judge