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At a Glance:
Title:
453-01-2388-m5
Date:
May 16, 2002
Status:
Retrospective Medical Necessity

453-01-2388-m5

May 16, 2002

DECISION AND ORDER

Transcontinental Insurance Company (Transcontinental) challenges a decision of the Texas Workers’ Compensation Commission Medical Review Division (MRD) ordering $1,344.00 in reimbursement to H. Lee Black, D.C. for cranial manipulation treatments it concluded were rendered to an injured worker, ___ (Claimant). This decision concludes that because Dr. Black failed to establish that cranial manipulations were medically necessary, he is not entitled to reimbursement.

I. PROCEDURAL HISTORY

Jurisdiction, notice, and venue were not contested. Therefore, those issues are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

II. STATEMENT OF THE CASE

The hearing convened and closed on March 20, 2002, at the William P. Clements Building, 300 West 15th Street, Austin, Texas. Administrative Law Judge (ALJ) Gary Elkins presided. Transcontinental was represented by its counsel, Jane Lipscomb Stone. Dr. Black, present by telephone, represented himself. Dr. Samuel Bierner testified as an expert witness on behalf of Transcontinental. The Commission did not participate.

III. DISCUSSION

Background

From August 8, 1998, through October 2, 1998, Dr. H. Lee Black, D.C. performed cranial manipulations on Claimant. “Cranial manipulation” is a process by which the bones in one’s cranium, or skull, are manipulated. The cranial manipulations were administered for the treatment of Claimant’s low back injury. In administering the cranial manipulations, Dr. Black billed Petitioner 28 units of CPT Code 99213 (intermediate level office visit) at a total cost of $1,344.00.

Summary of Parties’ Positions

Transcontinental opposes reimbursement, arguing that the manipulations were not medically necessary to treat Claimant’s compensable low-back injury. In addition, Transcontinental argues that Dr. Black failed to meet the documentation requirements of the Spine Treatment Guideline, failed to comply with Medical Fee Guideline requirements with respect to CPT Code 99213, and failed to add the appropriate “MP” modifier to CPT Code 99213, which designates that the billing is for a chiropractic manipulation. In support of his request for reimbursement, Dr. Black argues that his treatment was medically necessary to treat Claimant’s compensable injury and that Claimant experienced improvement with cranial manipulation.

Legal Standards

Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (l). Pursuant to the Act, an employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Tex. Lab. Code Ann. §408.021(a).

Pursuant to its mandate to implement policies that establish fair and reasonable reimbursement for medical services, the Commission adopted the 1996 Medical Fee Guideline (Guideline), found at 28 TAC § 134.201. The Guideline contains policies designed to ensure quality of medical care and to achieve effective medical cost control. As pertinent to this case, when billing a carrier, a provider must use the appropriate CPT Codes and modifiers, and must choose the name of the service or procedure that most accurately identifies each service performed. General Instructions I, VIII.

  1. Evidence, Argument, and Analysis
  2. CPT Code 99213

a. Transcontinental. Transcontinental argues that Dr. Black failed to add the modifier “MP” to CPT Code 99213, which is the appropriate method under which to bill chiropractic manipulations. In addition, Transcontinental contends, CPT Code 99213 indicates an intermediate level office visit and requires that a patient history, physical examination, and meaningful assessment be performed and documented. Nevertheless, Dr. Black’s office notes suggest he did not perform any of these services.

b. Dr. Black. Dr. Black testified that the insurance adjuster for Transcontinental told him that he could perform cranial manipulations on Claimant and that he would be reimbursed.

c. Analysis. A review of the certified record reveals that the cranial manipulations were billed under CPT Code 99213 without the appropriate “MP” modifier. Without the “MP” modifier, CPT Code 99213 is an improper code for the disputed procedure. Furthermore, Dr. Black’s office notes fell short of demonstrating that these services were adequately provided consistent with CPT Code 99213.

Medical Necessity

a. Transcontinental. Transcontinental noted that the Spine Treatment Guideline requires health care providers to furnish documentation that clearly explains how the treatment is related to the compensable injury. Transcontinental argued that Dr. Black’s documentation did not demonstrate that the cranial manipulations performed on the disputed dates of service were related in any way to the treatment of Claimant’s low back injury. In addition, Transcontinental noted that the medical records established that instead of getting better, Claimant was reporting pain in fifteen different areas of his body by December 5, 2000.

Expert witness Dr. Bierner opined that the extent, nature and duration of the cranial manipulations was not medically necessary for the treatment of Claimant’s compensable injury. He noted that this case had been reviewed by a number of chiropractic reviewers, all of whom determined that further manipulations and physical therapy would not be medically necessary to treat Claimant. Dr. Bierner also commented that the only movable joints on the cranium are those of the jaw. Because there are no other movable parts, he testified, it was unlikely that manipulating the cranium could benefit to the lower back.

b. Dr. Black. Dr. Black testified that no health care providers, prior to him, had been successful in treating Claimant, and that it was not until he formulated Claimant’s diagnosis that Claimant’s pain went away. He alleged that the insurance adjuster for Transcontinental knew that he was performing cranial work on Claimant and he was told that he would be reimbursed for his services. Finally, he testified that other providers were trying to treat Claimant from the wrong end and that as a craniopath; few people understand the benefit of cranial manipulations.

c. Analysis. Dr. Black failed to provide documentation that the cranial manipulations were medically necessary for the treatment of Claimant’s compensable injury. There is no objective medical evidence that moving the bones in a patient’s skull could have any beneficial medical effect on the treatment of a low back injury. Accordingly, Dr. Black is not entitled to reimbursement for the cranial manipulations.

Conclusion

Based on the foregoing analysis, Transcontinental has met its burden of proving by a preponderance of the evidence that treatment provided by Respondent H. Lee Black was not medically necessary and that Dr. Black is not entitled to any reimbursement for the medical services rendered to Claimant from August 8, 1998, through October 2, 1998.

IV. FINDINGS OF FACT

  1. Claimant, ____ suffered a compensable low-back injury on________. At the time of Claimant’s injury, Transcontinental Insurance Company (Petitioner) was the workers’ compensation insurance carrier for his employer.
  2. Between August 8, 1998 through October 2, 1998, Dr. H. Lee Black, D.C., a craniopath, performed cranial manipulations on Claimant.
  3. Cranial manipulation is a process by which the bones in one’s cranium, or skull, are manipulated.
  4. The cranial manipulations were administered for the treatment of Claimant’s low-back injury.
  5. In administering the cranial manipulations, Dr. Black billed 28 units of CPT Code 99213 (intermediate level office visit).
  6. Dr. Black billed Petitioner $1,344 for the treatment described in finding 4.
  7. Petitioner denied payment for these office visits, citing that they were not medically necessary.
  8. A dispute resolution review was conducted by the Medical Review Division regarding the medical payment dispute between Dr. Black and Petitioner. A Findings and Decision was issued February 9th, 2001 in which the MRD ordered reimbursement to Dr. Black in the amount of $1,344.
  9. In response to the MRD’s Findings and Decision, Petitioner timely filed a request for hearing before the State Office of Administrative Hearings.
  10. Notice of the hearing was sent to the parties on December 6, 2001. On October 17, 2001, the Commission sent the parties a Statement of Matters Asserted, which included references to the particular statutes and rules involved. On March 19, 2001 the Commission sent the parties an Amended Statement of Matters Asserted, communicating that counsel for the Commission would not participate in the hearing.
  11. Dr. Black billed CPT Code 99213 for intermediate office visits but failed to add the modifier “MP” which is the appropriate method under which to bill chiropractic manipulations.
  12. The Medical Fee Guideline requires that for an intermediate level office visit, a patient history, physical examination and meaningful assessment must be performed and documented. Dr. Black did not perform any of these duties as reflected in his office notes.
  13. The Spine Treatment Guideline requires health care providers to furnish documentation explaining how a particular treatment is related to a claimant’s compensable injury. Dr. Black’s documentation did not establish how cranial manipulations would be related to the treatment for Claimant’s low-back injury.
  14. Despite cranial manipulations performed by Dr. Black, by December 5, 2000, Claimant was reporting pain in fifteen different areas of his body, indicating that his overall condition had worsened, not improved.

V. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Labor Code Ann. §413.031 (Vernon Supp. 2002).
  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 §413.031(d) of the Act and Tex. Gov’t Code Ann. ch. 2003 (Vernon 2002).
  3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 (Vernon 2002) and Tex. Admin. Code (TAC) §§133.305.
  4. Based on Findings 11-14, the extent, nature and duration of the cranial manipulations was not medically necessary for the treatment of Claimant’s compensable low back injury.
  5. Dr. Blask is not entitled to reimbursement for charges related to cranial manipulation rendered to Claimant from August 8, 1998, through October 2, 1998.
  6. Based on the foregoing Findings and Conclusions, Dr. Black is not entitled to reimbursement from Petitioner for the disputed amount.

ORDER

IT IS, THEREFORE, ORDERED that Petitioner, Transcontinental Insurance Company, is not required to reimburse Dr. H. Lee Black, D.C. for any amount relating to cranial manipulations performed on Claimant, ____.

Signed this 16th day of May 2002.

Gary W. Elkins
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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