DECISION AND ORDER
I. PROCEDURAL HISTORY
Petitioner Liberty Mutual Insurance Company (Carrier) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker's Compensation Commission (TWCC) ordering reimbursement to Respondent Total Care Medical Centers (Provider) for medical services provided to_________. This decision orders the Carrier to reimburse the Provider $392.00 for massage therapy provided under CPT Code 97124.
The Administrative Law Judge convened a hearing on January 4, 2002. The hearing was concluded and the record closed that date. The Carrier was represented Mahon B. Garry, Jr., attorney. The Provider appeared by telephone through its employees, Greg Howard, Jr. and Annette Alonzo. TWCC waived appearance at the hearing.
II. EVIDENCE AND BASIS FOR DECISION
The issue presented in this preceding is whether the Carrier should reimburse the Provider $392.00 plus interest for massage therapy billed under CPT Code 97124, when the Carrier has already reimbursed the Provider for myofascial release provided during the same office visits, and
billed under CPT Code 97250. The Carrier argued that under the global fee concept the procedures
could not be billed separately because the treatments were provided at the same time and to the same area of the body.
The documentary record in this case consisted of the 31-page certified record of the MRD proceeding (Exh. 1), a one-page letter from the Carrier to the MRD (Exh. 2), and a six-page summary which discussed massage therapy as a component of myofascial release (Exh. 3).
The Parties previously litigated this issue in Docket No. 453-01-2392.M4, and the Carrier was ordered to reimburse the Provider for massage therapy billed under CPT Code 97124. Based on the evidence, the ALJ concludes that Petitioner's appeal should be denied. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law.
III. FINDINGS OF FACT
- On___________,_____________ (Claimant) suffered a compensable injury to his back when he slipped while mopping a floor.
- Claimant's injury is covered by worker's compensation insurance written for Claimant's employer by Liberty Mutual Insurance Corporation (Carrier).
- Respondent Total Care Medical Centers (Provider) treated the Claimant's injury during 10 office visits from September 12, 2000, through October 13, 2000.
- The Provider treated the Claimant's back injury with both myofascial release and massage therapy during each of the office visits referenced in Finding of Fact No. 3.
- The Texas Workers= Compensation Commission's Medical Fee Guideline treats massage therapy and myofascial release as separate and distinct procedures.
- Massage therapy is not a component of myofascial release.
- The global fee concept does not apply to myofascial release.
- The Carrier reimbursed the Provider for each unit of myofascial release provided to the Claimant, but not for massage therapy units.
- The Provider timely requested dispute resolution by the Texas Workers= Compensation Commission Medical Review Division (MRD).
- The MRD issued its findings and decision on February 23, 2001, concluding that the disputed expenses should be paid, and the Carrier timely appealed this decision.
IV. CONCLUSIONS OF LAW
- The Texas Workers= Compensation Commission (TWCC) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code '413.031.
- 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 '413.031 and Tex. Gov=t Code ch. 2003.
- The Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov=t Code '2001.052 in that it 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 section of the statutes and rules involved; and a short plain statement of the matters asserted.
- The Carrier has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code '413.031.
- The Medical Fee Guideline contains separate CPT codes for massage therapy and myofascial release because massage therapy is not a component of myofascial release.
- Based on Findings of Fact Nos. 5 - 7, the Carrier failed to prove that reimbursement for massage therapy should be disallowed because myofascial release is a global fee concept and massage therapy is a component of myofascial release.
- The Carrier should reimburse the Provider for providing treatment to Claimant in the amount of $392.00 plus interest.
IT IS, THEREFORE, ORDERED that Liberty Mutual Insurance Corporation reimburse Total Care Medical Centers for fees incurred in treating the Claimant in the amount of $392.00.
Issued this 16th day of January, 2002.
MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- Payment should be mailed to Total Care Medical Centers, c/o Accident & Injury Center, 4010 College, Suite 200, Beaumont, Texas 77707.↑