DECISION AND ORDER
Impairment & Pain Management (Provider) appealed the Findings and Decision of the Texas Workers' Compensation Commission's Medical Review Division (MRD). The MRD determined that Provider was entitled to reimbursement by Texas Mutual Insurance Company f/k/a The Texas Fund (Carrier) in the amount of $240.00, rather than the $720.00 sought by Provider, for chiropractic services provided to Stephen Lavone (Claimant) during the period September 3, 1999, through January 20, 2000. Provider appealed the MRD decision to the extent $480.00 was not deemed properly reimbursable from Carrier. The following Decision concludes that Provider is entitled to the reimbursement ordered by the MRD only, not the additional $480.00 sought in this appeal.
I. PROCEDURAL HISTORY, NOTICE AND JURISDICTION
On June 14, 2000, Provider filed with the Texas Workers' Compensation Commission (the Commission) a Request for Medical Dispute Resolution which was assigned to MRD after Carrier had denied certain claims for chiropractic services provided to Claimant. Carrier's denial was based on the ground that the treatment coded on the claims required a manipulation and no manipulation had been properly documented. There were fifteen separate office visits that were in dispute as to whether the pertinent charges had been properly documented and were properly coded. Although the amount originally billed by Provider was $65.00 per visit, all parties agree that the pertinent maximum allowable reimbursement (MAR) is $48.00. Thus, the controversy before the MRD was $720.00 ($48.00 x $15.00). MRD determined that Provider had documented a manipulation on five of the fifteen office visits and ordered Carrier to reimburse Provider $240.00 for services properly
documented and coded under CPT Code 99213-MP. Carrier did not appeal that decision. By letter dated March 20, 2001, Provider appealed the decision of the MRD denying reimbursement of an additional $480.00.
On April 11, 2001, the Commission served all parties with a Notice of Hearing, which 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, as required by TEX. GOV'T. CODE ANN. §2001.052 . A hearing was convened before Administrative Law Judge (ALJ) Charles E. Munson on November 13, 2001, at the Stephen F. Austin Building, 1700 N. Congress Avenue, Suite 1100, Austin, Texas. Provider was represented by Dr. Nimesh Patel and Ms. Deborah Cooks. Carrier was represented by Mr. Christopher Trickey, Attorney. The Commission was represented by Ms. Jacqueline Harrison, Attorney, APA Litigation; however, no one from the Commission appeared at the hearing. As an accommodation to Dr. Patel and Ms. Cooks, and in compliance with SOAH rules, the hearing was conducted through a telephone conference with only Carrier and its witnesses actually present in the hearing room. Claimant did not appear or participate. The hearing concluded on November 13, 2001.
No party challenged notice or the jurisdiction. The State Office of Administrative Hearings (SOAH) has jurisdiction over matters related to the hearing, 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 .
Claimant suffered a compensable injury to his lower back on _________________, while employed by _______. Following treatment by his primary care physician, Claimant was referred to Dr. Patel on August 17, 1999. Dr. Patel provided three basic treatments to Claimant: myofascial release, flexion distraction and lumbar manipulation. Those treatments were coded as CPT Code 99213-MP, which requires documentation confirming a manipulation was performed during the office visit. Carrier declined reimbursement on fifteen office visits citing inadequate documentation.
B. Summary of Parties' Positions
Provider asserted that Dr. Patel properly documented manipulative procedures on the disputed ten office visits involving the Claimant. If the manipulation has been documented and the coding is correct, Carrier is required to reimburse Provider up to the MAR of $48.00 per visit or $480.00.
Provider argued that the notes of Dr. Patel clearly identify the various procedures performed on the Claimant and that the key procedure of a flexion distraction is a type of manipulation defined in the Medical Fee Guideline (Guideline). Provider concedes that there are a variety of manipulative procedures or treatments available to a patient, including, for example, flexion distraction and lumbar manipulation. Provider and Carrier agree that myofascial release is not considered a manipulative treatment.
Carrier maintains Provider shoulders the burden of proving that the decision of the MRD was incorrect. Carrier concedes the earlier finding by the MRD that five of the fifteen office visits in dispute did adequately document a manipulation treatment on Claimant, that the treatments were properly coded, and, therefore, were subject to reimbursement. With respect to the remaining ten office visits, Carrier argues that Provider has not adequately documented a manipulative treatment was involved, that the coding on the pertinent claims is incorrect, and that no reimbursement is proper. Carrier contends Dr. Patel's notes in four of the ten disputed visits specifically reference "no manipulation" was provided Claimant. Carrier also disputes the conclusion of Provider that flexion distraction is a manipulative treatment. Carrier, through its expert witness, distinguished a manipulative treatment, such as a lumbar drop, from a mobilization treatment, such as a flexion distraction.
The Commission argues the MRD properly determined that only five of the fifteen office visits were subject to reimbursement, because the remaining office visits were not properly documented for CPT Code 99213-MP.
The primary evidence is the certified record provided by the MRD (Ex. 1). In addition, excerpts of the Guideline adopted as a rule by the Commission were introduced to provide clarification on various codes, requirements for complete and accurate documentation and coding. (Ex. 2.) An effort to offer a curriculum vitae of the expert witness provided by Carrier was rejected because of the late-filing of such evidence upon Provider. (Ex. 3.) Provider offered testimony from Dr. Patel, the treating chiropractor, and Ms. Deborah Cooks, the account representative for Provider responsible for collection of various claims and other matters as pertinent to this inquiry. Carrier presented Dr. William Defoyd, as an expert witness, and Ms. Deborah Dailey, a Medical Dispute Analyst.
Dr. Patel testified as to his general practice of providing notes during the course of examinations or treatments. As particularly pertinent to this dispute, Dr. Patel indicated his procedures provide him a clinical basis for recollecting treatments involved for particular patients rather than being concerned with coding for billable procedures under the Act. Dr. Patel identified three primary treatments for Claimant as pertinent to this case, myofascial release, flexion distraction, and lumbar drop manipulation. He confirmed that the myofascial release is not a manipulative procedure. The lumbar drop manipulation is a manipulation of the patient involving the movement of one or more joints. Dr. Patel characterized a flexion distraction as a manipulative treatment, albeit performed with a table or other passive-type apparatus. He testified the flexion distraction is a treatment that does not have a rapid velocity but generally accomplishes some movement of the joint.
Dr. Patel said references in his own notes to "no manipulation performed" or "no manipulation performed this visit" did not imply that there was no manipulative procedure, but meant that other types of manipulation, such as lumbar manipulation, were not done.
Both Dr. Patel and Ms. Cooks argued that the pertinent claims had been timely and properly completed to provide adequate documentation of the services and, therefore, the pertinent coding was correct. Although no supporting medical theory or authority was presented, Dr. Patel argued that the Texas Chiropractic College viewed flexion distraction as a manipulation.
The primary testimony by Carrier was from Dr. Defoyd, who was qualified as an expert. Dr. Defoyd agreed with the comments of Dr. Patel that a myofascial release was not a manipulative treatment and that a lumbar drop manipulation was a manipulative treatment. However, Dr. Defoyd characterized flexion distraction as a mobilization rather than a manipulation. In contrast to a manipulation which involves a sharp, sudden movement of the joint achieved by outside pressure which takes the joint beyond an inter-articular barrier, a flexion distraction often takes several minutes to provide some joint movement by use of a table apparatus. He opined this distinction is commonly accepted in the chiropractic field. Following review of the certified record, he concluded that the coding in the ten pertinent episodes was inaccurate because there was no corresponding documentation confirming a manipulation during the office visit required for CPT Code 99213-MR. Dr. Defoyd noted that specific Medicine Codes in the Guideline are provided for myofascial release (CPT Code 97250) and joint mobilizations (CPT Code 97265).
Ms. Bailey reviewed the notes of Dr. Patel. The notes were instrumental in the evaluation of the claims and resulting Explanation of Benefits (EOBs) concluding that payment for the ten pertinent office visits should be declined for reimbursement. Ms. Bailey noted that on four of the ten
disputed office visits Dr. Patel's own notes indicated no manipulation performed. She argued that manipulation is a prerequisite for reimbursement of a procedure billed under CPT Code 99213-MR.
The Commission presented no evidence.
D. Analysis and Conclusion
Provider must demonstrate by a preponderance of the evidence it is entitled to be reimbursed for the ten visits in dispute. For the reasons set forth below, the ALJ concludes that Provider has not met its burden.
All parties concede the controversy is whether ten office visits involved a manipulation and whether such services were properly documented and coded in order to qualify for reimbursement.
The MRD determined that five of the fifteen office visits were reimbursable. The basis of such decision was that the notes of Dr. Patel adequately documented a manipulation in those five instances and such were properly coded. The deciding issue in this dispute is whether a flexion distraction is a manipulation. If it is, then Provider has a strong argument that at least six of the ten visits are adequately documented and the coding is correct. The four episodes in which Dr. Patel's own notes suggest no manipulative procedures were involved present Provider a further problem for showing adequate documentation of a manipulation performed during each visit. On the other hand, if a flexion distraction is not a manipulation, Provider has not adequately documented the ten claims and the coding is incorrect. In that circumstance, reimbursement is not proper.
The most compelling evidence supporting the MRD decision is notes of Dr. Patel. In the fifteen pertinent instances, highlighted in Attachment A to this Decision, it becomes quite clear that the basis of the MRD decision was whether there was some straightforward representation that a manipulation procedure had taken place. In the five instances in which reimbursement was ordered in the earlier decision, Dr. Patel's notes confirmed some nature of a "lumbar drop manipulation." In the remaining ten disputed episodes, there was no mention of any specific manipulation. In four of the ten episodes, there was a specific reference in the notes that no manipulation was performed. In each of the ten disputed episodes, a flexion distraction was performed. There is no identification of flexion distraction as being a manipulation in the Guideline.
The MRD decision was based upon the lack of reference to an identified manipulation procedure. Provider must demonstrate error in that finding to prevail.
In the record before SOAH, there is no meaningful clarification of the four episodes in which the notes of Dr. Patel indicated "no manipulation performed." With respect to the difference of opinion as to whether a flexion distraction is a manipulation, taken in the light most favorable to Provider, there is a clash of conflicting opinion and definition between Dr. Patel and Dr. Defoyd.
A flexion distraction does not appear to be a manipulation--instead, this procedure appears to be a joint mobilization or something different from the dramatic procedure involved in a manipulation. In the absence of persuasive expert testimony, or a medical or chiropractic treatise, the ALJ gives more weight to the evidence and arguments offered by Carrier's expert witness on this subject. The presentation by Dr. Defoyd distinguishing between a slow-moving, lengthy flexion distraction and a high velocity, sudden manipulation was compelling.
The Guideline, adopted by rule of the Commission, imposes a duty on Provider to adequately document procedures in order to be paid. In this case, the pertinent code has a modifier which requires a manipulation (CPT Code 99213-MP). The documentation in the ten pertinent visits does not effectively describe a treatment that can be equated to a manipulation, particularly, since "manipulation" is not specifically defined in the Guideline. It is incumbent upon the Provider to describe its actions to confirm that the condition precedent to proper coding, i.e., manipulation, happened. Dr. Patel's own notes and letter of April 12, 2000, suggest otherwise.
Consequently, there is no showing in this record that the earlier decision of the MRD is incorrect. Instead, the evidence in this record supports and reaffirms the reasonableness of the earlier decision.
Accordingly, Provider is not entitled to the additional reimbursement sought in this appeal of $480.00.
III. FINDINGS OF FACT
- On _____________, Claimant __________ sustained a compensable injury to his lower back while employed by Packwell, Inc.
- Claimant was referred to Provider Impairment and Pain Management on August 17, 1999, by his primary care physician for treatment of his lower back.
- Treatments performed by Dr. Nimesh Patel, as pertinent to this case, were (a) myofascial release to the lumbar paraspinal musculature, (b) flexion distraction to the lumbar spine, and (c) lumbar spinal manipulation.
- Carrier Texas Mutual Insurance Company declined reimbursement on fifteen pertinent office visit treatments based on its position that the key component for billing under the Evaluation and Management Code, namely, reference or confirmation of a manipulation, had not been documented by Dr. Patel. Without the documentation, Carrier could not confirm the accuracy of the coding of CPT Code 99213-MP.
- Dr. Patel treated Claimant during fifteen office visits from September 3, 1999, through January 20, 2000. On five visits, September 15, 1999, September 22, 1999, October 15, 1999, December 10, 1999 and January 20, 2000, a lumbar drop manipulation was performed and documented. On the remaining ten visits, flexion distraction and myofascial release were performed and documented, however, on September 7, 1999, September 10, 1999, October 4, 1999 and October 25, 1999, Dr. Patel's notes indicate that no manipulation was performed.
- Myofascial release is a soft tissue treatment that is not a manipulation. Myofascial release is coded as CPT No. 97250.
- A joint mobilization is coded as CPT No. 97065.
- Flexion distraction is a partially passive procedure, often using a table apparatus, in which a joint is mobilized during a protracted procedure that may last several minutes.
- A manipulation is a high velocity, sudden movement of a joint achieved by an outside pressure or force which takes the joint beyond an inter-articular barrier.
- Flexion distraction is not a manipulation.
- The Medical Fee Guideline, adopted by rule of the Commission, identifies CPT Code 99213-MP which carries a modifier requiring a confirmation that a manipulation was performed during the office visit.
IV. CONCLUSIONS OF LAW
- The Texas Workers' Compensation Commission (Commission), including the Medical Review Division (MRD), has jurisdiction to decide the issues presented pursuant to §413.031 of the Texas Workers' Compensation Act (the Act), TEX. LABOR CODE ANN. ch. 401, et seq.
- The State Office of Administrative Hearings (SOAH) 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. GOVT. CODE ANN. ch. 2003 .
- The Notice of Hearing issued by the Commission conformed to the requirements of TEX. GOVT. CODE ANN. ch. 2001.052 .
- The hearing was conducted in conformity with the Administrative Procedure Act, TEX. GOVT. CODE ANN. ch. 2001 and the rules of SOAH at 1 TEX. ADMIN. CODE (TAC) § 155.
- Impairment and Pain Management (Provider) has the burden of proof. Section 413.031 of the Act and 28 TEX. ADMIN. CODE (TAC) § 134.201, §148.21(h), (i).
- The Medical Fee Guideline requires a medical provider to accurately code pertinent treatment, and, if necessary, accurately document specific aspects of the treatment to be eligible for reimbursement. 28 TEX. ADMIN. CODE (TAC) § 134.201.
- The use of the modifier "MP" imposes a requirement in the Evaluation/Management Ground Rules to confirm a manipulation was performed during the office visit. 28 TEX. ADMIN. CODE (TAC) § 134.201.
- Provider has not proven that a manipulation was performed by Dr. Patel on the ten office visits in question.
- Provider has not proven that a flexion distraction to the lumbar region of Claimant is a manipulation.
- Based on Findings of Fact Nos. 1-11, ten chiropractic services provided by Dr. Patel of Provider to Claimant between September 3, 1999, and January 20, 2000 were not properly documented and, consequently, the coding of CPT Code 99213-MP is not properly reimbursable.
- Based on Findings of Fact Nos. 1-11 and Conclusions of Law Nos. 5-11, Provider did not meet its burden of proving that it is entitled to additional reimbursement beyond the amount of $240.00, as ordered previously by the MRD.
IT IS, THEREFORE, ORDERED that Impairment and Pain Management’s appeal of the Commission Medical Review Division denial of its request for reimbursement of $480.00 be, and the same is hereby, denied.
Signed this 11th day of December, 2001.
CHARLES E. MUNSON
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
RECAP OF DISPUTED OFFICE VISITS
HIGHLIGHTED BY MRD DECISION
- The following five visits were determined to be properly documented and coded: 9/15/99, 12/10/99, 9/22/99, 1/20/00 and 10/15/99 all referencing a lumbar drop manipulation. Reimbursement of $240.00 ordered.
- The following office visits were denied reimbursement on the basis of inadequate documentation to confirm the manipulation required for the pertinent code: (a) visits on 9/7/99, 9/10/99, 10/4/99 and 10/25/99 referencing "no manipulation performed" or "no manipulation performed this visit"; (b) in addition, the following visits were denied which simply made reference to flexion distraction and other activities: 9/3/99, 9/17/99, 9/20/99, 9/27/99, 12/16/99 and 1/12/99.
- Also referred to as Impairment & Pain Center before the Commission.↑
- The Commission's Medical Fee Guideline adopted by rule in 28 TAC §34.201.↑