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At a Glance:
Title:
453-01-2689-m5
Date:
February 6, 2002
Status:
Retrospective Medical Necessity

453-01-2689-m5

February 6, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Insurance Company of the State of Pennsylvania (the Carrier), seeks reversal of a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) ordering the Carrier to reimburse Waco Ortho Rehab $1,141 for medical services provided to workers compensation claimant ___ between October 26, 1998, and April 7, 1999. The disputed services included $1,015 for numerous billings for CPT Code 97110 (therapeutic procedures with a 15 minute duration), $103 for CPT Code 99215 (extended office visit), and $23 for CPT Code 99080 (special reports and forms) to copy 46 pages of records for a designated doctor’s review.

The Administrative Law Judge convened a hearing on these issues on January 28, 2002. The hearing was concluded and the record closed that date. The Carrier was represented by Allain Collins, attorney. Respondent Waco Ortho Rehab was represented by David N. Bailey. The Commission did not participate in the hearing.

II. EVIDENCE AND BASIS FOR DECISION

The record in this case consisted of the 243-page certified record of the MRD proceeding. No additional evidence was offered during the hearing. Based on this record, the ALJ concludes that the Carrier’s petition should be denied, and that the Carrier should be required to reimburse Waco Ortho Rehab for the services in dispute. 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. In summary, however, the ALJ concludes the Carrier failed to show that the services provided were not medically necessary. With respect to the primary dispute, which related to billings under CPT Code 97110, the ALJ finds that the two-hour time limit for physical medicine sessions set forth in Section I.A.10.a of the TWCC Medicine Ground Rules (28 TAC §134.201) does not require that time spent on procedures without prescribed time limits be included in the two hour cap. Instead, only time spent on procedures that contain specified time limits should be included in assessing compliance with the two-hour maximum.[1]

III. FINDINGS OF FACT

  1. On ______, Claimant ___ suffered a compensable injury to her wrists diagnosed as repetitive strain injury.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by Insurance Company of the State of Pennsylvania (the Carrier).
  3. Petitioner Waco Ortho Rehab seeks reimbursement from the Carrier for $1,141in medical services provided to the Claimant between October 26, 1998, and April 7, 1999. These services included $1,015 for numerous billings for CPT Code 97110 (therapeutic procedures with a 15 minute duration), $103 for CPT Code 99215 (extended office visit), and $23 for CPT Code 99080 (special reports and forms) to copy 46 pages of records for a designated doctor’s review.
  4. The Carrier denied reimbursement of the expenses identified in Finding of Fact No. 3.
  5. The Petitioner timely requested dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD).
  6. The MRD issued its findings and decision on March 8, 2001, concluding that the disputed expenses should be paid, and the Carrier timely appealed this decision.
  7. The $1,015 billed pursuant to CPT Code 97110 is considered a “timed” code because it is billed in 15-minute increments.
  8. On several dates, Waco Ortho Rehab billed for between six and nine units of CPT Code 97110 in conjunction with other untimed codes that are within the definition of “physical medicine session” set out in Section I.A.10.a of the Medicine Ground Rules, 28 TAC §134.201.
  9. The units billed for CPT Code 97110 were not shown to be unreasonable or unnecessary treatment for the Claimant’s condition.
  10. Waco Ortho Rehab billed $125 pursuant to CPT Code 99215 (extended office visit) for a March 4, 1999, office visit. The MRD allowed recovery of $103 for this service in accordance with the Commission’s Maximum Allowable Recovery Guidelines.
  11. The $103 allowed by the Medical Review Division for the March 4, 1999, office visit has not been shown to have been unreasonable or unnecessary in view of the adequate documentation of services provided by Waco Ortho Rehab.
  12. The $23 billed for CPT Code 99080 (special reports and forms) to copy 46 pages of records for a designated doctor’s review was not shown to be unreasonable or unnecessary.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §413.031.
  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 Tex. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by the Commission 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.
  4. 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.
  5. Considering the ambiguity of Section I.A.10.a in the context of the Medicine Ground Rules and the practical problems with incorporating untimed modalities into the two-hour limit, the Carrier has not shown that Waco Ortho Rehab’s billings violated that section.
  6. The Carrier failed to establish that the treatment provided to the Claimant was not reasonably required by Tex. Lab. Code Ann. §408.021.
  7. Waco Ortho Rehab should be reimbursed $1,141 for medical services provided to workers’ compensation claimant ___, including $1,015 for CPT Code 97110 (therapeutic procedures with a 15 minute duration), $103 for CPT Code 99215 (extended office visit), and $23 for CPT Code 99080 (special reports and forms) to copy 46 pages of records for a designated doctor’s review.

ORDER

IT IS THEREFORE, ORDERED that Petitioner Insurance Company of the State of Pennsylvania shall reimburse Respondent Waco Ortho Rehab $1,141 for the services that are the subject of this dispute.

Issued February 6, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Kerry D. Sullivan
Administrative Law Judge

P:APA Decisions2002

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