DECISION AND ORDER
Wausau Underwriters Insurance Company (Carrier) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (the Commission) ordering reimbursement to Curtis Adams, D.C. (Respondent) for medical services rendered to______ (Claimant).This decision holds that Carrier should not reimburse Respondentfor office visits in which manipulation was provided to Claimant on five dates between March 1, 2000, and March 16, 2000.
I. JURISDICTION AND NOTICE
There were no contested issues of jurisdiction or notice. Therefore, those issues are addressed in the findings of fact and conclusions of law.
II. PROCEDURAL HISTORY
The hearing in this matter convened December 5, 2000, in the Stephen F. Austin Building, 1700 North Congress Avenue, Austin, Texas. Administrative Law Judge (ALJ) Sharon Cloninger presided. Carrier was represented by Mahon B. Garry, Jr., attorney. Respondent appeared by telephone through his employee Rick Muniz. No one appeared on behalf of the Commission. The record closed the same day.
III. BACKGROUNDAND APPLICABLE LAW
Claimant, age 30, incurred a compensable, job-related injury on____________, when he fell from a ladder striking his head and back on a railing. Claimant was Respondent’s patient at least from March 1, 2000, through March 16, 2000, during which time Respondent treated Claimant on five dates.Respondent billed Carrier under separate CPT codes for work conditioning and office visits with manipulation conducted on those five dates. Carrier initially reimbursed Respondent for the office visits with manipulation,and denied payment for the work conditioning on the grounds that it had not been pre-authorized. The office visits were reimbursed at $48.00 each under CPT Code 99213-MP.Later, Carrier audited the bills and determined that the work conditioning did not have to be pre-authorized and should have been paid. Carrier also determined that Respondent should be paid either for the office visits with manipulation or for the work conditioning, but not for both. Carrier decided to deny the office visit with manipulation payments as redundant and medically unnecessary, although those payments had already been made. (Pet. Ex. 1, p. 171). Instead, Carrier opted to pay for the work conditioning, which has a higher maximum allowable reimbursement (MAR) under the Medical Fee Guidelines (MFG) than does an office visit with manipulation. Rather than request Respondent to refund the office visit with manipulation payments, Carrier offset the amount remitted for work conditioning by the amount already paid for the office visits with manipulation.
On February 28, 2001, following Carrier’s denial of payment for the work conditioning -- and prior to Carrier’s decision to pay for the work conditioning -- Respondent submitted a request for dispute resolution to the MRD, seeking $624.00 in reimbursement for work conditioning that occurred on eight dates between March 1, 2000 and April 3, 2000. (Pet. Ex. 1, pp. 36-37).
On March 9, 2001 -- after Respondent submitted his request for dispute resolution but prior to issuance of the MRD decision -- Carrier sent a letter to the MRD indicating Carrier erroneously denied payment to Respondent for work conditioning. Carrier’s letter to the MRD went on to say the office visits billed on the work conditioning dates were instead being denied as redundant and not medically necessary.
On March 28, 2001, the MRD issued its Findings and Decision, ordering Carrier to pay Respondent $312.00 plus interest for five office visits including manipulation at $48.00 each and for two hours of work conditioning at $36.00 per hour. In the “Rationale” section of its decision, the MRD noted that the Carrier had originally paid for the office visits including manipulation and not the work conditioning, but upon auditing the bill had decided to pay for the work conditioning and not the office visits with manipulation, taking credit for the amount originally paid. The MRD said “Work conditioning is a single disciplinary approach and the provider is entitled to bill an office visit with manipulation in conjunction with work conditioning.”
At the beginning of the hearing, the parties agreed that the amount remaining in dispute is $240.00. The sole issue in this proceeding is whether Carrier should reimburse Respondent $240.00plus interest for the five office visits with manipulation that occurred between March 1, 2000, and March 16, 2000, and were billed under CPT Code 99213-MP,when Carrier has already reimbursed Respondent for work conditioning provided to Claimant on those same dates, billed underCPT codes 97545 and 97546. Carrier seeks a decision from the ALJ disallowing payment of the $240.00 remaining in dispute.
B. Applicable Law
Under the Texas Workers Compensation Act, an employee who sustains 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: (1) cures or relieves the effects naturally resulting from the compensable injury; (2) promotes recovery; or (3) enhances the ability of the employee to return to or retain employment.Tex. Labor Code Ann. § 408.21(a).
To assist health care providers and insurance carriers in determining the medical necessity of specific services and the maximum allowable reimbursement for those services, the Commission established Medical Fee Guidelines (MFG) in 1996, as authorized under Tex. Labor Code Ann. § 413.011. The MFG is found at 28 Tex. Admin. Code (TAC) § 134.201.
Under the MFG, medical procedures are assigned CPT  codes. In most instances, the MFG lists a maximum allowable reimbursement (MAR) for each CPT code. The insurance carrier is to reimburse the health care provider either the billed charge or the MAR, whichever is less.
The services at issue were billed using CPT Code 99213-MP, with an MAR of $48.00. The CPT code defines the services as “Office or other outpatient visit for the evaluation and management of an established patient. . . .Physicians typically spend 15 minutes face-to-face with the patient and/or family.” For an established patient,
[t]he doctor shall use the code 99213 with the modifier “-MP” when providing an office visit in combination with a manipulation on the day of service. . . .MFG, Medicine Ground Rule I.B.1.b.
By comparison, work conditioning is defined as a highly structured, goal-oriented, individualized treatment program using real or simulated work activities in conjunction with conditioning tasks. MFG, Medicine Ground Rules II.D.
. . . . All services performed by the interdisciplinary core team and other services as part of the [work conditioning] program shall be inclusive in the reimbursement of the program. . . .MFG, Medicine Ground Rule II. A.
The Commission’s rules require insurance carriers to retrospectively review all complete medical bills, as Carrier did in this case:
(a) The insurance carrier shall retrospectively review all complete medical bills and pay for or deny payment for medical benefits in accordance with the Act, rules, and the appropriate Commission fee and treatment guidelines. . . . 28 TAC §133.301(a).
IV. EVIDENCE AND ANALYSIS
A. Carrier’s Case
Carrier offered the certified record of the MRD hearing, which was admitted as Petitioner’s Exhibit 1, and did not call any witnesses.
Carrier does not dispute that both work conditioning and manipulation were performed on the dates in question. Instead, Carrier’s position is that Respondent can be paid for Respondent’s time spent supervising Claimant’s work conditioning, or for the time spent performing the manipulation, but not for both, because the manipulation was not performed during an office visit separate from the work conditioning. Counsel for Carrier also stated that if Respondent had billed for manipulation only, and not for office visit with manipulation, it would have been proper for Carrier to pay for work conditioning and the manipulation only, excluding payment for the office visit.
Counsel said that while the record is not crystal clear, it appears Claimant’s work conditioning was administered by Respondent, meeting the description of “supervision” in Medicine Ground Rule II.D.6. (Pet. Ex. 1, 7-9, 11-12, 14-15). To be reimbursed for an office visit with manipulation, a doctor must spend 15 minutes face-to-face with the patient, according to CPT code 99213. In this case, Respondent had already spent more than 15 minutes face-to-face with the Claimant during the work conditioning process, so should not be double-paid for the same 15 minutes.
Counsel did state that Respondent could be paid for the manipulation, and not the office visit, under CPT Code 97260 (manipulation performed by physician, one area) and/or CPT Code 97261 (manipulation performed by physician, each additional area). Counsel argued that if doctors had to bill for an office visit whenever they performed a manipulation, there would be no need for CPT Code 97260 to exist. Counsel concluded that if Respondent had billed for the manipulations under CPT Code 97260, that would have been appropriate in conjunction with work conditioning, and should be paid by Carrier.
B. Respondent’s Case
Respondent offered neither documentary evidence nor testimony.
Respondent’s representative stated in closing argument that the office visits with manipulation should be reimbursed because while Respondent personally provided the manipulation, a different person on Respondent’s staff conducted the work conditioning.Therefore, Respondent spent at least 15 minutes face-to-face with Claimant outside the work conditioning time.
Respondent’s representative also said that if the ALJ finds Respondent is not entitled to reimbursement for the office visits with manipulation, the proper procedure is for Carrier to finish paying the entire amount for work conditioning, and for Respondent to refund to Carrier the office visit payments, rather than for Carrier to take an offset against those payments.
C. Analysisand conclusion
Carrier bears the burden of proof by a preponderance of the evidence on the question of whether the ALJ should deny payment for the disputed services. 28 TAC § 148.2(h). Carrier is limited on appeal to its reasons for denial of payment as set forth in the record admitted as Petitioner’s Exhibit 1.The reasons for denial were that the office visit with manipulation billings were redundant and not medically necessary.
The office visit portion of Respondent’s billing appears to be redundant, in that there is no evidence Respondent spent at least 15 minutes face-to-face with Claimant separate from the time spent in work conditioning, and the time spent in work conditioning was well over 15 minutes per session. (Pet. Ex. 1, pp. 7-9, 11-12, 14-15, 31-32).
While Respondent argued that the work conditioning was administered by a different staff member, there is nothing in the record to support that contention. The only reference as to who administered the work conditioning is the word “I,” as in “I worked with the patient today on proper strengthening exercises so as not to re-injure himself again on the job.” (Pet. Ex. 1, p. 9). The statement appears in the work conditioning notes, on Respondent’s letterhead, with no signature. The ALJ can only presume “I” refers to Respondent since no other name, except Claimant’s, is mentioned in the work conditioning notes.
The fact that the MFG contains one CPT code for office visits with manipulation, and a separate CPT code for manipulation only, persuades the ALJ that the Commission contemplated that manipulation could be provided to a Claimant in a situations other than an office visit, such as in conjunction with work conditioning. If a manipulation was performed on the disputed dates in addition to work conditioning, it should have been billed under CPT Code 97260 for a MAR of $35.00, and should not have included billing for an office visit as well. It was incorrect for Respondent to bill for office visits with manipulation under CPT Code 99213-MP. It was proper for Carrier to offset payments for work conditioning by $48.00 each, based on its prior erroneous payment to Respondent for office visits with manipulation.
Because payment for the office visits would be redundant, in that Carrier has already reimbursed Respondent for time spent with Claimant in work conditioning, Carrier should not reimburse Respondent an additional $240.00 for office visits with manipulation.
V. FINDINGS OF FACT
- On___________________(Claimant) incurred a compensable injury under the Texas Workers’ Compensation Act, while working for an employer who had workers’ compensation insurance coverage with Wausau Underwriters Insurance Company (Carrier).
- Curtis Adams, D.C.(Respondent) treated Claimant’s injury during at least five visits between March 1, 2000, and March 16, 2000, billing Carrier for the treatments under CPT Codes 99213-MP (office visit with manipulation), 97545 (work hardening/conditioning, initial two hours) and 97546 (work hardening/conditioning, each additional hour).
- During each of the visits referenced in Finding of Fact No. 2, Claimant participated in work conditioning lasting more than 15 minutes, and Respondent provided Claimant with manipulation.
- Work conditioning and manipulation are separate and distinct treatments.
- Carrier initially reimbursed Respondent for the five office visits with manipulation, at a rate of $48.00 each, and denied payment for the work conditioning administered on the same dates, because it had not been pre-authorized.
- Upon review of the billing, Carrier decided the work conditioning administered between March 1, 2000, and March 16, 2000, did not require pre-authorization after all. Carrier simultaneously decided the office visits with manipulation payments had been made in error. Carrier then remitted payment to Respondent for the work conditioning, less the amount already paid for the office visits on the same dates.
- On February 28, 2000, Respondent sought medical dispute resolution through the Texas Workers Compensation Commission (the Commission), seeking reimbursement of $384.00.
- On March 28, 2000, the Commission’s Medical Review Division (MRD) issued a decision ordering Carrier to remit partial payment of $312.00 plus all accrued interest to Respondent.
- Carrier filed a timely appeal of the MRD decision on April 6, 2001, which culminated in a hearing before the State Office of Administrative Hearings on December 5, 2001.
- The parties stipulated at hearing that the amount remaining in dispute is $240.00.
VI. CONCLUSIONS OF LAW
- The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers' Compensation Act, Tex. Labor Code Ann. §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 Ann. §413.031(d), 28 Tex. Admin. Code (TAC) §145.3 and Tex. Gov't Code Ann., Ch. 2003.
- Adequate and timely notice of the hearing was provided in accordance with 28 TAC § 148.4.
- Carrier bears the burden of proof by a preponderance of the evidence on the question of whether the Administrative Law Judge should disallow additional payment for the disputed services. 28 TAC § 148.2(h)(i).
- When manipulation is performed as part of an office visit, it is billed under CPT Code 99213-MP with a MAR of $48.00.
- When manipulation is performed in conjunction with other treatment, it is separately billed under CPT Code 97260, with a MAR of $35.00.
- Carrier was required to pay for the work conditioning and for the manipulation on the disputed dates, but not for office visits with manipulation.
- Pursuant to the above findings of fact, Carrier proved that additional reimbursement to Respondent should be disallowed because payment for office visits with manipulation would be redundant when work conditioning on the same dates has already been reimbursed.
- Pursuant to the above findings of fact and conclusions of law, Carrier does not owe Respondent an additional reimbursement in the amount of $240.00 plus interest for treatment billed under CPT Code 99213-MP.
IT IS, THEREFORE, ORDERED that Wausau Underwriters Insurance Companyshall not remit $240.00, plus accrued interest, to Curtis Adams, D.C.
Signed this 25th day of January, 2002.
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- CPT Code 99213- MP is for office visits including manipulation.↑
- The Commission has incorporated usage of the American Medical Association’s 1995 Current Procedural Terminology (CPT) codes in its Medical Fee Guidelines. (See MFG, General Instructions, I.)↑
- MFG General Instructions VI (Reimbursement).↑
- Counsel for Carrier argued that because Carrier was obligated to reimburse Respondent either for the office visits or the work conditioning, but not for both, Carrier did not have a basis for denying the office visit payments until Carrier paid for the work conditioning.↑
- CPT Code 97260 has an MAR of $35.00, as opposed to the MAR of $48.00 for CPT Code 99213-MP (office visit with manipulation).↑
- There is no evidence in the record to support this contention.↑