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At a Glance:
Title:
453-01-2994-m5
Date:
April 18, 2002
Status:
Retrospective Medical Necessity

453-01-2994-m5

April 18, 2002

DECISION AND ORDER

Dean Allen, D.C., (Petitioner)[1] appealed the Findings and Decision of the Texas Workers' Compensation Commission's (the Commission) Medical Review Division (MRD) in a preauthorization dispute, MDR Docket No. M5-01-0743-01. The MRD upheld the denial of reimbursement by Liberty Mutual Fire Insurance Company (Carrier) for office visits provided workers’ compensation claimant ___(Claimant). This decision finds the reimbursement should not be paid to Petitioner because all reimbursement due for the office visits has already been paid.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues regarding notice of hearing. Therefore, those matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

The hearing convened April 1, 2002, at the Hearings Facility of the State Office of Administrative Hearings (SOAH) before SOAH Administrative Law Judge (ALJ) Catherine C. Egan. Attorney Scott Hilliard represented Petitioner. Attorney Shannon Butterworth represented Carrier. Pursuant to its written announcement, the Commission chose not to participate in the hearing. After receipt of evidence, the record was closed the same day.

II. DISCUSSION

A. Background Facts

In_________, Claimant sustained two separate injuries, one to her cervical spine and the other to her lumbar spine, compensable under the Texas Workers’ Compensation Act (Act). At the time of both compensable injuries, Claimant’s employer had workers’ compensation insurance coverage with Carrier. This dispute concerns office visits Claimant received from December 1999 through July 2000, from Petitioner.[2]

Each of Claimant’s injuries received an individual claim tracking number from the Commission. For each office visit, Petitioner billed Carrier for that office visit, using CPT Code 99213-MP, under each of the two claim tracking numbers.

B. Petitioner’s Position

Petitioner argued that the Commission’s rules did not specify how to bill an office visit during which a claimant was treated for two separate injuries with separate claim tracking numbers. Absent a specific instruction to the contrary, Petitioner felt it had to bill the office visit under each claim number because the services provided related to each injury. Petitioner further justified the two billings by noting that the treating doctor, Dr. Dean Allen, had to prepare separate written reports for each injury. Finally, Petitioner complained that if it was improper to bill under each claim tracking number, then Petitioner was at a loss as to how to document and bill the office visits as rendered for each injury.

Petitioner’s witness Dr. Laurent Pelletier testified the dual billings were justified because during each office visit Dr. Allen examined and evaluated Claimant’s two separate injuries in her cervical and her lumber spine. Dr. Pelletier considered the cervical and lumbar spine to be two separate body parts. For billing purposes, Dr. Pelletier analogized Claimant’s dual injuries to the situation where two patients, each having one of the same injuries Claimant had, are treated. In the latter case, the provider would submit a separate bill for each patient under a separate claim tracking number. Dr. Pelletier thought it was appropriate to do the same for Claimant’s office visits. Unless a separate file were maintained for each of Claimant’s injuries and each service rendered recorded in each file, Dr. Pelletier believed tracking Claimant’s medical treatment would become “a complete mess.” Billing under each claim tracking number was the best way to accurately document the treatment of each injury. While it might be possible for the treating doctor to evaluate two injuries in the fifteen minutes allotted for an office visit for an established patient under CPT code 99213, Dr. Pelletier believed the extra paperwork involved (the separate reports for each injury) justified the billing under each claim tracking number regardless of the actual length of the visit.

Dr. Pelletier stated if the patient had multiple injuries arising from the same accident and thus just one workers’ compensation claim number, then the treating doctor would only bill for one office visit even though two body parts were treated. According to him, the dual billing is justified because there are two separate claims, not because there are two different body parts to be treated during the office visit. He understood all services provided to treat an injury must be billed under the claim number for that injury. In Claimant’s case, it was proper to bill under each claim tracking number for each service rendered even if the service was provided simultaneously for the separate injuries.

Dr. Pelletier could not point to any part of the MRD record (Exh. 1) that contained references to treatment of Claimant’s lumbar spine. He thought that, because Carrier had paid Petitioner for the services regarding Claimant’s lumbar spine, only documents pertaining to the unpaid treatment of the cervical spine were submitted to MRD in this case.

C. Carrier’s Position

Carrier did not present any evidence at the hearing, but argued that Petitioner failed to show that billing under each claim tracking number was justified under the Labor Code or the Commission’s rules. Carrier pointed to TEX. LAB. CODE ANN. § 408.025(c), which requires the treating doctor maintain efficient utilization of health care. This requirement is reiterated in the Commission’s Spine Treatment Guideline, found at 28 TEX. ADMIN. CODE (TAC) § 134.1001 (c)(2). In particular, the rule at 28 TAC §134.001(c)(2)(A) requires the treating doctor to monitor the appropriateness of all services, how the service relates to the compensable injury, whether treatments are duplicative, and the appropriate costs of the services.

D. Analysis

In the General Instructions of its Medical Fee Guideline, the Commission requires documentation to support billings for services that are prolonged or otherwise greater than usually required. Also, the Commission’s rule requires that such extraordinary services be billed with the appropriate modifier.[3] General Instructions VIII(B), 28 TAC § 134.201. There was one office visit during which Dr. Allen addressed each injury. An office visit with physician-patient contact is billed according to the amount of “face to face” time spent with the patient. The CPT codes for office visits consider the total work done by the physician before, during, and after the visit in calculating the fee. Rule IV(c)(3)(a), Evaluation/Management Ground Rules, 28 TAC § 134.201. Therefore, Dr. Allen’s post-visit reports were included the amount paid for the office visit. If he found it necessary to generate two reports and thought the extra report merited higher reimbursement, he need to use the appropriate modifier for an usual level of service and document the need for the extra report. Petitioner provided no evidence that this was done.

Petitioner had the burden of proof in this matter. Therefore, Petitioner had to show that its billing practice fulfilled the health care goals stated in the Labor Code and the Commission’s rules. It failed to meet its burden of proof because Petitioner did not show that the duplicative billing was an efficient utilization of health care or that it complied with the Commission’s requirements that extraordinary services be billed under CPT code modifiers or supported by sufficient documentation.

Petitioner claimed that billing under each claim tracking number was justified, in part, because Dr. Allen wrote two separate reports, one for each compensable injury, after each office visit. The record lacks documentation of this extra report or justification to bill twice for the same office visit. As Dr. Pelletier admitted, the record contains only documents relating to the unpaid cervical spine claim. In order to justify two payment for one office visit, one would need to examine the work done under both claim numbers. Petitioner failed to provide sufficient documentation to support its claim that additional work justified additional compensation. Further, Petitioner failed to bill for the office visit using a modifier that would indicate the service was prolonged duration or of an extraordinary nature.

Carrier is correct that as the treating doctor, Dr. Allen was responsible for ensuring that the health care provided Claimant was efficient. Billing one office visit under each of two claim tracking numbers was not shown to be an efficient utilization of health care. Petitioner failed to show that the amount and quality of the health care provided in the office visit merited a higher level of compensation. Lack of a specific Commission rule for billing a service rendered for injuries having separate claim tracking numbers did not mean that Petitioner was, by default, entitled to claim reimbursement for that service twice. The Commission’s rules provide modifiers to be used when additional reimbursement is justified for unusual or extraordinary services. Petitioner chose not to use these modifiers. If accurate documentation of treatment were the main concern, instead of submitting two claims for reimbursement, Petitioner’s second bill could have explained that the office visit had been previously billed and this second entry was just for record-keeping purposes. Petitioner’s own record keeping problems did not justify including the office visit in the bills for each claim tracking number.

Petitioner failed to meet it burden of proof in this matter and its request for reimbursement for the office visits already reimbursed under Claimant’s lumber injury claim tracking number must be denied.

III. FINDINGS OF FACT

  1. In _________________(Claimant) sustained two separate injuries, one to her cervical spine and the other to her lumbar spine, compensable under the Texas Workers’ Compensation Act (Act).
  2. At the time of the compensable injury, Claimant’s employer had workers’ compensation insurance coverage with Liberty Mutual Fire Insurance (Carrier).
  3. The Texas Workers’ Compensation Commission (Commission) assigned each of her injuries a separate claim tracking number.
  4. For each office visit provided Claimant by her treating doctor, Dr. Dean Allen, from December 1999 through July 2000, Petitioner billed Carrier under each of the two claim tracking numbers.
  5. Petitioner billed the office visits under CPT code 99213-MP.
  6. During each office visit, Dr. Allen evaluated and treated of Claimant’s two separate injury and wrote a report about each injury.
  7. The record contained documentation only about Petitioner’s services to Claimant for the cervical spine injury.
  8. In its billings for the office visits, Petitioner did not use a modifier to indicate the service was of unusual quality or duration deserving additional reimbursement.
  9. Petitioner was reimbursed by Carrier for the office visits billed under the claim tracking number for Claimant’s lumbar spine injury.
  10. Pursuant to the notice of hearing issued by the Commission, Petitioner and Carrier appeared or were represented at the hearing in this matter. The Commission waived its appearance at the hearing.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers' Compensation Act (the Act), TEX. LABOR CODE ANN. § 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 § 413.031(d) of the Act and TEX. GOV'T CODE ANN. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV'T CODE ANN. ch. 2001.
  4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§ 2001.051 and 2001.052.
  5. Petitioner has the burden of proof in this proceeding. 28 TAC §§48.21(h) and (i).
  6. Petitioner failed to show that billing for one office visit under two claim tracking numbers constituted the efficient utilization of health care required by TEX. LAB. CODE ANN. § 408.025(c) and the Commission’s Spine Treatment Guideline, found at 28 TEX. ADMIN. CODE § 134.1001 (c)(2).
  7. Petitioner is not entitled to additional reimbursement for the office visits provided Claimant by Dr. Dean Allen from December 1999 through July 2000 and billed under the claim tracking number for Claimant’s cervical injury.

ORDER

IT IS ORDERED that Petitioners Bridgestone Management and Dr. Dean Allen are not entitled to additional reimbursement from Liberty Mutual Fire Insurance for the office visits from December 1999 through July 2000 billed under the claim tracking number for Claimant.’s cervical spine injury.

Signed this 18th day of April, 2002.

CATHERINE C. EGAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. For purposes of this hearing, the real party at interest was Bridgestone Management. Dr. Dean Allen worked in Bridgestone’s facility at the time of the services at issue in this case. Dr. Allen is no longer affiliated with Bridgestone and did not appear in this case.
  2. The dates of the disputed services were December 23, 24, and 27, 1999; January 26; February 7, 9, 18, 22, and 29; March 6 and 14; and July 27, 2000.
  3. The rule suggests General Modifiers A-21"(prolonged evaluation and management services) or A-22" (usual services) were available to cover this situation.
End of Document
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