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At a Glance:
Title:
453-01-3036-m5
Date:
April 10, 2002
Status:
Retrospective Medical Necessity

453-01-3036-m5

April 10, 2002

DECISION AND ORDER

This case involves a dispute over reimbursement for a November 22, 2000 office visit during which Respondent, Dr. Sevilla, treated claimant’s left knee. The amount in controversy is $48.00.

Petitioner, the University of Texas System (UTS) asserted that the office visit should not be reimbursed because the treatment related to the workers’ compensation claimant’s pre-existing osteoarthritis, not to the (1998 injury) compensable injury (a medial and lateral left knee meniscus tear) for which D.G. had corrective surgery on September 8, 1999. UTS also argued that the UTS carrier denied further reimbursement on May 31, 2000, and that the certified record shows_____ sustained a new left knee injury in (subsequent date of injury) while working at a new job. In response, Dr. Sevilla asserted that the purpose of the November 22, 2000 office visit was to treat claimant’s post-traumatic swelling and pain secondary to the medial and lateral meniscus tears that resulted from her compensable injury.

According to the record, x-rays taken when the claimant sustained an injury to her left thigh in early1998 showed the claimant had mild osteoarthritic changes in her left knee. In a Benefit Review Conference convened to address compensability of the claimant’s 1998 injury, the parties agreed the claimant’s left knee tear was compensable, but her osteoarthritis was not.[1] The question in this case is whether the pain the claimant experienced in November 2000 is related to her compensable injury. UTS claims the pain resulted from the claimant’s pre-existing osteoarthritis; Dr. Sevilla claims the pain resulted from the post-traumatic degenerative changes directly related to her compensable injury.

The Administrative Law Judge (ALJ) concludes that UTS failed to prove by a preponderance of the evidence that the office visit was for complaints unrelated to the injury. Dr. Sevilla explained in a March 2, 2000 report that because the claimant had to wait one year after the injury for the carrier to approve her surgery, she developed post-traumatic osteoarthritis due to a tear in her left meniscus.[2] Shortly before the injury, the claimant’s pre-existing osteoarthritis was found to be mild. The ALJ finds it significant that after the compensable injury occurred, the claimant had to wait over a year for the corrective surgery due to a compensability dispute. It is reasonable to conclude that this delay caused complications in her left knee from the medial and lateral meniscus tears and accelerated a formerly mild degeneration. Therefore, the ALJ finds that the claimant’s complaints of pain on November 22, 2000, naturally occurred from the compensable injury.

The ALJ does not agree with UTS’s interpretation of Dr. Sevilla’s March 2, 2000 office visit notes. UTS argued that the notes show the claimant sustained a new injury while working as a private nurse. However, those notes say only that the claimant’s left knee complaints were exacerbated while performing private nursing duties.[3] The ALJ cannot conclude from this statement that the claimant sustained another injury. The ALJ also cannot conclude from the Decision and Order in SOAH Docket No. 453-01-2492.M5 that Dr. Sevilla has a pattern of billing problems, as UTS argued at the hearing.[4]

The ALJ finds that UTS should reimburse Dr. Sevilla for the $48.00 office visit.

Findings of Fact

  1. On ___________, the claimant, _______, suffered a compensable injury to her left knee involving medial and lateral meniscus tears.
  2. The claimant was referred to the Respondent, Cesar A. Sevilla, M.D., who performed arthroscopic surgery on her left knee on September 8, 1999.
  3. Dr. Sevilla examined the claimant at his office on November 22, 2000, and diagnosed her with post-traumatic swelling and pain secondary to the medial and lateral meniscus tears.
  4. Dr. Sevilla billed the Petitioner, the University of Texas System (UTS) for $48.00 using CPT Code 99213.
  5. The Maximum Allowable Reimbursement (MAR) for CPT code 99213 is $48.00.
  6. UTS denied Dr. Sevilla’s claim under code R - Charge Unrelated to Injury.
  7. Dr. Sevilla filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement of $48.00.
  8. On April 12, 2001, the Commission’s Medical Review Division (MRD) granted Dr. Sevilla’s request for reimbursement.
  9. UTS filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  10. The May 29, 2001 notice of hearing 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.
  11. The hearing was held February 11, 2002, with ALJ Deborah L. Ingraham presiding and representatives of the UTS and Dr. Sevilla participating. The Commission did not participate in the hearing. The hearing was adjourned the same day.
  12. The claimant’s _________ compensable injury involved medial and lateral meniscus tears in her left knee, which were exacerbated and complicated by a one year delay of arthroscopic surgery due to a compensability dispute.
  13. On November 22, 2000, Dr. Sevilla saw the claimant for recurrent left knee pain secondary to the compensable injury.
  14. The delay of the claimant’s arthroscopic surgery caused post-traumatic pain, swelling, and accelerated degenerative changes resulting from the tear to her medial and lateral meniscus in her left knee.
  15. Under the Commission’s Medical Fee Guidelines, CPT Code 99213 is to be used for office or outpatient visits of an established patient and requires two of three key components: an expanded problem focused history, an expanded problem focused examination, or medical decision-making of low complexity.
  16. During the office visit, Dr. Sevilla performed an expanded physical examination of the claimant’s left knee and medical decision-making involving a diagnosis, recommendations, medication, work status, prognosis, orthosis, and treatment plan.

Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
  4. The Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Pursuant to Findings of Fact Nos.12-16, UTS has not met its burden of proving Dr. Sevilla is not entitled to reimbursement for the November 22, 2000 office visit.
  6. Dr. Sevilla’s request for reimbursement is granted.

ORDER

IT IS, THEREFORE, ORDERED that Cesar A. Sevilla, M.D.’s request for reimbursement of $48.00 from the University of Texas System for a November 22, 2000 office visit is granted, and the University of Texas System is ordered to reimburse Dr. Sevilla.

Issued this 10th day of April, 2002.

Deborah L. Ingraham
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Ex.1 at 000015.
  2. Ex. 1at 000044-000045.
  3. Ex. 1 at 000044.
  4. Court’s Ex.1.
End of Document
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