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At a Glance:
Title:
453-01-3056-m5
Date:
March 28, 2002
Status:
Retrospective Medical Necessity

453-01-3056-m5

March 28, 2002

DECISION AND ORDER

I. Summary

Petitioner, Waco Ortho Rehabilitation (WOR), seeks reversal of a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denying full reimbursement for physical therapy, muscle testing, and chiropractic services for the treatment of the claimant’s carpal tunnel syndrome in the left wrist. MRD ordered Pacific Indemnity Company (Pacific or Carrier) to pay $93.00, and accrued interest. WOR seeks reimbursement of an additional $3,713.00. The Administrative Law Judge (ALJ) concludes that Petitioner’s claim for reimbursement should be granted in part in the amount of $1,828.00. The ALJ convened a hearing on these issues on January 29, 2002, and the record closed February 1, 2002, following submission of additional evidence and objections to the evidence. The ALJ sustains the objections and does not admit the evidence offered as WOR Exhibit 2.

II. Discussion

The record in this case consisted of the certified record of the MRD proceeding and the testimony of Dr. David Bailey, President of a General Partner of WOR. Dr. Bailey testified that the claimant suffered from carpal tunnel syndrome in her left hand. He testified that she received treatment for that injury as well as for the same injury in the right hand, at no additional cost.

A.Burden of Proof

The Petitioner has the burden of proof in this case, pursuant to 28 Tex. Admin. Code §148.21(h). Thus, WOR has the burden of proving it is entitled to reimbursement in the amount of $3,713.00.

B. Issues and ALJ’s Analysis

Payment for treatment of the right hand

The Carrier accepted compensability for the left hand only. Therefore, the Carrier argues that any treatment performed on the right hand is not reimbursable. Dr. Bailey testified that he charges the same amount whether one or two hands are treated. His testimony was uncontroverted. Because the cost is the same to treat one or two hands, the Carrier should not receive a windfall by reducing the amount paid, when both hands are treated for the same price as one. Therefore, the ALJ finds that reimbursement should not be reduced or denied when both hands were treated at the same cost as one hand.

Two-hour time limit

The Carrier denied reimbursement for several dates of service on the theory that WOR had exceeded the two-hour time limit for physical medicine sessions set forth in the TWCC Medicine Ground Rules, 28 Tex. Admin. Code §134.201. Section I.A.10.a. of those rules defines a physical medicine session as:

any combination of four modalities (97010-97039), procedures (97110-97150) and/or

physical medicine activities and training (97220-97541). The maximum amount of

time allowed per session is two hours. If additional time is required to complete the

treatment rendered in a session, a maximum of one additional hour may be allowed.

DOP is required for time exceeding the two hour maximum. Two sessions are

allowed per day for the first week of the acute phase of the injury. Thereafter, only

one session per day is allowed.

Certain codes are considered “timed” codes because they are billed in 15-minute units. On some dates, WOR billed the Carrier for more than eight units of timed codes, or more than two hours, and untimed codes. On other dates, WOR billed the Carrier for eight units or fewer of timed codes plus untimed codes.

a. More than eight units of untimed codes.

To receive reimbursement for more than eight units of timed codes, WOR would have to provide a Documentation of Procedure (DOP) to demonstrate the reason for exceeding two hours.[1] WOR presented no evidence that it provided a DOP for those days where the timed codes exceeded two hours. Thus, the ALJ finds that WOR did not meet its burden to show it is entitled to reimbursement for more than eight units of timed codes per day. Therefore, on days where WOR seeks reimbursement for more than eight units, WOR is entitled to receive reimbursement for eight units only.

b. Timed and untimed codes.

On days where eight units or fewer of the timed codes were billed, or where the ALJ has found that only eight units will be allowed, WOR is entitled to reimbursement for the untimed codes in addition to the timed codes. WOR has the burden of proof to show that it complied with the rules and guidelines for billing. Dr. Bailey testified he had conferred with TWCC personnel many times, and they agreed with his interpretation of the rule. He stated he helped draft TWCC guidelines and advised TWCC on the guidelines. He testified the untimed codes should not be counted along with the timed codes to evaluate whether a treatment lasted longer than two hours. Dr. Bailey’s testimony was convincing and uncontroverted. Including the untimed codes within the two-hour time limit creates a practical problem, however, because there is no mechanism for determining how much time an untimed procedure takes, or should take. No one argued that a provider is required to record the time spent on the untimed procedures. For these reasons, the ALJ finds that WOR met its burden of proving that it is entitled to reimbursement for untimed codes billed on the same days as the untimed codes. WOR may recover costs for eight units of timed codes in one day and recover costs for untimed codes billed on the same day.

Other services

WOR billed for range of motion testing, comprehensive office visits, and other services[2] during the Claimant’s course of treatment. To receive reimbursement for range of motion testing, WOR was required to provide a report identifying the service provided, results, and interpretation of the tests, pursuant to Section I.E.2. of the Medical Fee Guidelines. WOR did not show they provided such a report. Therefore, the ALJ finds that the fees for motion testing should not be reimbursed.

Services such as comprehensive office visits are also not reimbursable. On August 24, 1998, the Carrier indicated that treatment after July 16, 1998, was not reasonably expected to provide any greater significant improvement in the claimant’s condition.[3] WOR did not dispute the statements in the letter. Therefore, the ALJ finds that any services billed after July 16, 1998, did not serve to cure or relieve the effects naturally resulting from the compensable injury, and are therefore, not recoverable.[4]

Summary

The chart below summarizes the amounts disputed and the amount to which the ALJ finds Petitioner is entitled to reimbursement. It does not address the charges after July 16, 1998, since they are not reimbursable, as discussed above under section 3.

Date Total Disputed Total Allowed

5/18/98 $57 $57

5/20/98 $232 $70

5/26/98 $127 $70

5/27/98 $92 $70

5/29/98 $92 $70

6/1/98 $143 $86

6/3/98 $108 $108

6/4/98 $129 $0

6/5/98 $108 $108

6/8/98 $127 $70

6/10/98 $143 $86

6/15/98 $178 $86

6/17/98 $108 $108

6/19/98 $57 $35

6/22/98 $108 $108

6/24/98 $108 $108

6/29/98 $108 $108

6/30/98 $92 $70

7/1/98 $108 $108

7/6/98 $143 $86

7/9/98 $108 $108

7/10/98 $108 $108

7/16/98 $169 $0

TOTAL $2753 $1828

III. FINDINGS OF FACT

  1. On_____________, the Claimant suffered the compensable injury of carpal tunnel syndrome in her left hand.
  2. Claimant’s injury is covered by worker's compensation insurance written for Claimant’s employer by Pacific Indemnity Company (Carrier).
  3. The disputed dates for services Waco Ortho Rehabilitation (WOR) provided to the Claimant are from May 18, 1998, through February 24, 1999.
  4. WOR requested dispute resolution by the Texas Workers= Compensation Medical Review Division (MRD) on February 28, 2001.
  5. The MRD issued its findings and decision on April 20, 2001, concluding that WOR was entitled to reimbursement in the amount of $93.00 plus accrued interest.
  6. WOR requested a hearing before the State Office of Administrative Hearings (SOAH).
  7. The hearing was held on January 29, 2002, at SOAH’s hearings facility in Austin, Texas. David Bailey, D.C. represented WOR. Mark Sickles represented the Carrier. The hearing adjourned the same day, and the record closed February 1, 2002.
  8. The charges for which WOR seeks additional reimbursement fall into three categories: (1) treatment of the right hand; (2) services that exceeded the two-hour time limit of the Medicine Ground Rules; and (3) testing and other services.

Treatment of the right hand

  1. Carrier denied reimbursement for several dates of service on the theory that WOR treated Claimant’s two hands, when treatment for the left hand was the only reimbursable treatment.
  2. The cost to treat both hands was the same as the cost to treat the left hand only.
  3. Carrier would receive a windfall if it were to pay less than the cost to treat one hand when both hands were treated for the same price as one.

Two-hour time limit

  1. Carrier denied reimbursement for several dates of service on the theory that WOR had exceeded the two-hour time limit for physical medicine sessions.
  2. On several dates, WOR billed in excess of eight units of timed codes and did not provide a Documentation of Procedure (DOP).
  3. On several dates, WOR billed eight units or fewer of the timed codes and also billed for other, untimed codes that are within the definition of “physical medicine session.”

Other services

  1. Carrier denied reimbursement for testing services.
  2. WOR did not provide a testing report identifying the service provided, results and interpretation of the tests.
  3. Carrier denied reimbursement for services performed after July 16, 1998, because the treatments did not serve to cure or relieve the effects naturally resulting from the compensable injury.
  4. Treatments performed after July 16, 1998, did not serve to cure or relieve the effects naturally resulting from the compensable injury.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code Ann. §413.031.
  2. 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 Tex. Labor Code Ann. §413.031 and Tex. Gov’t Code Ann. ch. 2003.
  3. The Notice of Hearing issued by the Commission conformed to the requirements of Tex. Gov’t Code Ann. §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. Waco Ortho Rehabilitation (WOR) has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code Ann.§413.031.
  5. WOR may not recover more than the costs for eight units of timed codes when it did not provide a Documentation of Procedure (DOP), pursuant to 28 Tex. Admin. Code '134.201 Section I.A.10.a.
  6. Untimed codes are not included within the two-hour time limit of the TWCC Medicine Ground Rules, 28 Tex. Admin. Code §134.201, Section I.A.10.a.
  7. Based on the Findings of Fact, Carrier should be required to reimburse WOR for the services billed under untimed codes for which it denied reimbursement based on Section I.A.10.a.
  8. WOR did not properly document the motion testing, comprehensive office visits and other services, as required by Section I.E.2. of the Medical Fee Guidelines.
  9. Based on the Findings of Fact, motion testing should not be reimbursed based on Section I.E.2. of the Medical Fee Guidelines.
  10. Based on the Findings of Fact, services billed after July 16, 1998, are not compensable pursuant to Tex. Lab. Code § 408.021(a)(1).
  11. WOR is entitled to reimbursement in the amount of $1,828.00.

ORDER

The claim by Petitioner, Waco Ortho Rehabilitation, for payment from Pacific Indemnity Company is granted in part in the amount of $1828.00.

Issued March 28th, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Wendy K. L. Harvel
Administrative Law Judge

  1. 28 Tex. Admin. Code §134.201, Section I.A.10.a.
  2. It is unclear in the record what the other services entailed.
  3. Ex. 1 at 339.
  4. SeeTex. Lab. Code §408.021(a)(1).
End of Document
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