DECISION AND ORDER
American Manufacturers Mutual Insurance Company (Petitioner, Carrier) seeks reversal of an amended decision by the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (the Commission) ordering Carrier to reimburse Waco Ortho Rehab (Respondent, Provider) $6,318.00 for medical services provided to A. A. (Claimant) between July 14, 1999, and December 29, 1999. The disputed services include $4,340.00 for numerous billings for CPT Code 97110 (therapeutic procedures with a 15-minute duration), $989.00 for CPT Code 97250 (myofascial release/soft tissue mobilization), and $989.00 for CPT Code 97265 (joint mobilization, one or more areas).
This Decision and Order concludes Carrier should pay Respondent $6,318.00, plus interest, for the disputed services.
I. Jurisdiction and Notice
The Commission has jurisdiction over this matter under Tex. Lab. Code Ann. ' 413.031. The State Office of Administrative Hearings (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. Govt Code Ann. chapter 2003.
Notice and jurisdiction were not contested by the parties. Adequate and timely notice of the hearing was provided in accordance with Tex. Govt Code Ann. '2001.052.
II. Procedural History
Administrative Law Judge (ALJ) Sharon Cloninger convened the hearing on April 29, 2002, at the SOAH hearings facility in Austin, Texas. The hearing concluded and the record closed that same day. Carrier was represented by Roy Horton, attorney. Respondent was represented by Scott C. Hilliard, attorney. The Commission did not participate in the hearing.
A. Burden of Proof
Under 28 Tex. Admin. Code (TAC) '148.21(h), Petitioner has the burden of proof in hearings such as this one. Thus Carrier has the burden of proving Respondent is not entitled to the reimbursement ordered by the MRD.
Issue and Applicable Law
The issue in this proceeding is the proper interpretation of Medicine Ground Rule I.A.10.a. (the rule) found in the Commission's Medical Fee Guideline (MFG), as adopted in 28 TAC '134.201. The rule is related to the limitations imposed on physical medicine sessions. Does the rule allow a provider to bill for either up to four untimed procedures per session, or for up to two hours of timed procedures per session, but not both; or does the rule allow a provider to bill for a combination of up to four untimed procedures and up to two hours of timed procedures per session?
In the instant case, regarding the disputed dates of service, Provider billed Carrier for a combination of timed and untimed procedures performed in each physical medicine session. Respondent billed for eight or more units of CPT Code 97110, a timed procedure, and also billed for other, untimed codes that are within the definition of "physical medicine session." The untimed procedures billed for were CPT Code 97250 (myofascial release) and CPT Code 97265 (joint mobilization).
Carrier denied reimbursement for CPT Codes 97250 and 97265, the untimed procedures, partly on the theory that Respondent had exceeded the two-hour time limit for physical medicine sessions set forth in the rule, which 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.
Carrier denied payment for CPT Codes 97250 and 97265 on 10 of the disputed dates because Provider had already been reimbursed for two hours of CPT Code 97110 on those dates. Carrier denied payment for CPT Codes 97110, 97250 and 97265 on the 13 remaining disputed dates because there was no medical documentation to support the services were rendered. The MRD decision orders Carrier to reimburse Provider for CPT Code 97110 on the 13 unpaid dates, and for CPT Codes 97250 and 97265 on all 23 dates in question, in essence finding that the rule allows Providers to be reimbursed for a combination of timed and untimed procedures in a physical session. In addition, the MRD decision orders Carrier to reimburse Provider for additional units of CPT Code 97110 on the 10 dates for which two hours have already been paid, because Provider's documentation supports payment for the additional time.
- Evidence, Arguments, and Basis for Decision
The evidence in this case consists of the 471- page certified record of the MRD proceeding. Neither party called witnesses. At the request of the parties, the ALJ took official notice of two prior SOAH decisions related to the rule at issue in this case. The ALJ also took official notice of the Commission's interpretation of the rule, as set out in admissions obtained in discovery in another case.
Carrier argued that the proper interpretation of the rule is that the provider is allowed to bill for either up to four CPT Codes per physical medicine session, or for two hours of treatment per physical medicine session, but may not combine the two. Carrier's position is that the dates of service in dispute exceed the rule for physical medicine in a session, and the Carrier should not be required to pay additional reimbursement
Respondent rgued that the two-hour limit referred only to the timed procedures and that up to four untimed procedures could be performed, and reimbursed, in conjunction with a two-hour CPT Code 97110 session. For example, since CPT Code 97110 is charged in 15-minute units, it would have to be billed eight times in a physical medicine session to reach the two-hour cap, so clearly if the Afour modality rule applied to timed procedures, only one hour of treatment under CPT Code 97110 could be provided, rendering the two-hour cap meaningless.
Basis for Decision
Based on evidence in the record and SOAH's prior decisions regarding the rule, the ALJ concludes that Carrier's petition should be denied, and that Carrier should be required to reimburse Respondent 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, with respect to the primary dispute, the ALJ finds the two-hour time limit for physical medicine sessions set forth in Section I.A.10.a. of the Commission's Medicine Ground Rules 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. Also, the ALJ concludes the Carrier failed to show that the services provided were not medically necessary.
IV. Findings of Fact
- On (date of injury), Claimant A. A., who was an employee of Fleetwood Homes of Texas, Inc. (Fleetwood), suffered a compensable low back injury.
- American Manufacturers Mutual Insurance Company (Petitioner, Carrier) was Fleetwood's carrier for workers' compensation insurance.
- The disputed dates for services provided to Claimant by Waco Ortho Rehab (Respondent) are from July 14, 1999, through December 23,1999. These services included $4,340.00 for numerous billings under CPT Code 97110 (therapeutic procedures with a 15-minute duration), $989.00 for numerous billings under CPT Code 97250 (myofascial release), and $989.00 for numerous billings under CPT Code 97265 (joint mobilization).
- Carrier denied reimbursement for the disputed services listed in Finding of Fact No. 3, on the theory that Respondent had exceeded the two-hour time limit for physical medicine sessions set forth in the Commission's Medicine Ground Rules, Section I.A.10.a., and because on some of the disputed dates there was not a showing of medical necessity.
- Respondent timely filed a Request for Medical Dispute Resolution with the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (the Commission) on March 8, 2000.
- The MRD issued its original Findings and Decision on March 13, 2001.
- The MRD withdrew its original decision and issued an amended decision on May 2, 2001. In the amended decision, the MRD ordered Carrier to reimburse Respondent $6,318.00 plus accrued interest.
- Carrier timely appealed the MRD's amended decision, requesting a hearing before the State Office of Administrative Hearings (SOAH).
- The hearing was held April 29, 2002, at SOAH's hearings facility in Austin, Texas.Attorney Roy Horton represented Carrier. Attorney Scott C. Hilliard represented Respondent.The hearing adjourned and the record closed that same day.
- The $4,340.00 billed pursunt to CPT Code 97110 is considered a Atimed code because it is billed in 15-minute increments.
- On the disputed dates of service, Respondent billed for at least eight units, or two hours, of CPT Code 97110 and also billed for other, untimed procedures that are within the definition of "physical medicine session.'' The other, untimed procedures were myofascial release (CPT Code 97250) and joint mobilization (CPT Code 97265).
- The units billed for CPT Code 97110 were not shown to be unreasonable or unnecessary treatment for the Claimant's condition.
- Respondent billed $989.00 pursuant to CPT Code 97250 (myofascial release/soft tissue mobilization) and $989.00 for CPT Code 97265 (joint mobilization, one or more areas) for physical medicine sessions provided between July 14, 1999, and December 29, 1999.
- The services outlined in Finding of Fact No. 12 have not been shown to have been unreasonable or unnecessary in view of the adequate documentation of services provided by Respondent.
- Including the untimed codes within the two-hour time limit creates a practical problem, because there is no mechanism for determining how much time an "untimed" procedure takes, or is supposed to take.
V. Conclusions of Law
- The Texas Workers= Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the Act), Tex. Lab. Code Ann. chapter 401 et seq.
- The State Office of Administrative Hearings (SOAH) has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. Chapter 2003.
- The Notice of Hearing issued by the Commission conformed with 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.
- Under 28 Tex. Admin. Code (TAC) '148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to '413.031 of the Act. Thus Carrier has the burden of proving Respondent is not entitled to the reimbursement ordered by the MRD.
- Considering the ambiguity of Section I.A.10.a in the context of the Medicine Ground Rules, the practical problems with incorporating untimed modalities into the two-hour limit, Carrier has not met its burden of proving that Respondent's billings violated that section.
- The Carrier failed to establish that the treatment provided Claimant was not reasonably required by Tex. Lab. Code Ann. '408.021.
- Carrier should. be required to reimburse Respondent $6,318.00 for the services for which it denied reimbursement based on Medicine Ground Rule Section I.A.10.a.
IT IS, THEREFORE, ORDERED that the Petitioner American Manufacturing Mutual Insurance Company shall reimburse Respondent Waco Ortho Rehab $6,318.00, plus interest, for the services that are the subject of this dispute.
Signed June 26th, 2002.
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- 1 CPT Code 97110 is considered a ''timed" code because it is billed in 15-minute units. Carrier paid for two hours per physical session of CPT Code 97110 on 10 of the 23 dates in dispute; the MRD ordered Carrier to pay for two hours of CPT Code 97110 for each of the remaining 13 dates.↑
- 2 The decisions are Liberty Mutual Insurance Company/Arrow Clinic v. Texas Workers= Compensation Commission and Arrow Clinic/Liberty Mutual Insurance Company (453-99-1216.M5), issued March, 2000; and Insurance Company of the State of Pennsylvania v. Waco Ortho Rehab and Texas Workers= Compensation Commission (453-01-2689.M5), issued February 6, 2002, citing reasoning set out in TASB Risk Management Fund v. Texas Workers= Compensation Commission and Waco Ortho Rehab (453-01.2175.M4), issued October 9, 2001.↑
- 3 The ALJ concurs with the reasoning set out in SOAH Docket No. 453-01-2175.M4. The ambiguity of Section I.A.10.a., the practical difficulty posed by the fact that providers are not required to keep track of time spent on untimed procedures, and the Commission's historical practice all militate in favor of excluding untimed procedures from the two-hour limitation.↑