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At a Glance:
Title:
453-01-3242-m5
Date:
October 8, 2002
Status:
Retrospective Medical Necessity

453-01-3242-m5

October 8, 2002

DECISION AND ORDER

This case is a dispute over whether additional reimbursement is appropriate for certain procedures rendered to_____ (Claimant) by Elizabeth Taylor, D.C. (Provider) between February 24, 1999, and January 4, 2000. Provider billed Employers Insurance of Wausau (Carrier) for manipulations and myofascial release procedures administered to Claimant which Carrier denied. The amount in controversy is $1,036.00.

The hearing was convened on August 12, 2002, before Steven M. Rivas, Administrative Law Judge (ALJ). Provider appeared and represented herself. Carrier appeared and was represented by Shannon Butterworth, attorney. The record closed the same day.

In this Order, the ALJ concludes Provider is entitled to a total of $96.00 of additional reimbursement over the amount already ordered by the Medical Review Division (MRD) for a total of $288.00.

I.

DISCUSSION

Background Facts

On________, Claimant ____ sustained a compensable injury. The circumstances of Claimant’s injury are not in dispute. At some point, Claimant was referred to Elizabeth Taylor, D.C., as part of his on-going treatment following his injury. Dr. Taylor treated Claimant with a series of manipulations and myofascial release procedures on several occasions between February 24, 1999, and January 4, 2000. Carrier denied reimbursement for the manipulations citing the medical documentation did not support manipulations were performed and, if so, did not indicate a significant change in Claimant’s condition as a result of the manipulations. Carrier also denied the myofascial release procedures because Provider had not received the necessary preauthorization to administer this procedure.

Provider filed a request for Medical Dispute Resolution (MDR) with the Medical Review Division (MRD). The MRD held Claimant was entitled to reimbursement in the amount of $192.00. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH) seeking additional reimbursement.

B. Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (the Act and provides the relevant statutory requirements regarding compensable treatment for workers’ compensation claims. In particular, Tex. Lab. Code Ann. §408.021 provides in pertinent part: (a) 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.

* * *

Under the Commission’s Medical Fee Guideline, Medicine Ground Rules (I)(A)(9)(c), CPT code 97250 is considered a physical medicine activity where supervision by the doctor or health care provider is required.

* * *

The Commission’s Medical Fee Guideline, Medicine Ground Rules (I)(B)(1)(b), direct the doctor to use CPT code 99213-MP when providing an office visit in combination with a manipulation on the same date of service.

* * *

The Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code '§ 134.1001(e)(2)(A)(i-vi), stipulates treatment of a work related injury must be adequately documented, evaluated for effectiveness, provided appropriately, cost effective, and objectively measured.

* * *

The Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code '§ 134.1001(e)(3)(A-B), further mentions the health care provider’s documentation is vital as an information source regarding the injured employee’s injury and treatment.

* * *

Under the Commission’s rule found at 28 Tex. Admin. Code § 134.600(h), non-emergency health care requiring preauthorization includes pain management and rehabilitation procedures.

Evidence and Analysis

The issue in this matter is whether Provider should be reimbursement for two separate procedures administered to Claimant on multiple occasions.

Myofascial release - 97250

Between the applicable dates, Provider administered and billed for numerous myofascial release procedures under CPT code 97250. As noted in the MRD Findings, none of the myofascial procedures were preauthorized as required by the Commission’s rule found at 28 Tex. Admin. Code '§ 134.600(h). On more than one occasion, Provider requested preauthorization for the myofascial release procedure but did not receive preauthorization for any request. Regardless, Provider rendered myofascial release procedures on Claimant because of the apparent relief given to Claimant by the procedures.

Provider asserted she relied Tex. Lab. Code Ann. §408.021(a)(1) which stipulates that an employee who sustains a compensable injury is entitled to all health care that cures or relieves the effects of the compensable injury. Since the myofascial release procedures relieved Claimant of the pain symptoms caused by his injury, Provider continued to administer the procedures despite never receiving preauthorization.

Provider accepted the risk of not getting reimbursed for this procedure and admitted she was aware of the denials for preauthorization. Provider points to the relief exhibited by Claimant as a means to obtain reimbursement after administering this procedure. However, Claimant’s relief does not refute the clear denials for preauthorization.[1]

Since Provider did not receive preauthorization as required under 28 Tex. Admin. Code § 134.600(h), it is not entitled to reimbursement for any of the myofascial release procedures it administered on Claimant.

Manipulation - 99213-MP

Between the applicable dates, Provider administered and billed Carrier for numerous manipulations under CPT code 99213-MP. Each manipulation was billed at $48.00. As noted in the MRD Findings, only four of the billed manipulations were deemed to have proper documentation and were allowed reimbursement. Provider asserted the MRD reviewer did not interpret the medical records correctly when it found no proper documentation existed for the remaining 26 entries.

Provider asserted Claimant received manipulations on each office visit where a manipulation was billed. In support of her argument, Provider pointed to the notes of Claimant’s office visits where the letters ACMT on each record indicated chiropractic manipulation therapy.[2] Provider further asserted the MRD reviewer did not understand the letters ACMT meant a manipulation was performed on the date of service.

Under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001(e)(2)(A), treatment of a work related injury must be, among other things, adequately documented, evaluated for effectiveness, and objectively measured.

The ALJ finds the letters ACMT are adequate to denote a manipulation was administered to Claimant on the disputed dates of service. However, an indication of treatment alone does not entitle Provider to reimbursement. Under the rule cited above, there must also be some evidence regarding the effectiveness of that treatment on Claimant, and that effectiveness, if any, must be objectively measured and recorded. Even if Claimant found no relief or substantial change from the manipulations, it still must be noted in Provider’s medical records to ensure reimbursement.

Of the dates of service where a manipulation was performed on Claimant, the ALJ found Provider had sufficient document for two visits that were not awarded reimbursement by the MRD, June 8, 1999, and August 17, 1999.[3] On each of those dates, Provider indicated Claimant had increased range of motion (ROM) following the manipulation. The remainder of Provider’s records, other than those records where the MRD awarded reimbursement, show no objective findings following manipulation.

After reviewing Provider’s records where a manipulation was administered, the ALJ found sufficient documentation for two visits that were not awarded reimbursement by the MRD. Since each manipulation was billed at $48.00, Provider is entitled to a total of $96.00 of additional reimbursement in addition to the $192.00 awarded by the MRD.

III.

FINDINGS OF FACT

  1. Claimant _____., suffered a compensable injury on ________
  2. At some point following the injury, Claimant was referred to Elizabeth Taylor, D.C., for treatment.
  3. Dr. Taylor administered a series of myofascial release and manipulation procedures on Claimant between February 24, 1999, and January 4, 2000.
  4. Provider billed Employers Insurance of Wausau (Carrier) for the myofascial release and manipulation procedures it performed on Claimant which Carrier denied.
  5. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement for the treatment rendered to Claimant.
  6. On May 4, 2001, the Commission’s Medical Review Decision (MRD) found Provider was entitled to reimbursement of $192.00.
  7. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH) seeking additional reimbursement.
  8. Notice of the hearing was sent July 16, 2002.
  9. The notice 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.
  10. The hearing was held August 12, 2002, with ALJ Steven M. Rivas presiding and representatives of the Provider, and Carrier participating. The hearing was adjourned the same day.
  11. Provider did not receive preauthorization to administer the myofascial release procedures it performed on Claimant between February 24, 1999, and January 4, 2000.
  12. In all but two of Provider’s records contained in the certified record, the documentation of Claimant’s manipulation therapy does not properly record the necessary information stipulated by the Spine Treatment Guideline.
  13. Sufficient documentation supports reimbursement for manipulations administered to Claimant on June 8, 1999, and August 17, 1999.
  14. Provider is entitled to additional reimbursement of $96.00 in addition to the $192.00 already awarded by the MRD.

IV.

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 Provider, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code § 148.21(h).
  5. Under the Commission’s rule found at 28 Tex. Admin. Code § 134.600(h), a provider is required to obtain preauthorization before administering certain procedures on patients including myofascial release.
  6. Provider is not entitled to reimbursement for the myofascial release procedures because it did not receive the required preauthorization.
  7. Under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001(e)(2)(A), treatment of a work related injury must be adequately documented, evaluated for effectiveness, and objectively measured in order to ensure reimbursement.
  8. Pursuant to the foregoing Findings of Fact and Conclusions of Law, Provider is not entitled to any reimbursement for the myofascial release procedures it administered to Claimant.
  9. Pursuant to the foregoing Findings of Fact and Conclusions of Law, Provider is entitled to additional reimbursement for the manipulations rendered to Claimant on June 8, 1999, and August 17, 1999, in the amount of $96.00 in addition to the $192.00 already awarded by the MRD.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Elizabeth Taylor, D.C., is entitled to receive additional reimbursement of $96.00, in addition to the $192.00 awarded to Provider by the MRD, from the Carrier, Employers Insurance of Wausau, for the manipulations rendered to Claimant on June 8, 1999, and August 17, 1999, for a total of $288.00 reimbursement.

Signed this 8th day of October, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

  1. Denial for Preauthorization letters. Pages 51 and 54 of the certified record.
  2. Provider’s medical records. Pages 93 through 122 of the certified record.
  3. Provider’s medical records. Pages 106 and 114 of the certified record.
End of Document
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