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At a Glance:
Title:
453-01-3424-m5
Date:
May 17, 2002
Status:
Retrospective Medical Necessity

453-01-3424-m5

May 17, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner, American Home Assurance Company (Carrier), appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC) ordering reimbursement to Respondent Arkansas Pioneer Chiropractic (Provider) for medical services provided to ____., Claimant. This decision orders the Carrier to reimburse the Provider $721.00.

The Administrative Law Judge convened a hearing on March 26, 2002. The hearing was concluded and the record closed that date. The Carrier was represented by Janice G. Menzies, attorney. The Provider appeared telephonically through Dr. Joseph P. Viernow, D.C.

II. EVIDENCE AND BASIS FOR DECISION

The issue presented in this preceding is whether the Carrier should reimburse the Provider $801.00 plus interest for medical services provided between February 18, 2000, and March 17, 2000,and billed under CPT Codes 99213 (office visit), 97113 (aquatic therapy), 97250 (myofascial release), and 97265 (joint mobilization).[1]

The Carrier argued that the medical services provided to the Claimant were not medically necessary and reasonably required because the Claimant had been over treated with both joint mobilization and myofascial release; that the aquatic therapy could have been done at home at a significant savings for the Carrier; and that the Carrier was double billed because a modifier should have been added to CPT Code 99213 making it an office visit with manipulation.

The documentary record in this case consisted of the 337-page certified record of the MRD proceeding (Exh. 1). Additionally, Dr. Viernow provided testimony that the Claimant suffered from a cumulative injury to the left wrist and hand (carpal tunnel syndrome). He stated that both joint mobilization and myofascial release were necessary because joint mobilization is an adjustment to the bones which increases range of motion, while myofascial release is an adjustment which uses force to return the bones to their normal position. Dr. Viernow testified that aquatic therapy was necessary at the office because the Claimant would not have the necessary equipment at home, and she would be less likely to do the exercises properly at home. The record also contains the Provider’s S.O.A.P. notes[2] documenting office visits and treatment for the contested services. (Exh. 1, pp. 22-104).

Based on the evidence, the ALJ concludes that Petitioner’s appeal should be granted in part. The particular facts, reasoning, and legal conclusions in support of this decision are set forth below in the Findings of Fact and Conclusions of Law.

III. FINDINGS OF FACT

  1. On________, ______ (Claimant) suffered a compensable injury to her left wrist and hand while working in a job which required her to type all day.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by American Home Assurance Company (Carrier).
  3. Respondent Arkansas Pioneer Chiropractic (Provider) treated the Claimant’s injury during 16 office visits from February 17, 2000, through March 21, 2000.
  4. The Provider treated the Claimant’s wrist and hand injury with aquatic therapy, myofascial release, and joint mobilization during the office visits referenced in Finding of Fact No. 3.
  5. Aquatic therapy was provided in the least intensive and most cost effective manner.
  6. Joint mobilization is an adjustment to the bones intended to increase range of motion.
  7. Myofascial release is an adjustment to the bones which uses force to return the bones to their normal position.
  8. Joint mobilization and myofascial release are distinct procedures.
  9. The Provider documented that aquatic therapy, myofascial release, and joint mobilization were medically necessary and reasonably required.
  10. The Provider billed the Carrier on February 28, 2000, for CPT Codes 99123 and 97265.
  11. The Provider billed the Carrier on March 17, 2000, for CPT Codes 99213-MP and 97265.
  12. The Provider timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  13. The MRD issued its findings and decision on May 14, 2001, concluding that the disputed expenses should be paid, and the Carrier timely appealed this decision.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (TWCC) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §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 Tex. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by TWCC conformed to 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.
  4. The Carrier has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code §413.031.
  5. Based on Findings of Fact Nos. 5 - 9, the Carrier failed to prove that reimbursement for aquatic therapy, myofascial release, and joint mobilization should be disallowed.
  6. The Provider shall use CPT 99213 with the modifier “MP” when providing an office visit in combination with a manipulation on the day of service. TWCC Medicine Ground Rules I. B.1. b.
  7. Based on Findings of Fact Nos. 10 and 11 and Conclusion of Law No. 6, the Provider double- billed the Carrier.
  8. Based on Conclusions of Law Nos. 5 - 7, Arkansas Pioneer Chiropractic is entitled to reimbursement in the amount of $721.00 for the services provided on the disputed dates of service between February 18, 2000, and March 17, 2000.

ORDER

IT IS, THEREFORE, ORDERED that American Home Assurance Company shall reimburse Arkansas Pioneer Chiropractic for fees incurred in treating the Claimant in the amount of $721.00.

Issued this 17th day of May, 2002.

MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Additional dates of service and CPT Codes considered in the MRD Decision were not appealed. At the MRD level the Provider claimed reimbursement of $2,594.00 of which the Carrier had paid $743.85.
  2. S.O.A.P. stands for subjective, objective, analysis of findings and plan.
End of Document
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