Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-01-3441-m4-etal
Date:
June 27, 2002
Status:
Medical Fees

453-01-3441-m4-etal

June 27, 2002

DECISION AND ORDER

Petitioner, the State Office of Risk Management, appealed Texas Workers’ Compensation Commission Medical Review Division (MRD) decisions that ordered payment for medical services provided to two claimants. Petitioner argued that Respondents were not entitled to reimbursement for more than two hours of physical medicine treatments per day, regardless of whether the treatments were for timed or untimed CPT codes. Because some physical medicine treatments are not required to be timed, Respondents argued that the two-hour time limit should not apply to the untimed CPT codes. This decision finds that Petitioner did not meet its burden of proving the treatments were not medically necessary and upholds the MRD award of additional payments.

I. PROCEDURAL HISTORY

The hearing was conducted on April 16, 2002, at the State Office of Administrative Hearings (SOAH), 300 West Fifteenth Street, Austin, Texas, before Administrative Law Judge (ALJ) Sarah G. Ramos. Stephen Vollbrecht, Deputy General Counsel, represented the Petitioner. Attorney Scott Hilliard represented Waco Ortho Rehab and the Back and Joint Clinic (Respondents). The Commission’s staff did not participate in the hearing.

II. EVIDENCE AND BASIS FOR DECISION

The record in this case included of the eighty-three page MRD record pertaining to Waco Ortho Rehab, Docket No. 453-01-3441.M4, the 126-page record pertaining to The Back and Joint Clinic, Docket No. 453-02-0978.M4. Three other exhibits were admitted: a synopsis of a Commission Appeals Panel decision, discovery propounded to the Commission, and the SOAH Decision and Order in Docket No. 453-01-2689.M5. For purposes of writing this Decision and Order, only the two MRD records and the SOAH decision were considered.

Claimants in both cases sustained compensable injuries. One claimant was treated by Waco Ortho Rehab, and the other was treated by The Back and Joint Clinic. When Petitioner denied certain reimbursement requests, both Respondents sought review from MRD, and MRD ordered some additional payments.[2]

Based on this record, the ALJ concludes that the petition should be denied, and that the Petitioner should be required to reimburse Waco Ortho Rehab 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, however, the ALJ concludes the Petitioner failed to show that the services provided were not medically necessary. With respect to the primary dispute, the ALJ finds that the two-hour time limit for physical medicine sessions set forth in Section I.A.10.a of the TWCC Medicine Ground Rules (28 Tex. Admin. Code §134.201) 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.[3]

III. FINDINGS OF FACT

  1. On_____, Claimant ___suffered a compensable injury.
  2. At the time Claimant___ was injured, the employer had worker’s compensation insurance through the State Office of Risk Management (Petitioner).
  3. Claimant ___ was treated for the compensable injury by The Back and Joint Clinic (Respondent).
  4. On___, Claimant ___suffered a compensable injury.
  5. At the time Claimant___ was injured, the employer had workers’ compensation insurance through Petitioner.
  6. Claimant ___was treated for the compensable injury by Waco Ortho Rehab (Respondent).
  7. After Petitioner declined payment requests from Respondents for certain physical medicine treatments provided, Respondents sought resolution from the Texas Workers’ Compensation Commission’s Medical Review Division (MRD).
  8. MRD ordered Petitioner to pay additional amounts, and Petitioner did not dispute some payments. However, Petitioner timely appealed MRD’s decisions pertaining to $482.00 to Waco Ortho Rehab, and $533.00 to The Back and Joint Clinic.
  9. At least ten days prior to the hearing, all parties received a hearing notice and a Statement of Matters Asserted.
  10. On certain service dates, Waco Ortho Rehab billed for timed service modalities that totaled two hours and then billed for untimed codes that are within the definition of “physical medicine session”set out in Section I.A.10.a of the Medicine Ground Rules, 28 Tex. Admin. Code (TAC) §134.201.
  11. The additional amounts billed were not shown to have been unreasonable or unnecessary.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) 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 hearing notice and Statement of Matters Asserted issued by the Commission’s staff conformed to the requirements of Tex. Gov’t Code §2001.052, in that they 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 Petitioner had the burden of proving by a preponderance of the evidence that it should prevail in this matter. 28 TAC §148.21(h).
  5. Considering the ambiguity of Section I.A.10.a in the context of the Medicine Ground Rules and the practical problems with incorporating untimed modalities into the two-hour limit, the Petitioner has not shown that Respondents’ billings violated that section.
  6. The Petitioner failed to establish that the treatment provided to the Claimant was not reasonably required. Tex. Labor Code Ann. §408.021.
  7. Waco Ortho Rehab should be reimbursed $482.00 for medical services provided to workers’ compensation claimant___.
  8. The Back and Joint Clinic should be reimbursed $533.00 for medical services provided to workers’ compensation ____.

ORDER

IT IS THEREFORE, ORDERED that Petitioner, the State Office of Risk Management, shall reimburse Respondent Waco Ortho Rehab $482.00, and The Back and Joint Clinic $533.00 for the services that are the subject of this dispute.

Issued June 27, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Sarah G. Ramos
Administrative Law Judge

  1. 1Docket No. 453-02-0978.M4 was consolidated into this docket.
  2. 2 Respondents did not appeal the MRD's decision.
  3. 3The ALJ concurs with the reasoning in Decisions and Orders issued in Docket Nos. 453-01-2175.M4 and 453-01-2689.M5. The ambiguity of Section I.A.10.a. and the practical difficulty posed by the fact that providers are not required to keep track of time spent on untimed procedures militate in favor of excluding untimed procedures from the two-hour limitation.
End of Document
Top