DECISION AND ORDER

This case is a dispute over whether reimbursement is appropriate. F. C.(Claimant) sustained a compensable injury on (date of injury). On January 11, 2001, Lois M. Hansen, MA, LPC, (Provider) rendered medical services to Claimant. Provider billed the University of Texas System (Carrier) for the medical service rendered. Carrier reimbursed an amount it deemed reasonable. Provider seeks additional reimbursement. The amount in controversy is $350.00.

The Administrative Law Judge (ALJ) concludes the Provider is entitled to a total of $350.00 in additional reimbursement.

I.

DISCUSSION

A.Background Facts

On (date of injury), Claimant F.C., while working as a nurse in a prison, sustained a compensable injury while taking care of a paraplegic inmate. She immediately was seen by her family doctor, Ray Perez, M.D. Subsequently, she came under the care of William Langeland, D.C. During her care, Dr. Langeland referred Claimant to Jim Cain, M.D., for a lumbar MRI which was performed on November 29, 2000. As part of her treatment and evaluation, Claimant was then referred to Stephen Esses, M.D., who examined Claimant and forwarded his findings to Dr. Langleland on January 4, 2001. Finally, Claimant was referred to Lois M. Hansen, M.A., L.P.C., for a psychosocial evaluation which was performed on January 11, 2001. On that same date, Provider interviewed Claimant, reviewed Claimant’s medical records and prepared a psychosocial evaluation report of Claimant. Provider billed Carrier a total amount of $800.00 for the above mentioned services. Carrier reimbursed Provider $450.00. Provider filed a request for Medical Dispute Resolution (MDR) with the Medical Review Division (MRD). The MRD held Provider was entitled to additional reimbursement in the amount of $350.00. Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).

B. Applicable Law

The Texas Labor Code contains the Texas Workers= Compensation Act (the AAct) 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.

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The Texas Administrative Code addresses the relevant statutory requirements for conducting and billing for services related to mental health, specifically psychosocial evaluations. In particular, 28 Tex. Admin. Code ‘134.1000(f) provides:

(f) Ground Rules.

(5) CPT Codes. The Texas Workers’ Compensation Commission identifies the five digit numeric codes obtained from the Physician’s Current Procedural Terminology, Fourth Edition, Copyright September 1993, for reporting medical services and procedures.

(A) The CPT codes for initial mental health services may include:

(Office Visit series 99201-99205 (new patients) and 99211- 99215 (established patients);

(ii) Consultation codes 99241-99245, or 99271-99275;

(iii) CPT code 90801 for initial office visit psychiatric diagnostic interview examination including history, this code will be reimbursed at hourly increments up to three hours. Interviews exceeding this three hour timeframe will require documentation to substantiate the length of service; and

(iv) CPT code 90825 for review of records.

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28 Tex. Admin. Code ‘134.1000(g) goes on to include:

(g) Assessment/Evaluation of Mental Disorders.

(4) Documentation Requirements for Assessment/Evaluation. As part of the assessment/evaluation of the patient by the Qualified Mental Health Provider, a report must be prepared containing enough information to document the level of assessment provided. This report must include:

1. (A)reason for referral;
2. (B)history of present injury;
3. (C)past medical history and treatment;
4. (D)past assessment and treatment of pre-existing mental disorders;
5. (E)past and present substance abuse history, if any;
6. (F)current and past medication;
7. (G)history of head injury or other neuropsychological insult, past or present;
8. (H)social history including pertinent family, educational, vocational information, etc;
9. (I)current factors and/or significant lifestyle changes contributing to symptomatology which are injury related (see subsection (f)(8) of this section);
10. (J)factors and/or significant lifestyle changes, contributing to symptomatology which are non-injury related (the period of time reviewed should include the six months preceding the injury and the two years prior to the date of the current evaluation);
11. (K)present mental/emotional symptoms, including clinically pertinent elements of a mental status exam (see appendix E in subsection (n) of this section);
12. (L)results of any psychological, cognitive, pain/disability, or neuropsychological testing administered;
13. (M)ICD-9-CM diagnosis;
14. (N)Global Assessment of Functioning/Psychosocial Stressor Scale Score;
15. (O)details of a causal link of present mental/emotional status to the compensable injury (a clear statement regarding whether or not the injury has caused or exacerbated a diagnosable mental disorder and how the mental diagnosis is injury related) (refer to subsection (f)(1) and (8) of this section);
16. (P)a problem list comprised of a behavioral description of the diagnosis and/or the problem(s) identified during the assessment/evaluation;
17. (Q)the rationale or justification for initiating, continuing, changing, modifying or discontinuing treatment based on:
    1. a statement on how treatment is likely to have a detectable positive effect on the patient’s overall condition, course of recovery (see subsections (c)(1)(A)(i) and (f)(1) and (4) of this section and subparagraphs (O) and (P) of this paragraph);
    2. ability to participate in and benefit from treatment; or
    3. ability to return to/retain employment;
18. (R) goals/termination criteria of treatment (see Ground Rules, subsection (f)(7) of this section); and
19. (S)a plan of treatment, including:
    1. type of intervention/treatment modality;

    (ii)frequency of treatment;

    (iii)expected duration of treatment;

    2. (iv)expected clinical response to treatment; and
20. (5)specification of a re-evaluation timeframe.

C. Analysis

As part of her treatment, Dr. Langeland, Claimant’s treating doctor, referred Claimant to Provider for an evaluation. Provider conducted an extensive interview with Claimant and reviewed Claimant’s medical records. Claimant’s injury occurred on and the interview was done on January 11, 2001. Less than two months had elapsed since the injury so there were not many medical records generated at the time of the interview. Provider reported her findings in a report dated January 11, 2001, and forwarded the report to Dr. Langeland as requested.

Carrier reimbursed Provider for the time spent interviewing Claimant but denied reimbursement for review of records and drafting the evaluation report. Provider billed Carrier $450 under CPT code 90801 for the initial interview of Claimant. Carrier paid this amount in full. However, Carrier asserts Provider could have conducted the interview, reviewed the medical records and drafted a brief report within the time it took to interview the Claimant. Carrier bases this assertion on the fact that there were not many records to review because most of Claimant’s medical history was presented by Claimant herself.

Provider billed Crrier $120.00 under CPT code 90825 for review of records. While it may be true that the record does not contain voluminous amounts of medical records, Provider asserts it reviewed not only the medical records on file but all other Aaccumulative data. Although the accumulative data was not pointed out, the record does indicate Provider reviewed reports of Dr. Langeland, an MRI report from Dr. Cain, and a medical evaluation from Dr. Esses. Provider additionally asserts it did not, nor would it have been proper to, review this material during the initial interview with Claimant. Indeed, during the interview Provider must have drafted notes or recorded other data to be used in substantiating her findings. This material can likely be considered accumulative data.

Provider billed Carrier $230.00 under CPT code 90889 for preparation of her report on Claimant. Carrier simply believes there was no basis for Provider’s report because there was little or no review of medical records, no psychological testing, and no verification of Claimant’s medical history. Most of Claimant’s medical history was discovered by Provider by what Claimant told Provider during the initial interview. Provider did not verify any of Claimant’s medical history that could not be verified by reading the material from Drs. Langleland, Cain, and Esses. Carrier believes that since Claimant’s medical history was not verified, it should serve as no real basis for forming an evaluation of Claimant. Carrier further argues the subjective nature of Claimant’s medical history and present condition are less reliable than objective findings made by Claimant’s past treating doctors or providers. Again, since there is very little verifiable background information on Claimant, the report itself is questionable as to its quality and reliability. The Carrier further argues Provider’s report is little more than a reiteration of Dr. Esses report of January 4, 2001.

Although somewhat compelling, this information should be looked at closely by Claimant’s treating doctor in determining a treatment plan for Claimant. Carrier’s arguments attack the quality of Provider’s report but do not accurately point to any reason(s) why Provider is not entitled to reimbursement. So long as all necessary elements under 28 Tex. Admin. Code ‘134.1000(g)(4) are included in the evaluation report, a provider who drafts the report is entitled to reimbursement. The report itself indicates Claimant’s medical history was largely self-reported and unverified, but this is information to be used by the treating doctor in assessing treatment. The fact that Provider did not verify Claimant’s medical history should not alone prevent reimbursement of Provider’s services. A brief review of the report and the rule reveals the evaluation report substantially complies with the rule. Since no other deficiencies of the report were addressed, the Carrier should reimburse the Provider for drafting the report.

II.

FINDINGS OF FACT

1. Claimant, suffered a compensable injury on (date of injury).
2. Claimant was first seen by her family doctor, Ray Perez, M.D.
3. Claimant was then referred to William Langeland, M.D., who became her treating doctor.
4. Dr. Langeland referred Claimant to Jim Cain, M.D., for an MRI examination, which was performed on November 29, 2000.
5. Claimant was referred to Stephen Esses, M.D., for a medical examination, which was performed on January 4, 2001.
6. Dr. Langeland referred Claimant to Lois M. Hansen, M.A., L.P.C. (Provider), for a psychosocial evaluation, which was performed on January 11, 2001.
7. As part of the evaluation, Provider interviewed Claimant, reviewed Claimant’s medical records, and drafted a report of her findings.
8. For the interview portion of the evaluation, Provider billed the University of Texas System (Carrier) $450.00 under CPT code 90801.
9. For the records review portion of the evaluation, Provider billed Carrier $120.00 under CPT code 90825.
10. For drafting a report of her findings, Provider billed Carrier $230.00 under CPT code 90889.
11. For CPT codes 90801, 90825, and 90889, which were all performed on January 11, 2001, Provider billed Carrier a total of $800.00.
12. Carrier reimbursed Provider $450.00 for CPT code 90801 only.
13. Carrier denied additional reimbursement to Provider for CPT codes 90825 and 90889 claiming Provider could have performed all three tasks in the same amount of time it took to complete code 90801.
14. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers= Compensation Commission (the Commission), seeking additional reimbursement for the CPT codes it performed on January 11, 2001.
15. On May 18, 2001, the Commission’s Medical Review Decision (MRD) found Provider was entitled to additional reimbursement of $350.00.
16. Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
17. Notice of the hearing was sent March 27, 2002.
18. 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.
19. The hearing was held April 30, 2002, with ALJ Steven M. Rivas presiding and representatives of the Carrier, and Provider participating. The hearing was adjourned the same day.
20. Provider reviewed medical records of Claimant and properly billed for this service under CPT code 90825.
21. Provider drafted an evaluation report of her findings and properly billed for this service under CPT code 90889.

III.

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 Carrier, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code ‘ 148.21(h). Carrier failed to prove that the Provider was not entitled to additional reimbursement of $350.00.
5. Pursuant to the foregoing Findings of Facts and Conclusions of Law, Provider is entitled to additional reimbursement for the services rendered to Claimant on January 11, 2001.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Lois M. Hansen, M.A., L.P.C., is entitled to additional reimbursement of $350.00 from the Carrier, the University of Texas System, for the services rendered to Claimant on January 11, 2001.

Signed this 27^th day of June, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge