DECISION AND ORDER
Accidental Injury Treatment Center (Petitioner) appealed the findings and decision of the Texas Workers’Compensation Commission’s (Commission) Medical Review Division (MRD) in MDR Docket No. M5-00-0614-01, which denied reimbursement for paravertebral injections and office visits provided J.D. (Claimant). The MRD decision, issued June 1, 2001, upheld the denial of reimbursement by the Texas Workers’ Compensation Insurance Fund (Carrier-now the Texas Mutual Insurance Company) on the basis the services were not medically necessary and were billed inappropriately. This decision finds Petitioner is not entitled to reimbursement.
I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY
There were no contested issues of jurisdiction, notice or venue. Therefore, those matters are addressed in the findings of fact and conclusions of law without further discussion here.
The hearing in this matter convened and closed June 27, 2002, at the State Office of Administrative Hearings, 300 W. 15th Street, Austin, Texas, with Administrative Law Judge (ALJ) Ann Landeros presiding. At the beginning of the hearing, Dr. Dareld Morris appeared telephonically on behalf of Petitioner. Before the evidentiary portion of the hearing started, Dr. Morris announced he was not going to participate in the hearing and he was going to hang up the telephone, which he subsequently did. By disconnecting the telephone, Dr. Morris waived Petitioner’s appearance, and Petitioner thus failed to prosecute its claim.
After Dr. Morris hung up, Katie Kidd, Carrier’s counsel asked to be allowed to present its case. The ALJ then received evidence and argument from Carrier. The Commission did not participate in the hearing.
A. Background Facts
In_________, Claimant sustained injuries to Claimant’s neck and right shoulder that were compensable under the Texas Workers’ Compensation Act (Act). At the time of the compensable injury, Claimant’s employer had workers’ compensation insurance coverage with Carrier. In February 1998, Claimant began treatment with Dr. Morris at Petitioner’s facility. Dr. Morris administered what he described as “paravertebral injections” to Claimant on March 16, April 13, May 11, June 8, and June 29, 1999. Carrier declined to reimburse for these injections and the contemporaneous office visits, asserting that the services were not medically necessary and were billed under the wrong code. Carrier argued that, as described in the supporting documentation provided by Dr. Morris, the injections were not “paravertebral” and should not have been billed as such. Further, Carrier asserted that the separate billing of the injections was improper, as the procedure was global to the office visits billed contemporaneously. The MRD found the services were not medically necessary.
At the hearing, Carrier had admitted into evidence the certified record of the MRD decision (Exh. 1), then presented the expert testimony of Dr. Robert Joyner, M.D. Dr. Joyner is board certified in both pain management and anesthesiology. He has practiced in pain management since 1985 and his practice includes treatment of workers’ compensation patients. He has also served as a designated doctor for workers’ compensation patients. Based on his training, experience, and knowledge, and his review of the MRD record in this case, Dr. Joyner found that not only were paravertebral injections not medically necessary health care for Claimant’s compensable injury, but also that Dr. Morris had not actually provided the billed services.
In his medical records, Dr. Morris described injections into the muscle, which would have been trigger point injections, not paravertebral. Dr. Morris’ records showed that the type of needle used for the injections was too short to penetrate the foramen as is required to be paravertebral. Dr. Morris did not appear to use a fluoroscopic guide. Prudent medical practice requires the use of such a guide in post-laminectomy patients so the physician can tell where the medicine is going. Dr. Morris’s palpation of the area where the injection occurred also indicated that the injections were trigger point, not paravertebral, injections. Dr. Joyner noted that, based on Claimant’s symptoms, even had the injections been paravertebral, they would not have been appropriate medical care. And even had paravertebral injections been appropriate, Dr. Morris administered the injections too frequently, especially in light of their failure to relieve Claimant’s pain.
Dr. Joyner noted that the CPT code Dr. Morris used for the disputed treatment is actually for “paravertebral nerve blocks.” CPT code 64440 is used for an injection on a single nerve. CPT code 64441 is used to bill injections of multiple nerves during the same office visit. For multiple injections during one office visit, Dr. Morris improperly billed multiples of CPT code 64440, rather than one instance of 64441.
Dr. Joyner also found that Dr. Morris also improperly billed the office visits under CPT code 99214. That CPT code requires documentation of a higher level of service than Dr. Morris provided. To support a bill under CPT code 99214, the physician had to perform a detailed examination of six organ systems and the musculoskeletal system and to make complex medical decisions. Dr. Morris failed to document he did any of these tasks. Dr. Morris also failed to document why the services billed with the A-22" modifier were unusual services. Finally, the medical records did not show any improvement or relief to Claimant after the injections that would justify repeated injections. Dr. Joyner testified that because of the possibility of serious complications from trigger point injections (infection, nerve root damage, joint necrosis), repeated injections without noticeable pain relief are contraindicated.
Petitioner had the burden of proof in this matter. 28 TAC §§ 148.21(h) and (i). Pursuant to the Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. § 408.021(a). Health care includes all reasonable and necessary medical services including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. § 401.011(31).
Because its representative declined to participate in the hearing, Petitioner forfeited its opportunity to meet its burden of proof. Further, the evidence presented proved Petitioner’s bills were inaccurate and the services provided were not medically necessary. Dr. Joyner’s testimony was persuasive. Dr. Morris did not perform the “paravertebral” injections that Petitioner billed. Petitioner not only billed for the wrong type of injection, it improperly billed for multiple injections on one office visit under a CPT code that was to be used only for single injections during an office visit. Not only were Petitioner’s billings of the injections incorrect, it also billed the incorrect CPT code for the office visits. Dr. Morris also failed to document that either the injections or the office visits constituted either unusual services or involved a high level of medical decision making based on extensive physical examinations of Claimant. Finally, Petitioner failed to show that the injections, whatever their nature, or the office visits during which they were administered, were medically necessary healthcare. There was no evidence that Claimant benefitted f rom the injections or that they tended to cure or relieve the naturally occurring effects of the compensable injury.
Petitioner is not entitled to reimbursement for its billings for paravertebral injections or office visits for Claimant.
III. FINDINGS OF FACT
- In________, Claimant sustained an injury to his neck and right shoulder that was compensable under the Texas Workers’ Compensation Act (Act).
- At the time of Claimant’s compensable injury, Texas Workers’ Compensation Insurance Fund (Carrier) was the workers’ compensation insurer for Claimant’s employer.
- From March to June 1999, Claimant was receiving chiropractic care from Dr. Dareld Morris, D.C., at Accident Injury Treatment Center (Petitioner) for ongoing pain.
- Dr. Morris administered injections to Claimant during office visits that occurred March 16, April 13, May 11, June 8, and June 29, 1999.
- Dr. Morris administered multiple injections during each office visit.
- The injections were intramuscular and done with a needle that was too short to reach the foramen.
- Paravertebral injections must be done with a needle that can reach the foramen.
- Paravertebral injections should only be done using a fluoroscopic guide.
- Dr. Morris did not use a fluoroscopic guide during the injections.
- The injections did not cure or provide noticeable pain relief to Claimant.
- The injections involved risk of infection and other medical complications.
- Because they did not cure or relieve Claimant’s pain, the injections should not have been repeated.
- Petitioner billed for the injections described in Finding of Fact No. 4 under CPT code 64440, which is the code for a single paravertebral injection.
- Petitioner billed multiple instances of CPT code 64440 for each office visit.
- CPT code 64441 is the proper code for multiple paravertebral injections administered during a single office visit.
- Petitioner billed the office visits listed in Finding of Fact No. 4 under CPT code 99214.
- CPT code 99214 is for office visits involving complex medical decisions, which should include examinations of multiple organ systems and the musculoskeletal system.
- Dr. Morris did not document making complex medical decisions or examining multiple organ systems or the musculoskeletal system during his office visits with Claimant.
- Petitioner appealed the decision of the Texas Workers’ Compensation Commission's Medical Review Division, which upheld Carrier’s denial of reimbursement for the injections and the office visits.
- Pursuant to the notice of hearing sent by the Commission, Petitioner’s representative, Dr. Dareld Morris, appeared telephonically at the hearing held June 27, 2002, but then announced he was refusing to participate in the hearing and hung up the telephone before the evidentiary portion of the hearing began.
- When Dr. Morris hung up, Petitioner forfeited its opportunity to participate in the hearing.
- Carrier’s representative chose to participate in the hearing and presented evidence.
IV. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers' Compensation Act (Act), TEX. LABOR CODE ANN. § 413.031.
- 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 §413.031(d) of the Act and TEX. GOV'T CODE ANN. ch. 2003.
- The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV'T CODE ANN. ch. 2001 and the Commission’s rules, 28 TEX.ADMIN.CODE (TAC) § 133.305(g).
- Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§ 2001.051 and 2001.052.
- Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i).
- Pursuant to the Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. § 408.021(a).
- Health care includes all reasonable and necessary medical services, including a medical
- appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A). A medical benefit is a
- payment for health care reasonably required by the nature of the compensable injury.
- TEX. LAB. CODE ANN. § 401.011(31).
- Petitioner failed to prove that the injections administered Claimant by Dr. Dareld Morris on March 16, April 13, May 11, June 8, and June 29, 1999, were medically necessary healthcare for Claimant.
- Petitioner failed to prove that Claimant’s office visits with Dr. Morris were properly billed under CPT code 99214 or were medically necessary healthcare.
- Petitioner is not entitled to reimbursement for either the injections or the office visits billed to Carrier for Claimant.
IT IS ORDERED that Petitioner, Accidental Injury Treatment Center, P.A., is not entitled to reimbursement for injections or office visits provided Claimant on March 16, April 13, May 11, June 8, and June 29, 1999.
Signed this 7th day of August, 2002.
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- Prior to Dr. Morris’ quitting the hearing, the parties stipulated on the record that the compensable injury did not include Claimant’s thoracic back. That stipulation was accepted by the ALJ.↑