DECISION AND ORDER
Twin City Fire Insurance Company (Carrier) sought review of two decisions by the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (Commission) ordering it to reimburse Billing R Us (Respondent) for anesthesia services that Dr. Sherolyn Simmons (Provider) performed for N.W. (Claimant) on May 9 and 15, 2000. The MRD concluded the Provider had documented a level of service higher than that reimbursed by the Carrier, but also had billed more than allowed by agency rules for both dates of service. The MRD ordered the Carrier to make some additional payment to the Provider. Based on the evidence, the Administrative Law Judge (Judge) concluded that the Carrier failed to carry its burden of proof to demonstrate that the MRD erred, and should reimburse the Respondent $520.00 for the two dates of service.
The hearing was held on May 2, 2002, and the record closed that day.
II. Factual Background
Claimant underwent cervical epidural steroid injections on May 9 and 15, 2000; Dr. Simmons provided intravenous sedation during Claimant's treatment on both dates. Dr. Simmons is a medical doctor and an anesthesiologist. Claimant had injured her neck on (date of injury) at her job. The Carrier did not dispute that the injections were appropriate, compensable treatment, or, that intravenous sedation was medically necessary to administer the injections to Claimant. The Carrier did not dispute that Dr. Simmons provided a half hour of service at each injection. Rather, the Carrier asserted that the Provider had failed to document the level of service for which she had billed, using an incorrect CPT code to describe it. The Carrier argued that the amounts it reimbursed the Provider B $240.00 for one injection session, and $200.00 for the second B were commensurate with the type of service provided to Claimant. The Provider had billed $1,050.00 for each session. Respondent argued that the Carrier had misapplied the fee guidelines and had denied payment on grounds inconsistent with the treatment codes billed.
The MRD ordered the Crrier to reimburse Respondent an additional $240.00 for one session and an additional $280.00 for the second session. (TWCC Exhs. 1, Pp. 1-4 and 2, Pp. 1-4). In reaching its conclusion, the MRD applied the Anesthesia Ground Rules. Medical Fee Guideline (MFG) 28 Tex. Admin. Code (TAC) '134.201 (Eff. date April 1, 1996), Pp. 193-202. Those guidelines state that the amount due for anesthesia services is determined by totaling Aunits of service, then applying a per-unit dollar amount to the total number of units to get the maximum reimbursement allowed. The unit total combines elements of time and relative value units (RVU), which are based on the type of service, type of patient, and difficulty of the service provided. The MRD concluded the Provider in this case had, on each date of service, documented that she provided two units of service time, a half hour, plus 10 RVU units for the type of the procedure billed. The Provider described her service as Aanesthesia for procedures on cervical spine and cord, not otherwise specified. (CPT Code 00600). As the per-unit multiplier is $40.00 when an anesthesiologist performs the service, the MRD concluded the Carrier should reimburse Dr. Simmons a total of $480.00 for each of two 12-unit sessions of service that she performed.
For its prt, the Carrier contended that the Provider billed under an incorrect code, asserting that CPT Code 00600 applies only to services in aid of surgery, rather than in aid of the less-invasive steroidal injections. In denying the claim, the Carrier contended that the Provider should have billed her service under CPT Code 01999, which is described as an Aunlisted anesthesia procedure, requiring documentation of procedure to justify payment. Using CPT Code 01999, intravenous sedation for injections would be reimbursable at a difficult level of three RVUs, plus time units, resulting in a maximum reimbursement of $240.00 in this case. In support of its position, the Carrier offered an excerpt from the February 1994 edition of the TWCC Problem Solver, a newsletter circulated to Amedical associations whose members process workers= compensation claims. (Pet. Exh. 1). That newsletter states that, in 1994, anesthesia for injections should be billed as Atime only because the injections are a Asurface procedure. Even assuming this publication was an authoritative statement of agency policy, this advice was issued approximately two years before the MFG applicable to this dispute was enacted. The current MFG was adopted effective April 1, 1996. The Carrier presented no evidence to show that the agency now considers anything issued prior to the most current MFG to be authoritative, or has applied the interpretation it issued in 1994 to cases arising after the current MFG was published. Further, the Judge was unable to discern any reference in the current Anesthesia Ground Rules to the distinction made in 1994 between Ainvasive and Asurface procedures. The MRD did not apply or evaluate that distinction. Both these circumstances further suggest this distinction was not carried over intact into the Anesthesia Ground Rules in the 1996 MFG. In this case, the Provider had argued to the MRD that the current Anesthesia Ground Rules focus on the body part treated, rather than the type of procedure, and noted that there is no specific instruction on coding sedation performed in connection with a spinal steroid injection.
fter reviewing those rules, the ALJ is persuaded that the MRD correctly applied the Anesthesia Ground Rules to this case. The ground rules do not contain a specific instruction or limitation on the type of sedation appropriate to spinal injections, nor is there anything in the Ground Rules that suggest that a Provider must use CPT Code 01999 exclusively when providing anesthesia for an injection. The description attached to CPT Code 00600 references only Aa procedure, and does not specify that procedure must be surgical. Further the general information section of the Anesthesia Ground Rules, MFG at P. 193, does not limit care to surgery:
Anesthesia care may include but is not limited to general, regional, or monitored anesthesia care, supplementation of local anesthesia, or other supportive services in order to afford the patient the anesthesia care deemed optimal by the anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) during any procedure. (Emphasis supplied).
Further, the Provider supplied no evidence that would support the use of risk factors above the normal 10 RVU level for the type of service billed.
The MRD's computation of amounts due under the Anesthesia Ground Rules was accurate, and the Provider should be reimbursed as set out in the MRD's orders regarding these two dates of service.
III. Findings of Fact
- On_________, N.T. (Claimant) injured her neck at her place of employment. Treatment for that injury was compensable under the Tex. Labor Code ' 413.015 (the Act).
- On May 9 and 15, 2000, Claimant's physician administered cervical epidural steroid injections to Claimant to treat her neck injury. Sedation of Claimant during these injections was medically necessary to treat Claimant's compensable injury, within the meaning of the Act.
- Dr. Sherolyn Simmons (Provider) administered intravenous sedation to Claimant on May 9 and 15, 2000, in support of the administration of the cervical steroid injections. Dr. Simmons is a medical doctor and an anesthesiologist.
- The Provider used CPT Code 00600 to bill for the anesthesia services she provided to Claimant in connection with the administration of cervical epidural steroid injections on both dates of service. The standard valuation of this service, expressed in relative value units (RVU), is 10 RVU. On each date of service, the Provider provided anesthesia services for half an hour. Half an hour of service represents two billable units of service.
- The Provider did not document any special circumstances that would support reimbursement to her at a rate in excess of the maximum allowable recovery amounts set forth in the Anesthesia Ground Rules, Medical Fee Guideline (MFG), 28 TAC '134.20, for normal cervical procedures (CPT Code 00600).
- The Provider billed $1,050.00 for each of two dates of service. The maximum amount payable for a standard 12-unit service session rendered by an anesthesiologist would be $480.00, under the terms of the Anesthesia Ground Rules, MFG.
- The Carrier reimbursed the Provider $200.00 for services she had rendered on May 9, 2000, and reimbursed the Provider $240.00 for services she rendered on May 15, 2001.
- The Provider appealed the Carrier's denial of benefits for both dates of service to the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (TWCC).
- In June 11, 2001, the MRD ordered the Carrier to reimburse the Provider an additional $280.00 for services she rendered on May 9, 2000. On June 12, 2001, the MRD ordered the Carrier to reimburse the Provider an additional $240.00 for services she rendered on May 15, 2000.
- The Carrier filed timely requests for a hearing at the State Office of Administrative Hearings (SOAH) on both MRD decisions.
- On July 25, 2001, the Commission issued a notice of hearing which included the date, time, and location of the hearing, and the applicable statutes under which the hearing would be conducted. The notice stated additional facts on the nature of the matters asserted would be issued within 10 days of the hearing. The Commission timely filed statements of matters asserted, and consolidated the two cases for hearing.
- SOAH Administrative Law Judge Cassandra Church convened a hearing on May 2, 2002, and the record closed on that date.
- Respondent is entitled to receive any reimbursement the Carrier may be ordered to make for Provider's services performed on May 9 and May 15, 2000.
IV. Conclusions of Law
- The Texas Workers= Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code ' 413.031.
- SOAH 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.
- The notice of hearing issued by the Commission 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.
- The petitioning party, Twin City Insurance Company (Carrier), has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code ' 413.031.
- The Carrier failed to meet its burden of proof to show that the MRD had incorrectly applied the applicable provisions of the Medical Fee Guideline (MFG) 28 Tex. Admin. Code (TAC) '134.20, specifically, the Anesthesia Ground Rules.
- Under ' 413.015 of the Act, the intravenous anesthesia services provided by the Provider on May 9 and 15, 2000, were medically necessary to aid in treatment of Claimant's compensable neck injury, and should be compensated at the rate provided in the MFG, Anesthesia Ground Rules, for anesthesia in aid of cervical procedures.
IT IS HEREBY ORDERED that Twin City Fire Insurance Company reimburse Billing R Us in the amount of $520.00 for the medical services performed for Claimant by Dr. Sherolyn Simmons on May 9 and 15, 2000.
Signed June 28, 2002.
STATE OFFICE OF ADMINISTRATIVE HEARINGS
CASSANDRA J. CHURCH
Administrative Law Judge
- Reltive value units (RVUs) are a means widely used in medical service compensation to quantify the value and level of services that a medical provider performs. The source of the RVUs, which appear in the Anesthesia Ground Rules, is not listed, although the MFG introduction refers to a number of possible sources, i.e., the CPT/HCPCS, the ICD-9-CM and the Aglobal service surgery guidelines. MFG, P. iv, ATWCC and the Importance of Proper Coding.↑
- The Provider had also billed for two Arisk unitsof service in connection with each injection, which, if approved, would have made the total service units 14. However, as neither MRD decision evaluated the record in regard to the risk units, and the Provider did not pursue her own appeal of the MRD's action, the Judge concludes the Provider had abandoned her claim in regard to those service units.↑
- The ALJ notes that the Carrier denied the claim for the May 9, 2000, date of service for the reason set forth above. However, the Carrier denied the claim for the May 15, 2000, date of service on the basis that the service was not billed under any anesthesia code and did not have time unit information. (TWCC Exh. 2, P. 14). The former reason appears to be misapplied in that CPT Code 00600 is an anesthesia code, and the Provider cured the lack of detail by a later submission. However, in dialog with the provider after its initial denial, the Carrier apparently clarified the nature of its objections. (TWCC Exh. 1, Pp. 8-12).↑
- The Carrier also submitted as authority the Decision in SOAH Docket No. 453-99-2324.M5. The Judge in that case concluded that monitored anesthesia care was not, under the facts in that case, shown to have been medically necessary. However, that case does not control the outcome here as the Carrier here did not put medical necessity in issue. Further, there is virtually no medical evidence in this case regarding Claimant's medical condition before, after, or during the course of injections.↑