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At a Glance:
Title:
453-01-3777-m4
Date:
April 25, 2003
Status:
Medical Fees

453-01-3777-m4

April 25, 2003

DECISION AND ORDER

Reliance National Indemnity Company[1] (Petitioner or Carrier) has appealed two Findings and Decisions of the Texas Workers' Compensation Commission's (Commission) Medical Review Division (MRD), both of which were issued July 5, 2001. Therein, the MRD ordered the Carrier to reimburse Billing R Us an additional $520 for anesthesia services provided by Dr. Sherolyn Simmons, M.D., P.A. (Provider) to the injured worker (Claimant). For the reasons detailed below, this Decision concludes the appropriate amount of additional reimbursement owed to the Provider is $360 for the services rendered on May 30 and June 6, 2000.

The hearing was convened on August 15, 2002, at the State Office of Administrative Hearings' (SOAH) facilities in the William Clements Building, Fourth Floor, 300 West 15th Street, Austin, Texas. Petitioner appeared through its attorney, Steven M. Tipton. Respondent Billing R Us participated through its representative, Debi Martinez. The Commission did not participate in the hearing. The hearing adjourned, and the record closed upon receipt of closing arguments and responses September 10, 2002.

I. Notice and Jurisdiction

Because there were no contested issues regarding notice or jurisdiction those matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

II. BACKGROUND

Claimant suffered a compensable injury to his back on__________. Following this injury, Dr. Sherolyn Simmons provided professional anesthesia services in connection with the Claimant’s receipt of lumbar epidural steroid injections (ESI) on May 30 and June 6, 2000. Charges for these services were filed using Current Procedural Terminology (CPT)[2] Code 00630, which is one of several codes in the Anesthesia Ground Rules (AGR) that are used to describe procedures done in the area of the spine and spinal cord. According to the AGR, the total anesthesia value (TAV) for a procedure is determined by adding together: (1) the basic value, which is related to the complexity of the anesthesia service; (2) time units that correspond to the time spent by the provider in personal attendance on the patient (one "unit" equals one fifteen-minute segment of time); and (3) modifying units that relate to the patient's general physical status and/or whether the anesthesia service was provided under particularly difficult circumstances.[3] The total of these units is then multiplied by the monetary value assigned to the service provider as shown in the AGR. Relevant to this case, the monetary value established by the MFG for anesthesiologists is $40 per unit.[4]

For each of the two service dates at issue, the Provider calculated its charges using a TAV of twelve units comprised of: a basic relative value unit (RVU) of "8" assigned to CPT Code 00630, two time units based on the record of thirty minutes spent by Dr. Simmons to provide the anesthesia service, and two modifying units.[5] The Provider billed $900 for each service date or a total of $1800. The Carrier reimbursed the Provider $200 (five units) for the May 30 service and $240 (six units) for the June 6 service or a total of $440,[6] using denial codes F and M.[7] The Carrier’s TAV assumes a basic RVU of "3" and allows two units for time, but none for risks

When it could not resolve the difference in payments and charges, the Provider filed a request for medical dispute resolution on May 22, 2001.[8] The MRD found that general anesthesia was administered and billed in accordance with the MFG. Using the Provider’s TAV of twelve units, the MRD determined the appropriate reimbursement for each service was $480 (12 units x $40) or a total of $960. Together, the MRD's two orders require the Carrier to reimburse the Provider an additional $520, i.e., $960 less the $440 earlier reimbursed, covering both dates of service. The Carrier filed a request for a hearing and appeal of the MRD's orders on July 19, 2001.

III. ARGUMENT and Evidence

A. Carrier

When asked to identify specific points of error on appeal, the Carrier responded that the MRD: (1) failed to require the Provider to document the appropriateness of the level of treatment/services rendered in this case; (2) failed to recognize Provider’s coding error, i.e., using Code 00630 rather than Code 01999 to bill for anesthesia given in connection with a lumbar ESI; and (3) failed to require documentation supporting the two additional modifying risk units. Concerning the last point, the Carrier specified that the Provider did not use the modifiers designated in the AGR and, according to the Provider’s own documentation in the Anesthesia Record, the Claimant is designated as an "ASA II," which translates to a "P2" with a "0" unit value under the AGR's physical status modifiers.[9]

In the hearing, the Carrier focused primarily on the issue of coding error, asserting that it is the type of underlying procedure, not the area of the body where the procedure is done, that determines the correct CPT code to use for billing purposes. The Carrier maintains that Code 00630 is for use when the anesthesia service is administered in connection with a more invasive underlying procedure in the spine and spinal cord area that does not have a specific code to describe it from among the anesthesia Spine and Spinal Cord codes. It contends that since the underlying ESI procedure in this case is not one of the more invasive spine area procedures associated with anesthesia codes 00600 - 00670, the appropriate billing code is CPT Code 01999 in the AGR’s "Other Procedures."[10] The Carrier insists that the facts in this case show that Code 01999, which has no maximum allowable reimbursable (MAR) and requires documentation of procedure (DOP) to justify payment, provides a more reasonable basic value that is realistically related to the complexity of the anesthesia service rendered.

The Carrier strongly disagrees with the Provider’s insistence that the phrase "not otherwise specified" in Code 00630[11] means anesthesia for any procedure done in the lumbar area, no matter how simple and non-invasive, is to be billed using Code 00630.[12] On the contrary, it insists that the Provider’s use of CPT Code 00630 as the default for anesthesia for any type of underlying procedure within the lumbar area renders CPT Code 01999 useless. In support of this position, it notes that each body area listed among the anesthesia CPT codes has at least one code that includes the phrase "not otherwise specified." The Carrier points out that if the Provider is correct then: (1) there is at least one default or "catch-all" code for every body area for any procedures performed within a body area that do not have a specific code and description; and (2) no procedures are left to fall within the AGR’s codes for "Other Procedures."

To demonstrate the illogic of the Provider's position in relation to the rest of the MFG, the Carrier points out that using Code 00630, which has an RVU of 8, puts administering anesthesia for the relatively simple non-invasive ESI procedure on par with the administration of anesthesia for more invasive surgeries such as a total hip replacement (CPT Code 01214 - 8 RVUs), a cesarean hysterectomy (CPT Code 00855 - 8 RVUs), and a radical amputation of the penis with bilateral inguinal and iliac lymphadenectomy (CPT Code 00936 - 8 RVUs). Moreover, adopting the Provider’s interpretation of how to use Code 00630 effectively assigns a higher value and complexity to administering anesthesia for an ESI than for such procedures as a total knee replacement (CPT Code 01492 - 7 RVUs), total ankle replacement (CPT Code 01486 - 7 RVUs), or any procedures done to the upper arm, elbow, forearm, wrist and hand (CPT codes 01700 - 01860).

The Carrier cites to additional evidence of the distinction between ESIs and the type of procedures contemplated under the Spine and Spinal Cord codes in the MFG's Surgical Ground Rules (SGR) that state ESIs "shall be billed using code 62289 only" and which provide a MAR value of $263 for this procedure.[13] In contrast, the Carrier points out those surgical procedures involving the spine and spinal cord have significantly greater MARs ranging from $3035 to $4046 under CPT codes 63001 - 63048.[14] The Carrier maintains that the significant difference between the MAR for ESIs and MARs for the more invasive spine and spinal cord surgical procedures demonstrates the distinct difference between the skill, severity of the medical problem, risk of patient, and risk of physician between ESIs and the other surgical procedures. Even more to the point, the Carrier notes that the record shows the underlying ESI procedures in this case took only fifteen minutes on May 30 and five minutes on June 6.[15]

Finally, the Carrier offers page 2 of the February 1994 TWCC Problem Solver, which addresses why certain claims filed under CPT Code 00630 were being returned with instruction to charge the claims under Code 01999.[16] The response states that: (1) the 00630 code is "only for invasive procedures" on the lumbar spine, not surface procedures, e.g., manipulation under anesthesia, facets, or trigger point injections; (2) surface procedures were paid as "time only" and IV sedation was the only anesthesia given; and (3) "general anesthesia" was to be reimbursed at the 8 RVU level due for invasive procedures. Recognizing that this problem solver is interpreting the use of codes in the 1991 MFG that is no longer in effect, the Carrier argues the problem solver’s advice is still relevant because there are no material changes between the 1991 and 1996 MFGs that invalidate this interpretation of how the 00630 and 01999 CPT codes are to be used.

B. Provider

The Provider argues that the applicable ground rules do not specify the use of or otherwise limit the provider to the exclusive use of Code 01999 when providing anesthesia for an injection and points out that anesthesia CPT codes are listed by the region of the body where the procedure was done - not by the technique used to administer anesthesia. Citing the portion of the AGR, which states that anesthesia care may include but is not limited to general, regional, or monitored anesthesia care (MAC), or other supportive services, the Provider asserts that it is the anesthesiologist who is designated to determine what form of anesthesia care is "optimal" for each patient during a procedure,[17] and the Carrier cannot substitute its judgment as to the appropriate technique in its efforts to reduce costs. Although the Carrier's second denial after reconsideration refers to the anesthesia service given as "IV sedation," the Provider points out that general anesthesia and MAC were administered to the patient.[18]

The Provider maintains the term "not otherwise specified" in Code 00630 is used to describe a procedure performed in the lumbar region that is not otherwise specifically described in codes 00630 - 00634, and disagrees with the Carrier’s characterization of Code 01999 as a "default" code for when the non-invasive underlying procedure has no specific code. The Provider contends Code 01999 is reserved for a procedure performed for which: (1) a specific body area is not listed among the CPT codes; and (2) no other code or category better describes the procedure, e.g. anesthesia given for an incision and draining of an abscess.

The Provider complains that the Carrier’s reliance on the 1994 TWCC problem-solver is misplaced because this document addresses the use of CPT codes under the 1991 MFG, which is no longer applicable. The Provider maintains it had never seen this document before the hearing, and that it was not among the materials formally issued by the TWCC to providers to assist them in billing as required under the Commission’s rules. Referring to the various literature[19] provided by the Carrier as examples of recent coding revisions that support its argument, the Provider first argues the revisions do not apply to the services rendered in this case and then notes even these most current versions do not contain a specific code for anesthesia for ESIs. Further, the Provider maintains that the Carrier's challenge to the correct coding in the hearing ignores the fact the Carrier used the wrong denial codes to explain its failure to reimburse. The Provider contends it was never informed prior to the hearing that payments were denied based on a perceived coding error and had no opportunity to address the Carrier's contention on that issue. The Provider did not address the question of risk associated with administering anesthesia to the Claimant in its argument or with evidence.

IV. ANALYSIS

Coding

According to the MFG, "accurate coding of services rendered is essential for proper reimbursement" and "[r]eimbursement for services is dependent on the accuracy of the coding and documentation." The importance of correct coding is also reflected in the Commission’s rules that specify a retrospective review of medical bills may include a review for the "accuracy of coding in relation to the medical record and reports."[20] The anesthesia CPT codes establish the basic value of the anesthesia service rendered, to which units for time spent and attendant risks may be added. In this case, the Provider contends the MFG allows it to determine the basic value of that service solely on the basis of the area of the body where the procedure is being performed and without regard for the nature or complexity of the underlying procedure that prompts the need for anesthesia. The Carrier argues that the more reasonable and logical reading of the MFG shows that the anesthesia CPT code used for billing should accurately reflect the complexity of the anesthesia service rendered and to do so requires consideration of the nature of the underlying procedure B the relative complexity or simplicity of which is reflected in the procedure’s own assigned MAR. Upon consideration of the Carrier’s detailed and thorough review of what is evident in the current provisions of the 1996 MFG and anesthesia CPT codes, the ALJ is persuaded that the MFG does not require or otherwise permit the automatic billing for anesthesia under Code 00630 without taking into account the underlying procedure and type of anesthesia service actually rendered.

First, to automatically assign a RVU of "8" to an anesthesia service solely because the underlying procedure was performed in the lumbar area ignores the AGR requirement that the basic value of the service is supposed to reflect the complexity of the anesthesia service rendered. Here, the evidence does not show that the underlying ESI procedures required a more complex level of anesthesia service as is suggested by the use of Code 00630 with its RVU of 8. Second, setting the basic value of the anesthesia service by looking only to the area of the body where the underlying procedure is performed and blindly ignoring the nature of that underlying procedure produces the incongruous result in this case where the maximum value of the underlying ESI[21] is $263, but the associated anesthesia service is calculated to be $480. Such a result is not reasonable and does not promote the efficient utilization of health care available to the injured worker.

The Provider is correct that the MFG does not specify the exclusive use of Code 01999 when providing anesthesia for an injection. Nonetheless, consideration of the great disparity between the MAR set for ESIs by the MFG and the MARs established for the various anesthesia codes and their corresponding underlying procedures leads the ALJ to conclude that CPT Code 01999 is the more appropriate code for anesthesia service when the underlying procedure is the generally simpler and non-invasive ESI. Although it has no presumed basic value as does Code 00630, using Code 01999 to bill for anesthesia administered in connection with a lumbar ESI does not preclude a provider from establishing whatever basic value is reasonably related to the complexity of the service rendered as documented in the patient's medical condition and/or circumstances under which the anesthesia was administered.[22] Neither does Code 01999 interfere or otherwise prevent the provider from administering whatever form of anesthesia care he/she deems optimal for a patient based on the patient’s medical condition. An additional positive aspect to using Code 01999 for anesthesia service related to ESIs is that it would be unlikely to produce the somewhat ridiculous disparity between the charges for the underlying procedure and the related anesthesia service seen in this case.

Failure to preserve coding issue

Although the Carrier’s arguments in the hearing regarding proper coding have great merit, the Provider correctly points out that the Carrier did not base its prior denial of payments on these well-articulated coding arguments nor did it raise a coding challenge before the MRD. Instead, the record shows that for each date of service the Carrier’s explanation of benefits (EOB) to the Provider was initially denial code "F" and a partial payment of $200 based on three RVUs (instead of the eight provided under Code 00630), two time units, and no modifying risk units. Upon resubmission, the second EOB used denial code "M" and written comments that indicate either: (1) the Carrier thought anesthesia by IV sedation was provided on both service dates; or (2) it was telling the Provider that IV sedation was the only appropriate anesthesia technique for an ESI, and reimbursement for anesthesia service would only be made on that basis.[23]

As was noted earlier, Code "F" (fee guideline MAR reduction) tells the provider that the carrier is reducing payment from the amount billed in accordance with the appropriate MAR for that treatment/service. This code is not used for reductions based on lack of documentation or for charges for which TWCC has not established an MAR. Code F does not state or otherwise imply that the CPT code used to charge for the service is incorrect and is being challenged by the Carrier. The second EOB, Code M, stands for "no MAR" and is used when the carrier is reducing payment from the billed amount when TWCC has not set an MAR for the treatment or service. Again, nothing about this explanation indicates the anesthesia code used for billing is being challenged by the Carrier. The ALJ finds that: (1) the Carrier’s use of codes F and M to explain why reimbursement was denied did not put the Provider on notice of the coding basis for denial argued for the first time in this hearing; (2) the Carrier provided no rationale for why it failed to present the coding issue to the MRD for consideration and to plead this issue in its request for a contested case hearing; and (3) the Carrier has cited no authority that allows it to raise coding as an issue for the first time in the SOAH hearing. In addition to these errors, the Carrier’s issuance of a partial reimbursement based on its determination that Code 01999 is the correct code for anesthesia administered for ESIs appears to violate TWCC Rule 133.301(b), which provides that "[n]either the carrier nor the carrier’s agent shall change codes on the medical bills submitted by the provider without affording the provider the opportunity to submit additional documentation, prior to payment."[24] (emphasis added) If the Carrier disagreed with the Provider’s use of CPT Code 00630, the appropriate response is to deny reimbursement for charges based on Code 00630 and provide the required explanation(s) with an appropriate denial code and written comments that would have put the Provider on notice that the Carrier perceived a coding error. As Rule 133.301(b) contemplates, the Provider would then have had the opportunity to present additional documentation to support its use of Code 00630. Instead, it appears that the Carrier relied on the TWCC problem-solver and simply substituted the code submitted by the Provider for its own preferred Code 01999, which it believed was appropriate due to the nature of the underlying procedure (ESIs) and the type of anesthesia service it believed was rendered on both service dates (IV sedation). There is no evidence indicating the Carrier met the requirements of this rule prior to substituting the code submitted by the Provider and making a partial reimbursement.

Failure to place medical necessity at issue

The evidence shows that the May 30 service is plainly documented as "general" anesthesia, and the June 6 service is listed as "MAC." The Carrier presented no evidence that these particular anesthesia services were not medically necessary. Regardless of opinions expressed by unknown persons in an arguably out-of-date TWCC problem-solver, the applicable law and rules empower the doctor, not the insurance company, to make the medical decisions about what care is reasonable and necessary for the injured worker/patient. Using his/her best medical judgment, the doctor may determine that general anesthesia or MAC rather than IV sedation is medically necessary for a particular patient receiving an ESI. If the Carrier disagrees, its recourse is to challenge the medical necessity of that choice. However, the record shows that nowhere in the EOBs did the Carrier list: (1) exception codes U or V, which tell a provider that a carrier is challenging the treatment or service on the grounds that it is medically unreasonable and/or unnecessary; or (2) code N, which tells the provider the service was not appropriately documented and must include an explanation of what documentation is missing that is sufficient to give the provider a chance to correct an error when seeking reconsideration.

Although it never informed the Provider that it was denying payments based on medical necessity, in its July 11, 2001, letter to the MRD, the Carrier clearly disagrees with the Provider’s decision to administer general anesthesia and MAC for the underlying ESI procedures.[25] The letter indicates that the Carrier attached a copy of a December 19, 2000 SOAH decision[26] that found the MACs rendered for surface injections in that case were not medically necessary. However, the ALJ observes that: (1) this decision was issued over six months after the Provider provided the anesthesia service at issue and cannot reasonably be expected to impact the choice of service determined by the Provider to have been appropriate and "optimal" for the claimant in this case; (2) the challenge to the reasonableness and medical necessity of the MAC provided by a second anesthesiologist for injections was clearly at issue from the beginning; and (3) the decision reached is based on evidence specific to that hearing.

Considering the Carrier’s failure to clearly articulate a medical necessity challenge and the inapplicability of the December 2000 SOAH decision to this case, whether the anesthesia services rendered in this case are medically necessity has not been properly placed at issue in this case.

Additional Risk Units

The record shows the two modifying risk units were put at issue when the Carrier failed to include them in its initial calculation. As such, the Provider had sufficient notice these two units were being challenged, and it had the opportunity to address that issue before the MRD and in this contested hearing. The record contains no documentation or testimony from the anesthesiologist that justifies two additional risk units, particularly when the patient is shown by the Anesthesia Record to have been assessed as an "ASA II."[27] The ALJ finds no support in the record for including two modifying/risk units in the calculation of charges.

Summary Conclusion

Upon consideration of the above, the ALJ concludes the Carrier has failed to show by a preponderance of the evidence that the MRD's determination should be overturned except as it relates to the two additional units it allowed based on the risk modifiers. The record does not support allowing even one additional unit for risk. Accordingly, the ALJ finds it is appropriate to reduce the TVA by two units, which results in a total of $400 ($40 x 10) that should be reimbursed for each service date. Total reimbursement still due the Provider is $360, i.e., $800 less the $440 earlier reimbursed.

III. FINDINGS of Fact

  1. On________, the Claimant was injured at his place of employment. Compensability is not at issue.
  2. On May 30 and June 6, 2000, the Claimant received lumbar epidural steroid injections (ESI) to treat his injury. The ESI procedures are not at issue in this case.
  3. In conjunction with the lumbar ESIs described in Finding of Fact No. 2, Dr. Sherolyn Simmons (Provider), a medical doctor and anesthesiologist, administered general anesthesia to the Claimant on May 30, 2000, and monitored anesthesia care (MAC) on June 6, 2000. On each date of service, the anesthesia services were provided for half an hour.
  4. The Provider charged for its services under Current Procedural Terminology (CPT) Code 00630. The basic value of anesthesia service billed under CPT Code 00630, expressed in relative value units (RVU), is "8." The Provider added two units representing thirty minutes of time of service and two modifying units for risk to the basic value "8" and requested reimbursement based on a total anesthesia value (TAV) of twelve units per service.
  5. The Carrier provided partial reimbursement totaling $440 for both dates of service based on a TAV of five units for each service: 3 RVU, two units for time, and none for risk.
  6. The Carrier's explanation of benefits, which denied charges for services using only denial codes "F" and "M, did not state or otherwise imply that: the Provider used the wrong CPT code for billing; the anesthesia services were not medically necessary; or that there was a lack of adequate documentation.
  7. By letters dated May 22, 2001, the Provider filed requests for medical dispute resolution with the Texas Workers’ Compensation Commission’s (TWCC or Commission) Medical Review Division (MRD) concerning the Carrier’s denial of full payment for the medical services rendered by the Provider on May 30 and June 6, 2000.
  8. On July 5, 2001, the MRD issued two decisions and orders that required the Carrier to reimburse the Provider a total of $520 in addition to the $440 already paid for the anesthesia services at issue. The MRD's order is based on the Provider’s proposed TAV of twelve units per service multiplied by the monetary value of $40 per unit for anesthesiologists established in the Anesthesia Ground Rules.
  9. The Carrier filed a request for hearing and appeal of the MRD’s orders on July 19, 2001.
  10. On August 10, 2001, the Commission issued a notice of hearing to be held at the State Office of Administrative Hearings (SOAH). The notice contained a statement of the time, place, and nature of the hearing, and a statement of the legal authority and jurisdiction under which the hearing was to be held. On May 6, 2002, the Commission further filed a statement of the matters asserted and reference to the relevant statutes and rules involved. The hearing convened on August 15, 2002.
  11. There is no evidence to support the inclusion of modifying risk units in the calculation of the TAV for the anesthesia services in this case. In this case, the TAV without risk units is ten units per service.
  12. Based on a TAV of ten units per service at the established monetary value of $40 per unit, the total reimbursement for each anesthesia service is $400 or a total of $800 for the services at issue in this case.

IV. CONCLUSIONS of Law

  1. TWCC has jurisdiction over this matter pursuant to Tex. Lab. Code Ann. § 413.031 (Vernon Supp. 2002).
  2. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §413.031 and Tex. Gov't Code Ann. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov't CodeAnn., ch. 2001 and 1 Tex. Admin. Code ch. 155.
  4. Timely appeals of the MRD’s orders were filed by the Carrier. Tex. Admin. Code §§ 133.305. (p) and 148.3.
  5. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
  6. The party seeking relief bears the burden of proving by a preponderance of the evidence that it should prevail in hearings. 28 Tex. Admin. Code § 148.21(h).
  7. Based on the above Findings of Fact, the Carrier did not meet its burden of proof to show that the Provider was properly denied reimbursement based on denial codes "F" and "M."
  8. Based on the above Findings of Fact, the Carrier did not properly and timely raise other issues concerning the appropriate charges for the anesthesia services at issue in this case.
  9. Based on the above Findings of Fact and Conclusions of Law, the Provider is entitled to additional total reimbursement of $360 for the services provided on May 30 and June 6, 2000, based on a TAV of ten units per service.

ORDER

It is hereby ORDERED that the Carrier shall reimburse the Provider for the services at issue in this hearing in the amount of $360 plus interest at the rate and for the time as provided by law.

Issued the 25th day of April 2003.

Leslie Craven
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Reductions were originally made by Petitioner's predecessor in interest, Hartford Insurance.
  2. The Commission’s 1996 Medical Fee Guideline (MFG) is effective for all medical services rendered on or after April 1, 1996 and is applicable to this case. The 1996 MFG incorporates the five-digit numeric CPT codes obtained from the Physicians’ Current Procedural Terminology, Fourth Edition, Copyright 1994 by the American Medical Association.
  3. Carrier Exhibit (Ex.) C: AGR I. (B) &(C) at 193-194.
  4. Carrier Ex. C: AGR I. (B) (4).
  5. Carrier Ex. E at 11-12 and Ex. F at 11-12.
  6. It appears from the record that an additional unit was inadvertently paid for the June 6 service, which explains the MRD’s finding that reimbursement was made for eleven and not ten units. Carrier does not seek reimbursement of that one additional unit in this case.
  7. TWCC Form 62 shows that: (1) "F" tells the provider that the carrier is reducing payment from the billed amount to match the appropriate fee guideline MAR. Denial code "F" is not used for reductions based on lack of documentation or for charges for which TWCC has not established an MAR; and (2) "M" is used when the carrier is reducing payment from the billed amount when TWCC has not set an MAR for the treatment or service.
  8. Carrier Ex. E at 8-9 and Ex. F at 8-9.
  9. Carrier Ex. C: AGR at 193 and 196.
  10. Carrier Ex. C: AGR at 202.
  11. The description for CPT Code 00630 is stated as "Anesthesia for procedures in lumbar region; not otherwise specified." (emphasis added) Carrier Ex. C at 198.
  12. But see Twin City Fire Ins. Co. v. Billing R Us, SOAH Dkt. No. 453-01-3594.M4, D&O issued June 28, 2002. In presenting this argument, the Carrier acknowledges an earlier SOAH decision that accepted the Provider's interpretation of this phrase. It insists, however, that the record in that case was not as fully developed, and the judge did not have the benefit of a more complete analysis of the MFG concerning the meaning of this phrase within the general structure of the AGR CPT codes, the existence of distinctions between types of procedures, and the effect of those distinctions on how the AGR codes are to be used.
  13. Carrier Ex. B: SGR I. (E) (4) (c) at 66, and codes at 175-176.
  14. Carrier Ex. B: SGR at 176.
  15. Carrier Ex. E at 15 and Ex. F at 15.
  16. Carrier Ex. D and Provider Ex. D.
  17. Carrier Ex. C at 193: AGR I (A).
  18. Carrier Ex. E at 7, 9-10 and 15.
  19. Medicare training rules for anesthesia services, American Medical Association’s 2002 CPT anesthesia code revisions for radiological procedures, and Medicode’s 2001Anesthesia Crosswalk.
  20. 28 Tex. Admin. Code § 133.301(a) (7) unchanged by amendments effective July 15, 2000.
  21. It took a total of fifteen minutes on May 30 and five minutes on June 6 to provide the underlying ESIs. See Carrier Ex. E and F at 15.
  22. DOP is used when the medical services provided are not specifically listed or are unusual or too variable to have an assigned MAR, and the documentation required to establish the value claimed may vary based on the complexity of the procedure. See 1996 MFG at 1: "General Instructions" III.
  23. Carrier Ex. E at 10, 13, and 21; and Ex. F at 10, 13, and 19. Note, in a June 11, 2001, letter to the MRD, the Carrier explains that it relied on the 1994 problem-solver in coming up with the "correct" payment, which uses Code 01999 for the "administration of sedation."
  24. 28 Tex. Admin. Code § 133.301(b) effective February 20, 1992 is applicable to this case based on the May 30 and June 6, 2000, dates of service. The most current version of Section 133.301(b) applies to "all dates of service on or after July 15, 2000," and sets noticeably different requirements for when a carrier seeks to change the CPT code submitted with the medical bill.
  25. Carrier Ex. E at 21, 25-36 and Ex. F at 19, 24-35.
  26. Tex. Workers’ Compensation Comm’n Ins. Fund v. U.S. Anesthetic Services, P.A. and Tex. Workers’ Compensation Comm’n, SOAH Dkt. No. 453-99-2324.M5 [consolidated], D&O issued Dec. 19, 2000.
  27. Generally equivalent to the physical status modifier "P2" classification in AGR I. (C) (2) (a).
End of Document
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