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At a Glance:
Title:
453-01-3858-m5
Date:
September 12, 2002
Status:
Retrospective Medical Necessity

453-01-3858-m5

September 12, 2002

DECISION AND ORDER

This case is a dispute over whether additional reimbursement is appropriate for joint mobilizations provided to____ (Claimant) between October 7, 1999, and February 7, 2000, by Bridgestone Management (Provider). Texas Mutual Insurance Company (Carrier) denied reimbursement to Provider on the basis that it had already reimbursed Provider a fair and reasonable amount based on the services performed. Provider requested medical dispute resolution with the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD). The MRD approved additional reimbursement in the amount of $2,064.00, on July 2, 2001, in Docket No. M4-01-1700-01, citing proper documentation substantiating the charges for joint mobilizations performed on Claimant. Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).

The hearing was convened on July 23, 2002, before Steven M. Rivas, Administrative Law Judge (ALJ). Carrier appeared and was represented by Katie Kidd, attorney. Provider appeared and was represented by Scott Hilliard, attorney. The record closed the same day. This decision finds that Carrier should reimburse Provider a total of $2,064.00 for the joint mobilizations performed on Claimant.

I.DISCUSSION

Background Facts

On___________, Claimant, ____ sustained a compensable injury.[1] Claimant underwent certain medical procedures through Provider between October 7, 1999, and February 7, 2000. On those dates, Provider performed joint mobilizations and spine manipulations to Claimant’s lumbar region. Provider billed Carrier for the joint mobilizations under CPT code 97265 and spine manipulations under CPT code 99213 MP. The Carrier denied payment for the joint mobilizations on the basis that a mobilization is included in a manipulation, therefore; billing for both procedures amounted to double-billing for essentially the same procedure.

B. Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (the “Act”) 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.

* * *

Under Tex. Lab. Code §413.011(d) Guidelines for medical services fees must be fair and reasonable and designed to ensure the quality of medical care and to achieve effective medical cost control. The guidelines may not provide for payment of a fee in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or by someone acting on that individual's behalf. The commission shall consider the increased security of payment afforded by this subtitle in establishing the fee guidelines.

  1. Analysis
  2. Joint Range of Motion

There are three distinct levels of joint range of motion: active, passive and par physiological. The first level, the active range of motion, refers to how far a person’s own muscles can move a joint without any assistance from another person, or otherwise.

Moving a person’s joint beyond the active range of motion is considered the passive range of motion level. The passive level is where joint mobilization occurs. Joint mobilization is a procedure that simply involves the movement of a joint by applying mild to moderate force to that joint. A measure of resistance may be noted while performing a mobilization, but not to the point where a patient would normally feel any discomfort. An example of mobilization was demonstrated at the hearing by Bill A. DeFoyd, M.A., D.C.,[2] by bending his right hand index finger forward until he met a certain amount of resistance.[3] By this demonstration it was noted at the hearing that a joint mobilization was similar to bending a joint to a point before it popped.

At the end of the passive range of motion level, the par physiological level begins. It is here that a manipulation takes place. Again, using Dr. DeFoyd’s example at the hearing, a manipulation occurs where a joint is bent with enough force that an audible popping sound is heard at the joint. In common terms, the ALJ found this occurs where someone is “cracking their knuckles.” A mobilization, in slight contrast, is the same act of cracking one’s knuckles but not exerting enough force to cause the popping sound.

Joint Mobilization and Manipulation.

The first issue is whether a joint mobilization is an integral part of a manipulation and, if so, whether it should be billed separately. In this case, the main argument of Carrier is that mobilization is an inherent part of a manipulation, and, therefore, Carrier should not have to pay Provider for both the mobilization and the manipulation.

Generally, for a patient to undergo a manipulation, a mobilization of the joint must be performed as well. An analogy offered by Dr. DeFoyd was that a person who drives from Austin to Dallas on IH-35 must always pass through Waco. Where Dallas is the manipulation, Waco, the mobilization, would inevitably be visited prior to arriving at Dallas. Hence, where a manipulation of a joint is the desired result, a patient would first have to undergo a mobilization of the joint. The Provider does not argue this point but points out, using Dr. DeFoyd’s analogy, even though a person has to travel through Waco to arrive at Dallas, Waco and Dallas are two different places.

Provider relies on a letter from Mary S. Mathis of the Commission outlining the differences between joint mobilization and manipulation.[4] In the letter, Ms. Mathis describes CPT code 97265 as a joint mobilization, a therapeutic procedure for one or more areas to last 15 minutes each. The letter indicates CPT codes 97260 or 97261 are used for a manipulation, or physical medicine activities and training. Ms. Mathis further indicates a manipulation is a separate procedure from a mobilization. Finally, Ms. Mathis asserts in her letter, manipulations and mobilizations are treatments that can, in any combination of four, comprise a physical medicine session.[5]

Dr. DeFoyd’s testimony of how mobilizations are inherent to manipulation procedures was somewhat compelling, but the fact that there are separate CPT codes for mobilizations and manipulations is more persuasive in determining mobilization is a different procedure than manipulation. There being two separate CPT codes available to bill for a mobilization and/or manipulation, this ALJ finds it is not improper for a Provider to bill for each procedure, especially where it can be shown both procedures were performed on different parts of the body.

Mobilization and Manipulation in the Lumbar Region.

Between October 7, 1999, and February 7, 2000, Claimant visited Provider for treatment of low back pain attributed to Claimant’s compensable injury. For each visit, Provider made notes of the Claimant’s subjective complaints, findings, treatment, and plan of action. For each visit, the notes are almost identical. Although sometimes worded slightly different, the treatment rendered to Claimant on each visit consisted of the following:

“Claimant was treated with joint mobilization to the lumbar region. The treatment included manipulation to the lumbar region.”

The above description of treatment is at the heart of the matter in this dispute. Provider employed lazy techniques of treatment documentation and that lack of specificity started this dispute. On the other hand, Carrier’s failure to follow up on Provider’s description fed into this dispute. Carrier could have cleared up this dispute by asking the Provider if the mobilization was performed on the exact same part of the lumbar region. Without a clear determination of what was done on each date of service, the ALJ is forced to make a finding on not who is right in this matter, but who should prevail for committing the least amount of harm.

Carrier attempted to show that a joint mobilization procedure preceded the manipulation to the Claimant’s lumbar region on each visit. Even if Carrier can prove that the joint mobilization was performed on the same joint as the manipulation, it still would not be necessarily improper to bill for both the mobilization and manipulation since they are two separate procedures having two separate CPT codes. But based on the evidence before this ALJ, Carrier failed to prove that the joint mobilization preceded the manipulation of the same joint on every visit.

Although both procedures were performed to Claimant’s lumbar region, this ALJ did not find that each procedure was performed on the exact same part of the lumbar region. Dr. DeFoyd admitted both on direct and cross examination that a mobilization to one part of the lumbar region and a manipulation to another part was possible. However, Dr. DeFoyd asserted that in order to be entitled to payment for both procedures, Provider should have thoroughly explained why both a mobilization and manipulation were required to the lumbar region. This ALJ agrees, nevertheless, the Carrier could have taken steps to determine what parts of the lumbar region were mobilized, manipulated, or both.

Dr. DeFoyd further testified that Provider’s notes, did not specify what areas of the lumbar spine were treated. The fact that it cannot be determined what specific areas of the lumbar spine were treated supports Provider’s position that Carrier cannot prove a mobilization and manipulation were performed on the exact same part of the lumbar region.

Conclusion.

In determining whether Provider is entitled to payment for the mobilizations rendered to Claimant, the MRD and this ALJ considered the Provider’s notes for the applicable dates of service. From the notes, there is no dispute that both mobilizations and manipulations were rendered to Claimant. Whether these procedures were performed to the same part of the lumbar region was not proven by Carrier. Even if it had proven the mobilization and manipulation were administered to the same part of the lumbar region, reimbursement would not necessarily have been disallowed since there are separate and distinct CPT codes for mobilizations and manipulations. For these reasons, this ALJ finds Carrier should provide additional reimbursement to Provider for the mobilization procedures it performed on Claimant between October 7, 1999, and February 7, 2000.

I.FINDINGS OF FACT

  1. Claimant, ____ suffered a compensable injury on_____________.
  2. Claimant was treated by Bridgestone Management (Provider) for lower back pain caused by the compensable injury.
  3. Between October 7, 1999, and February 7, 2000, Provider performed joint mobilizations and manipulations on Claimant.
  4. Provider billed Texas Mutual Insurance Co. (Carrier), for the services rendered to Claimant between October 7, 1999, and February 7, 2000.
  5. Carrier reimbursed Provider for all services rendered except the joint mobilizations performed between October 7, 1999, and February 7, 2000
  6. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement for the treatment.
  7. rendered to Claimant.
  8. On July 2, 2001, the Commission’s Medical Review Decision (MRD) found Claimant was entitled to reimbursement of $2,064.00.
  9. Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  10. Notice of the hearing was sent June 17, 2002.
  11. 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.
  12. The hearing was held July 23, 2002, with ALJ Steven M. Rivas presiding and representatives of the Carrier, and Provider participating. The record closed the same day.
  13. Carrier failed to offer sufficient evidence that Claimant is not entitled to additional reimbursement for the joint mobilizations performed on Claimant between October 7, 1999, and February 7, 2000.

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).
  5. Pursuant to the foregoing Findings of Facts and Conclusions of Law, Provider is entitled to additional reimbursement for the services rendered to Claimant between October 7, 1999, and February 7, 2000.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Bridgestone Management is entitled to additional reimbursement of $2,064.00 from the Carrier, Texas Mutual Insurance Co., for the services rendered to Claimant between October 7, 1999, and February 7, 2000.

Signed this 12TH day of September, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

  1. The circumstances of how Claimant’s injury occurred were not part of the record nor were they addressed at the hearing.
  2. Testifying witness for Carrier.
  3. The body part in question was Dr. DeFoyd’s first metacarpel philangeal on his right hand.
  4. Page 43 of the Certified Record, a letter addressed to Judy French of Americare Chiropractic Center and dated June 5, 2000.
  5. See id.
End of Document
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