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At a Glance:
Title:
453-02-0042-m5
Date:
November 1, 2002
Status:
Retrospective Medical Necessity

453-02-0042-m5

November 1, 2002

DECISION AND ORDER

This case is an appeal by Arrow Clinic (“Petitioner”) from the Findings and Decision of the Texas Workers’ Compensation Commission’s Medical Review Division (“MRD”) in a fee dispute. The MRD concluded that Petitioner was entitled to additional reimbursement of only $2,901.00 upon unpaid billings to Liberty Mutual Fire Insurance Co. (“Respondent”) of $7,575.46, covering medical services to a claimant under the Texas Workers’ Compensation Act (“the Act”), TEX. LABOR CODE ANN. ch. 401 et seq.

The MRD’s partial disallowance of billings was based primarily upon an asserted lack of documentation that the claimant’s therapeutic exercise was supervised by a physician in exclusive one-to-one sessions, as billed.

This decision affirms that of the MRD.

I. JURISDICTION AND VENUE

The Texas Workers’ Compensation Commission (“Commission”) has jurisdiction to consider appeals from decisions of its MRD pursuant to § 413.031 of the Act. The State Office of Administrative Hearings (“SOAH”) 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.

II. STATEMENT OF THE CASE

The hearing in this docket was convened on October 29, 2002, at SOAH facilities in the William P. Clements Building, 1700 North Congress Avenue, Austin, Texas. Administrative Law Judge (ALJ) Mike Rogan presided over the hearing. The Commission, as Respondent, did not appear or participate.[1] Respondent Liberty Mutual Fire Insurance Co. was represented by Shannon Butterworth, Attorney. Petitioner was represented by Dr. Herman R. Barnes, who appeared by telephone. After presentation of evidence and argument, the hearing was adjourned and the record was closed on October 29, 2002.

The record developed at the hearing revealed that the claimant suffered a compensable back injury and was eventually referred to Petitioner for rehabilitative treatment. For services rendered between June 7 and October 12, 1999, Petitioner billed Respondent (the insurance carrier for claimant’s employer at the time of the injury) a total of $11,300.46. Respondent paid $3,725.00 of the billed amount, but denied payment of the remainder. Respondent then sought medical dispute resolution from the Commission’s MRD.

The MRD issued a decision on July 20, 2001, finding that Petitioner was entitled to additional reimbursement of only $2,901.00 on the previously unpaid billings of $7,575.46. Most of the discrepancy between billings and recommended reimbursement related to the provision of therapeutic exercise services under CPT Code 97110 on 18 separate dates between June 10 and July 31, 1999. In each instance, the MRD found that Petitioner’s pertinent office notes did not “clearly indicate exclusive one-to-one session.” In addition, the MRD cited general documentation requirements in the Commission’s Spine Treatment Guideline (“STG”).[2] Accordingly, the MRD refused to recommend reimbursement for the CPT Code 97110 services at issue, beyond those amounts previously paid by Respondent for such services.

III. EVIDENCE, ARGUMENT, AND DISCUSSION

The certified record compiled by the Commission-i.e., the MRD’s Findings and Decision, with accompanying documents, including materials offered by the Petitioner-was admitted into evidence as Exhibit 1.

Petitioner contended that the documentation provided in this case was in fact adequate to demonstrate that services under CPT Code 97110 were provided in a “one-to-one setting,” as required by the Commission’s 1996 Medical Fee Guideline (“MFG”).[3] Testifying on behalf of Petitioner, Dr. Herman R. Barnes, D.C., affirmed that he had provided constant one-on-one supervision of the claimant’s therapeutic exercise in this case. He also asserted that a knowledgeable person examining the records in this case would perceive that the disputed daily office notes do reflect the constant presence of a physician during the exercise sessions, in that they contain detailed observations that only the physician could reasonably be expected to make. (These observations include an assessment of the patient’s attitude and effort, a fairly specific anatomical description of the exercises performed and the portions of the nerve system involved in those exercises, and an account of the number of repetitions performed for each exercise.)

Respondent countered that the record as a whole in this case-with or without the additional comments provided by Dr. Barnes at the hearing-contains nothing to document that a health care provider was present for one-to-one supervision during the entirety of any disputed session under CPT Code 97110. According to Respondent, a nurse or other assistant readily could have compiled and placed in writing all or most of the information contained in the disputed office notes. Documentation explicitly demonstrating the full-time presence of the physician is necessary, Respondent summarized, in order to avoid the all-too-common practice by which a health care provider conducts exercise for a group of patients but bills as if each such patient had received one-to-one treatment.

In the ALJ’s view, Petitioner has provided no new evidence or argument sufficient to compel the reversal of any of the MRD’s previous findings or recommendations. The records in question clearly do not indicate explicitly that the disputed sessions under CPT Code 97110 were conducted on a one-to-one basis. Nor is the information compiled in Petitioner’s daily office notes for those sessions intrinsically so technical, complex, or specific that its mere presence can lead to the deduction that a physician supervised the entirety of those sessions. The ALJ must conclude that Petitioner has failed to comply with the MFG and STG, with respect to those billings previously disallowed by the MRD.

IV. CONCLUSION

The ALJ finds that, under the record provided in this case, no basis exists for reversing the decision of the MRD with respect to Petitioner’s proper reimbursement for medical services provided.

V. FINDINGS OF FACT

  1. On ______the claimant in this case suffered an injury to his back that was a compensable injury under the Texas Worker’s Compensation Act (the Act), TEX. LABOR CODE ANN. ch. 401 et seq.
  2. During the claimant’s rehabilitative process, the treating physician referred him to Arrow Clinic (“Petitioner”) for physical therapy.
  3. Petitioner subsequently billed Liberty Mutual Fire Insurance Company (“Respondent,” the insurance carrier for claimant’s employer at the time of the injury) $11,300.46 for medical services under CPT Codes 97012, 97032, 97035, 97110, 97112, 97250, 97260, 97261, 99205, and 99213-MP, provided between June 7 and October 12, 1999.
  4. Respondent paid Petitioner $3,725.00 of the billed amount, but denied payment of the remainder.
  5. Petitioner made a timely request to the Commission’s Medical Review Division (“MRD”) for medical dispute resolution with respect to the disputed reimbursements.
  6. The MRD, in a decision dated July 20, 2001, in dispute-resolution docket No. M5-00-1018-01, found that Petitioner was entitled to additional reimbursement of only $2,901.00 on the previously unpaid billings of $7,575.46. Most of the discrepancy between billings and recommended reimbursement related to the provision of therapeutic exercise services under CPT Code 97110 on 18 separate dates between June 10 and July 31, 1999. In each instance, the MRD found that Petitioner’s pertinent office notes did not “clearly indicate exclusive one-to-one session.” In addition, the MRD cited Petitioner’s failure to comply with general documentation requirements in the Commission’s Spine Treatment Guideline (“STG”), 28
  7. TEX. ADMINISTRATIVE CODE (“TAC”) § 134.1001. Accordingly, the MRD refused to recommend reimbursement for the CPT Code 97110 services at issue, beyond those amounts previously paid by Respondent for such services.
  8. Petitioner requested in timely manner a hearing with the State Office of Administrative Hearings (“SOAH”), seeking review and reversal of the MRD decision insofar as it recommended reimbursement of less than the entire amount initially sought by Petitioner from Respondent.
  9. The Commission mailed notice of the hearing’s initial setting to the parties at their addresses on September 11, 2001. The initial hearing date was continued three times upon requests of the parties, with proper notice of such continuances provided by SOAH.
  10. A hearing in this matter was convened on October 29, 2002, at the William P. Clements State Office Building in Austin, Texas, before Mike Rogan, an Administrative Law Judge with the State Office of Administrative Hearings. All parties were represented.
  11. Neither the office notes described in Finding of Fact No. 6 nor any other documentation in this case indicates that a physician or other authorized health care provider provided one-to-one supervision of those exercise sessions for which Petitioner billed Respondent under CPT Code 97110.

VI. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issues presented pursuant to § 413.031 of the Act.
  2. 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.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV’T CODE ANN. ch. 2001 and the Commission’s rules, 28 TAC § 133.305(g) and §§ 148.001-148.028.
  4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§2001.051 and 2001.052.
  5. Petitioner, the party seeking relief, bore the burden of proof in this case, pursuant to 28 TAC § §148.21(h).
  6. Based upon the foregoing Findings of Fact, Petitioner failed to comply with the STG, 28 TAC § 134.1001(e)(2)(A) and (e)(3)(A) and (B), and with the Commission’s 1996 Medical Fee Guideline, Medicine Ground Rules I.A.9.b, in seeking reimbursement for services under CPT Code 97110, as noted in Finding of Fact No. 6.
  7. Based upon the foregoing Findings of Fact, the medical services for the claimant noted in Finding of Fact No. 3 (to the extent approved for reimbursement by the MRD, as noted in Finding of Fact No. 6) represent elements of health care medically necessary under§ 408.021of the Act.
  8. Based upon the foregoing Findings of Fact and Conclusions of Law, the Findings and Decision of the MRD, issued in this matter on July 20, 2001, are affirmed. No reimbursement of Petitioner, beyond that recommended in the MRD’s decision, should be approved.

ORDER

IT IS THEREFORE, ORDERED that the Liberty Mutual Fire Insurance Company reimburse Arrow Clinic for physical therapy and related services only in accordance with the Findings and Decision of the Medical Review Division of the Texas Workers’ Compensation Commission, issued in this matter on July 20, 2001. Reimbursement beyond that identified in the Medical Review Division’s Findings and Decision is not appropriate.

Signed this 1st day of November, 2002.

MIKE ROGAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. The staff of the Commission was initially designated as a Respondent in the proceeding but formally elected not to participate, although it filed a “Statement of Matters Asserted” that recommended upholding the MRD’s decision.
  2. 28 TEX. ADMINISTRATIVE CODE § 134.1001(e)(2)(A) and (e)(3)(A) and (B).
  3. 28 TEX. ADMINISTRATIVE CODE § 134.201, Medicine Ground Rules I.A.9.b.
End of Document
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