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At a Glance:
Title:
453-02-0139-m5
Date:
January 6, 2003
Status:
Retrospective Medical Necessity

453-02-0139-m5

January 6, 2003

DECISION AND ORDER

This is a dispute over reimbursement for therapeutic exercises (CPT Code 97110), work hardening services (CPT Codes 97545-WH and 97546-WH), and some miscellaneous services (CPT Codes 97035 -ultrasound, 97250-myofascial release, and 99213-office visit). The amount in dispute is $6977.40.[1]

The ALJ finds the Provider, Suhail Al-Sahli, D.C., proved the therapeutic exercises were medically necessary. He orders the Carrier, RCH Protective Cooperative (RCH) to reimburse Dr. Al-Sahli for them, in the amount of $3,045.00.

Dr. Al-Sahli also proved he was entitled to reimbursement for the work hardening services. Although there was some question as to whether RCH has already paid him for those services, the preponderance of the evidence suggests not. Therefore, the ALJ orders RCH to pay Dr. Al-Sahli $3,686.40 for those services. Dr. Al-Sahli shall either refuse payment or return any duplicate payment if in fact he has already been paid.

Finally, Dr. Al-Sahli proved he was entitled to reimbursement of $224.00 of the $246.00 in dispute for the miscellaneous services, for a total reimbursement of $6,955.40.

I. Discussion

A. Factual Background and Procedural History

The Claimant, an employee with___, sustained injuries to her knee, thumb, and back on___, while trying to restrain a patient. She began treatment with Dr. Al-Sahli on January 20, 1999, and completed her treatment on September 17, 1999. RCH reimbursed Dr. Al-Sahli for much of his treatment, but did not reimburse him for other portions.

Dr. Al-Sahli filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (TWCC or the Commission) on May 5, 2000. At the time of filing, the dispute was for dates of service from April 20, 1999, through September 17, 1999.

The Commission’s Medical Review Division (MRD) did not consider any dates of service before May 5, 1999, because of its one-year rule, 28 Tex. Admin. Code (TAC) §133.305(a-b). For the remaining dates, beginning on May 11, 1999, it ordered reimbursement of $2,612.00 for various services.

The MRD did not order reimbursement for CPT Codes 97110, 97545-WH, or 97546-WH. It found the services rendered under CPT Code 97110 from May 11, 1999, through July 28, 1999, were medically necessary. It declined to order reimbursement, however, because, in its opinion, the documentation did not demonstrate the one-on-one supervision required by that code.

The MRD did not order reimbursement for the work hardening services, Codes 97545-WH and 97546-WH, because the documentation it had been provided did not include explanations of benefits (EOBs) for those services.

Generally, the MRD ordered reimbursement for CPT Codes 97035, 97250, and 99213. For three dates of service, however, it found the documentation did not contain EOBs. It denied reimbursement for those codes for those three dates.

Dr. Al-Sahli filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH). Adequate and timely notice of the hearing was provided to all parties on September 20, 2001. The hearing was convened on October 22, 2002, with ALJ Henry D. Card presiding. Dr. Al-Sahli represented himself; Mr. Steven Tipton represented RCH. The hearing was adjourned the same day.

B. CPT Code 97110 (Therapeutic Exercises)

RCH denied reimbursement for the therapeutic exercises because it deemed them medically unnecessary. Ex. 1, pages 214-247. The ALJ finds Dr. Al-Sahli proved them to have been medically necessary. Both his observations and the Functional Capacity Evaluation conducted by physical therapist Franco S.P. Munoz established that the Claimant still had pain and could not perform her job requirements at the time the exercises were being conducted. Mr. Munoz recommended, in his July 1, 1999, evaluation, that she continue with her current rehabilitation program. Ex. 1, page 37. The record does not contain any evaluations or examinations that refute Dr. Al-Sahli’s or Mr. Munoz’s observations.

The MRD agreed the exercises were medically necessary. It denied reimbursement because of inadequate documentation that the exercises were conducted with one-on-one supervision, which is a requirement for Code 97110. RCH did not cite documentation problems in its EOBs, however. The only reason for non-reimbursement it provided in those EOBs was lack of medical necessity. Under the Commission’s rules, as interpreted by SOAH decisions, RCH cannot rely upon a different reason for denying reimbursement after the Request for Dispute Resolution has been filed. See, e.g. Docket No. 453-96-1446.M4, Liberty Mutual Fire Insurance Company v. Texas Workers' Compensation Commission and Nervchek (Nov. 12, 1996) (Judge Corbett) and Docket No. 453-97-0973.M4, Naehritz v. Texas Workers’ Compensation Commission and Texas Workers’ Compensation Insurance Fund (May 14, 1998) (Judge Card).

The ALJ concludes RCH should be required to reimburse Dr. Al-Sahli for the $3,045.00 in services provided under CPT Code 97110 from May 11, 1999, through July 28, 1999.

C. CPT Codes 97545-WH and 97546-WH (Work Hardening)

Dr. Al-Sahli provided work hardening services to the Claimant from August 9, 1999, through September 17, 1999. The August 9-19 dates of service were not before the MRD because RCH had already paid for them. The MRD denied reimbursement for the other dates of service because there were no EOBs in the record. After that decision, RCH paid for the September 13-17 dates of service. The services provided from August 20 through September 3, 1999 are still in dispute, however.

The payment for work hardening on the other dates of service implies that the work hardening performed from August 20 through September 3, 1999 was medically necessary. RCH did not dispute medical necessity. Dr. Al-Sahli presented into evidence an EOB stating that payment should be made for those dates of service. Petitioner’s Ex. 3, page 6.[2] The ALJ finds those services were medically necessary and that Dr. Al-Sahli properly submitted them to the Carrier.

The EOB states it was paid on October 27, 1999. Dr. Al-Sahli had no record of receiving that check, however, and those dates of service did not appear on RCH’s payment schedule, which was read into evidence. Therefore, the ALJ finds Dr. Al-Sahli should be reimbursed $3,686.40 for the work hardening performed on those dates.

D. CPT Codes 97035, 97250 and 99213

As was mentioned above, the MRD generally ordered reimbursement for these CPT codes. It did not order reimbursement for those codes for May 29, June 1, and June 8, 1999, again because there were no EOBs in the record.

The record does contain HCFAs for June 1 and June 8, 1999, which indicates the bills were submitted to RCH. That fact, combined with the fact that RCH paid for the identical services on other dates, lead the ALJ to find that Dr. Al-Sahli should be reimbursed $224.00 for those services on those dates.

The record does not contain a HCFA for May 29, 1999. The ALJ finds Dr. Al-Sahli should not be reimbursed for the one service performed on that date--CPT Code 97035 in the amount of $22.00.

E. Summary

The ALJ concludes RCH should reimburse Dr. Al-Sahli $6,955.40 for the services at issue in this case.

II. Findings of Fact

  1. The Claimant, an employee with____, sustained injuries to her knee, thumb, and back on____, while trying to restrain a patient.
  2. The Claimant began treatment with Dr. Al-Sahli on January 20, 1999, and completed her treatment on September 17, 1999.
  3. RCH reimbursed Dr. Al-Sahli for much of his treatment, but did not reimburse him for other portions.
  4. Dr. Al-Sahli filed a Request for Medical Dispute Resolution with the Commission on May 5, 2000.
  5. At the time of filing, the dispute was for dates of service from April 20, 1999, through September 17, 1999.
  6. The MRD did not consider any dates of service before May 5, 1999, because of its one-year rule, 28 Tex. Admin. Code (TAC) §133.305(a-b).
  7. For the remaining dates, beginning on May 11, 1999, the MRD ordered reimbursement of $2,612.00 for various services.
  8. Dr. Al-Sahli filed a timely request for a hearing before SOAH.
  9. Notice of the hearing was provided to all parties on September 20, 2001.
  10. 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.
  11. The hearing was convened on October 22, 2002, with ALJ Henry D. Card presiding. Dr. Al-Sahli represented himself; Mr. Steven Tipton represented RCH. The hearing was adjourned the same day.
  12. RCH denied reimbursement for the therapeutic exercises (CPT Code 97110) because it deemed them medically unnecessary.
  13. Both Dr. Al-Sahli’s observations and the Functional Capacity Evaluation conducted by physical therapist Franco S.P. Munoz established that the Claimant still had pain and could not perform her job requirements at the time the exercises were being conducted.
  14. Mr. Munoz recommended, in his July 1, 1999, evaluation, that the Claimant continue with her current rehabilitation program.
  15. The record does not contain any evaluations or examinations that refute Dr. Al-Sahli’s or Mr. Munoz’s observations.
  16. The therapeutic exercises were medically necessary.
  17. RCH did not cite documentation problems in its EOBs relating to CPT Code 97110.
  18. Dr. Al-Sahli provided work hardening services (CPT Codes 97545-WH and 97546-WH) to the Claimant from August 9, 1999, through September 17, 1999.
  19. RCH has reimbursed Dr. Al-Sahli for work hardening services performed from August 9-19 and September 13-17, 1999.
  20. The payment for work hardening on the other dates of service implies that the work hardening performed from August 20 through September 3, 1999 was medically necessary.
  21. RCH did not dispute the medical necessity of the work hardening services.
  22. An EOB states that payment should be made for the August 20 through September 3, 1999, dates of service.
  23. Although the EOB states it was paid on October 27, 1999, Dr. Al-Sahli had no record of receiving that check and those dates of service did not appear on RCH’s payment schedule.
  24. The work hardening services from August 20 through September 3, 1999, were medically necessary.
  25. Dr. Al-Sahli properly submitted bills for the August 20 through September 3, 1999, work hardening services to RCH.
  26. RCH has not yet paid Dr. Al-Sahli for the work hardening services performed from August 20 through September 3, 1999.
  27. Dr.Al-Sahli submitted bills to RCH for CPT Codes 97035, 97250, and 99213 for June 1 and June 8, 1999.
  28. Dr. Al-Sahli did not submit a bill to RCH for CPT Code 97035 for May 29, 1999.
  29. RCH paid for CPT Codes 97035, 97250, and 99213 for other dates of service.

III. Conclusions of Law

  1. 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.
  2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  3. Dr. Al-Sahli has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  4. Dr. Al-Sahli proved he was entitled to reimbursement of $3,045.00 for services provided under CPT Code 97110 from May 11, 1999, through July 28, 1999.
  5. Dr. Al-Sahli proved he was entitled to reimbursement of $3,686.40 for work hardening services provided under CPT Codes 97545-WH and 97546-WH from August 20 through September 3, 1999.
  6. Dr. Al-Sahli proved he was entitled to reimbursement of $224.00 for services provided under CPT Codes 97035, 97250 and 99213 on June 1 and June 8, 1999.
  7. Dr. Al-Sahli did not prove he was entitled to reimbursement of $22.00 for work performed under CPT Code 97035 on May 29, 1999.
  8. RCH should reimburse Dr. Al-Sahli $6,955.40 for the services at issue in this case.

ORDER

IT IS, THEREFORE, ORDERED that RCH Protective Cooperative shall reimburse Dr. Suhail Al-Sahli $6,955.40 for the services at issue in this case. Dr. Al-Sahli shall either refuse payment or return any duplicate payment if in fact he has already been paid for any of those services.

Signed this 6th day of January, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

  1. There was considerable confusion in this case over what amount was in dispute, but the ALJ believes this amount to be correct.
  2. For reasons neither party understood, the one-page EOB was attached to several other EOBs that were concerned with other dates of service.
End of Document
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