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At a Glance:
Title:
453-02-0177-m4
Date:
August 21, 2002
Status:
Medical Fees

453-02-0177-m4

August 21, 2002

DECISION AND ORDER

American Home Assurance Company (AHAC) appeals an award of $4,977.00 to Waco Ortho Rehab (Waco Ortho) by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC). Since the date of the award, AHAC has made partial payment, leaving $2,023.00 in dispute for various services provided by Waco Ortho. AHAC disputes the remaining charges based on lack of preauthorization, unbundling of services, and lack of documentation. Waco Ortho disputes AHAC’s arguments and requests payment for the remaining charges. The Administrative Law Judge (ALJ) finds that AHAC did not establish that the services were improperly documented or processed and finds that Waco Ortho is entitled to additional reimbursement of $2,023.00.

I. Jurisdiction and Procedural History

There were no challenges to notice or jurisdiction and those matters are stated in the findings of fact and conclusions of law without further discussion here. ALJ Thomas H. Walston convened a hearing on the merits on July 29, 2002, at the hearing facilities of the State Office of Administrative Hearings in Austin, Texas. Attorney Steve Tipton represented AHAC and attorney Scott Hilliard represented Waco Ortho. The hearing concluded and the record closed the same day.

II. Discussion

Claimant ___sustained a compensable injury to her lower back on_________. ___initially received treatment, including physical therapy, from another provider (the record does not establish the identity of that provider). The services in dispute for Waco Ortho were provided between September 26, 2000, and January 16, 2001.

A. Range-of-Motion Testing

Background: The first item in dispute is CPT Code 05851, range-of-motion (ROM) testing using a dual inclinometer method. Waco Ortho submitted three bills for this testing on September 26 and November 8, 2000, and January 16, 2001. The Maximum Allowable Reimbursement (MARS) for this service is $36.00 for each testing, and MRD approved total payment of $108.00 for these three tests.

AHAC argues that ROM tests should be included as part of the charge for an office visit with instrumentation (i.e., not billed separately) when the ROM testing is performed by a physical therapist or an occupational therapist. AHAC agrees that a separate charge can be made for ROM testing when it is performed by the treating doctor or under the treating doctor’s direct supervision. But it argues that there is inadequate evidence to establish that a doctor performed the testing in this case, and it contends that Waco Ortho has improperly unbundled these services.

Waco Ortho states that the ROM testing was performed by ___ treating doctor, and it points out that the reports for these tests contained in the official record are signed by “Craig E. Cernosek, D.C.” It also argues that AHAC has the burden of proof as the appellant and that AHAC offered no evidence to establish that anyone other than Dr. Cerosek performed the ROM testing or had it performed under his direct supervision.

ALJ’s Analysis: AHAC offered no evidence on who performed the ___ROM testing. Waco Ortho also offered no direct evidence, but it cited the signed doctor’s reports contained in the official record as some evidence that Dr. Cernosek either performed the ROM testing or had it performed under his direct supervision.

Because AHAC is the appellant, it has the burden of proof. But AHAC offered no evidence to establish that ___ROM testing was not performed either by, or under the direct supervision of, Dr. Cernosek. Further, the ALJ finds that the signed doctor reports are evidence that Dr. Cenosek performed the testing or had it performed under his supervision. Therefore, the ALJ denies AHAC’s appeal on this issue and finds that Waco Ortho is entitled to reimbursement of $108.00 for the ROM testing on the dates mentioned above.

B. Preauthorization for Physical Therapy

(1) October 16, 19, and 20, 2000

Background: The parties agree that ___could receive up to eight weeks of physical therapy without preauthorization. They also agree that Waco Ortho received preauthorization on November 17, 2000, for six additional weeks of therapy, three times per week.

The first dates of service that AHAC disputes based on lack of preauthorization are October 16, 19, and 20, 2000. For these dates, Waco Ortho billed a total of $1,149.00 for CPT Codes 97265, 97250, 97110, and 97014, and the MARS totaled $1,143.00. AHAC contends that Waco Ortho provided these therapy services to ___after her first eight weeks of therapy (which did not require preauthorization) had expired, but before November 17, 2000, when Waco Ortho obtained preauthorization for additional physical therapy. But AHAC offered no evidence on what therapy ___received before October 16, 2000, other than a reference to the prior treating doctor’s referral letter,[1] which stated that ___received “about four weeks” of treatment.

Waco Ortho agrees that the referral letter stated that ___received “about” four weeks of therapy. But even assuming ___previously received a full four weeks of therapy, Waco Ortho states that the dates of service October 16, 19, and 20, 2000, would only have been the eighth week of physical therapy. Thus, Waco Ortho states, because it provided these services during the first eight weeks of therapy, no preauthorization was required and AHAC should pay reimbursement for these services.

ALJ’s Analysis: AHAC offered no evidence to establish the number of weeks of therapy ___received prior to receiving therapy from Waco Ortho, other than the cryptic “about four weeks” comment in the prior treating doctor’s referral letter. And Waco Ortho is correct that the week of October 16, 2000, would have been only its fourth week of therapy. Combining Waco Ortho’s four weeks of therapy with the prior four weeks results in a total of eight weeks of physical therapy, for which no preauthorization was required. Therefore, the ALJ denies AHAC’s appeal on this issue and finds that Waco Ortho is entitled to $1,143.00 reimbursement for physical therapy services provided to ___on October 16, 19, and 20, 2000.

(2) December 4, 2000

MRD approved reimbursement of $280.00 for services performed December 4, 2000. AHAC does not actually dispute this item for lack of preauthorization. Instead, it simply states that it has already paid $140.00 of this amount, and Waco Ortho does not dispute this payment. AHAC did not offer any other evidence to contest this charge. Therefore, the ALJ grants in part AHAC’s appeal on this item, and the amount of reimbursement currently owed is reduced from $280.00 to $140.00.

(3) January 10 and 12, 2001

Background: Waco Ortho billed $628.00 for physical therapy services provided to ___on January 10, and 12, 2001. The MARS for these services is $626.00.

AHAC denied payment for these services because they were provided more than six weeks after the preauthorization given on November 17, 2000, for six weeks additional therapy. By AHAC’s calculation, the six-week preauthorization period expired on January 5, 2001.

Waco Ortho responds that the preauthorization period does not necessarily run from the date of the preauthorization letter. It also points out that it only provided 18 additional therapy sessions (6 weeks X 3 per week), but because of the November and December holiday season, it simply took longer than six calendar weeks to provide six weeks of therapy. In Waco Ortho’s view, a provider should be allowed reasonable additional time to provide the authorized services due to holidays or other extenuating circumstances.

ALJ’s Analysis: A copy of the written preauthorization contained in the record simply states the “Length of Treatment” as “6 wks (3 x wk x 6 wks).” The preauthorization does not specify a beginning or ending date. Therefore, the ALJ agrees with Waco Ortho that it was not required to provide all the services within six calendar weeks of the date of preauthorization. The limitation in this preauthorization is reasonably interpreted as a limit on the amount of therapy provided, not a temporal limitation, provided that the services are provided within a reasonable time. In this case, Waco Ortho acted reasonably in taking seven calendar weeks to provide six weeks of therapy, in light of the holiday season that occurred during the treatment. Therefore, the ALJ denies AHAC’s appeal on these services and finds that Waco Ortho is entitled to $626.00 additional reimbursement for physical therapy services provided on January 12, 2001.

C. Non-prescription Medication

Background: AHAC disputes a $6.00 charge on December 8, 2000, for an over-the-counter muscle relaxer described as ADC303." AHAC complains that this description is insufficient to determine exactly what was given to ___.

Waco Ortho responds that this was an over-the-counter medication that chiropractors are authorized to sell at their offices, which was described by CPT Code 99070.

ALJ’s Analysis: The parties offered virtually no evidence on this issue, presumably due to the small amount in controversy. Thus, the ALJ cannot determine whether the description was adequate. But since AHAC has the burden of proof in this case, the ALJ denies its appeal on this issue and finds that Waco Ortho is entitled to $6.00 reimbursement for this non-prescription medication.

In summary, the ALJ finds that after AHAC is credited with the payments it has made since the date of the MRD decision, Waco Ortho is entitled to additional reimbursement of $2,023.00.

III. FINDINGS OF FACT

  1. On________, Claimant ___suffered a compensable in the course and scope of her employment.
  2. ___injury is covered by workers’ compensation insurance written by American Home Assurance Company (AHAC).
  3. As a result of ___injury, she received treatment from Waco Ortho Rehab.
  4. Craig E. Cernosek, D.C., was ___treating doctor.
  5. Waco Ortho performed range-of-motion (ROM) testing using a dual inclinometer method on ___on September 26 and November 8, 2000, and January 16, 2001.
  6. Waco Ortho billed the ROM testing under CPT Code 05851. The Maximum Allowable Reimbursement (MARS) for this service is $36.00 for each test. AHAC denied payment for these services, but MRD approved reimbursement of $108.00.
  7. The ROM testing was performed by ___treating doctor, Craig E. Cernosek, D.C.
  8. Waco Ortho did not improperly unbundle the charges for ROM testing.
  9. Waco Ortho is entitled to total reimbursement of $108.00 for the three ROM tests performed on ___on September 26 and November 8, 2000, and January 16, 2001.
  10. The physical therapy services provided by Waco Ortho to ___on October 16, 19, and 20, 2000, were included within the first eight weeks of physical therapy for ___, which did not require preauthorization.
  11. Waco Ortho billed a total of $1,149.00 for CPT Codes 97265, 97250, 97110, and 97014 for the physical therapy provided to ___on October 16, 19, and 20, 2000. The MARS for these services totaled $1,143.00.
  12. Waco Ortho is entitled to total reimbursement of $1,143.00 for the physical therapy provided to ___on October 16, 19, and 20, 2000.
  13. AHAC has paid $140.00 of $280.00 billed by Waco Ortho for physical therapy services provided to ___on December 4, 2000.
  14. Waco Ortho is entitled to additional reimbursement of $140.00 for the physical therapy provided to ___on December 4, 2000.
  15. Waco Ortho billed $628.00 for physical therapy services provided to ___on January 10, and 12, 2001. The MARS for these services is $626.00.
  16. On November 17, 2000, AHAC gave Waco Ortho preauthorization for six weeks of additional physical therapy for ___. This preauthorization did not specify a beginning or ending date.
  17. Because of the November and December 2000 holiday season, it took Waco Ortho longer than six calendar weeks to provide six weeks of therapy.
  18. Waco Ortho acted reasonably in taking seven calendar weeks to provide six weeks of therapy, in light of the holiday season that occurred during the treatment.
  19. Waco Ortho is entitled to $626.00 additional reimbursement for physical therapy services provided between November 17, 2000, and January 12, 2001.
  20. Waco Ortho charged $6.00 on December 8, 2000, for an over-the-counter muscle relaxer (described as ADC303") provided to ___
  21. Waco Ortho is entitled to reimbursement of $6.00 for the over-the-counter muscle relaxer provided to ___on December 8, 2000.
  22. In a decision issued August 22, 2001, the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) ordered AHAC to pay Waco Ortho additional reimbursement totaling $4,977.00.
  23. Except for the items discussed in Findings of Fact Nos. 5 through 21, AHAC has paid all amounts awarded by MRD in its decision issued August 22, 2001.
  24. AHAC timely appealed MRD’s decision to the State Office of Administrative Hearings (SOAH).
  25. On September 19, 2001, notice of a hearing in this case was mailed to all parties to this case.
  26. On July 29, 2002, a hearing convened in Austin, Texas, on AHAC’s appeal. Representatives of Waco Ortho and AHAC appeared. No one representing the Commission appeared at the hearing. The record closed the same day.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code (Labor Code) § 413.031.
  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 Labor Code §413.031 and Tex. Gov’t Code (Gov’t Code) ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code §§ 2001.051 and 2001.052.
  4. Based on Findings of Fact Nos. 5 through 23, Waco Ortho is entitled to additional reimbursement from AHAC in the amount of $2,023.00.

ORDER

IT IS ORDERED that Waco Ortho Rehab shall have and recover of and from American Home Assurance Company the total sum of $2,023.00 for the services provided to ___that are the subject of this proceeding.

Signed August 21, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

THOMAS H. WALSTON

ADSTRATIVE LAW JUDGE

  1. This letter was not introduced into evidence by either party.
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