DECISION AND ORDER
I. PROCEDURAL HISTORY
Petitioner, Liberty Mutual Insurance Company (Liberty Mutual), seeks to avoid reimbursement to First Rio Valley Medical (First Rio Valley) for the sterile whirlpool treatment administered to workers compensation Claimant_____ on December 7, 2000. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) granted the forty-dollar reimbursement to First Rio Valley. Petitioner challenged the MRD’s decision.
The Administrative Law Judge (ALJ) convened the hearing on September 9, 2002. The hearing concluded and the record closed on that date. Attorney Shannon Butterworth represented the Petitioner, but First Rio Valley did not appear and was not represented at the hearing.
II. EVIDENCE AND BASIS FOR DECISION
The issue in this case is whether Petitioner properly denied reimbursement to First Rio Valley for the sterile whirlpool treatment administered to the Claimant because the service was covered under a global procedure that had already been paid.
The documentary evidence consisted of the 63-page certified record of the MRD proceeding. Ms. Butterworth clarified that the MRD’s failure to consider Liberty Mutual’s response was due to a typographical error. While the response was untimely filed with the MRD, the ALJ will nevertheless consider it. Liberty Mutual initially denied the whirlpool treatment based on denial code, Global (“G”). The Global fee is a concept where a single fee is billed and paid for all necessary services performed before, during, and after a surgical procedure (i.e., necessary and related procedures are bundled into one global procedure for billing purposes). As indicated in the explanation of benefits form (TWCC-62), exception or denial code G is described as “Unbundling” and is to be used when the carrier is denying payment for a treatment or service because the charge was included in another billed procedure. In the August 23, 2001, response to the MRD, Liberty Mutual further explained the reason for denying payment for the whirlpool treatment, stating that CPT 97022 (whirlpool)is denied as this is considered to be an integral component of CPT 97035 (ultrasound). Liberty Mutual further stated: “These are different procedures that all provide the same therapeutic goal which is the delivery of heat to an affected body area. There is little additional benefit by performing two or more of these modalities at the same session.” By the latter statement, Liberty Mutual appears to attempt to change its denial code, Global, to Unnecessary, reasoning that since the same type of heat treatment was previously administered to Claimant, it was not necessary to provide the whirlpool treatment also. However, since Petitioner had not previously alerted First Rio Valley of this reason for denial, it is not permitted to change or add a denial code at this stage.
The MRD concluded that the whirlpool treatment, billed under CPT Code 97022-22, was not global to any other code, and that it should be paid as billed. The ALJ agrees and orders the Petitioner to reimburse the claim. The particular facts, reasoning, and legal analysis in support of this decision are set out below in the Findings of Fact and Conclusions of Law.
III. FINDINGS OF FACT
- On________, Claimant, an employee of_________, suffered a compensable injury that resulted in a lumbar sprain.
- _________had workers’ compensation coverage with the Liberty Mutual Insurance Company (Liberty Mutual or Petitioner) at that time.
- Claimant was diagnosed with a lumbar sprain and facet syndrome and was treated by First Rio Valley Medical (First Rio Valley or Respondent) for lower back pain.
- On December 7, 2000, Claimant was experiencing moderate to constant pain in his lower back. Claimant rated his pain as a five on a scale of one to ten, with ten being the worst.
- On December 7, 2000, Respondent rendered the following services to Claimant: joint mobilization procedures on the lumbar spine, therapeutic massage to promote relaxation of muscles, ultrasound therapy, and sterile whirlpool treatment.
- Claimant’s treating physician ordered the sterile whirlpool treatment to stimulate the blood circulation to the injured part of his spine, reduce the amount of pain, and create passive exercise. The ultrasound treatment was ordered to provide a mild sedative effect and to break down scar tissue in order to expedite the healing process.
- The whirlpool must be sterilized after each patient’s use in order to prevent bacterial infection.
- After the December 7, 2000 treatments, Claimant experienced a decrease in symptoms.
- Respondent submitted its charges ($235) to Petitioner for the treatments provided. The whirlpool treatment was billed under CPT Code 97022-22.
- Petitioner paid the charges, except for the $40 sterile whirlpool treatment charge, denying it under the Global exception code.
- Petitioner presented no evidence that sterile whirlpool treatment is included or bundled in the ultrasound (CPT Code 97035) procedure.
- Respondent requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD) on March 23, 2001, seeking reimbursement for the sterile whirlpool treatment.
- On September 17, 2001, the MRD issued a decision recommending the $40 reimbursement for the sterile whirlpool treatment because the physician-ordered treatment (CPT Code 97022) is not Global to any other code.
- The MRD did not consider Petitioner’s response to request for medical dispute resolution because it concluded the response was not timely.
- Petitioner received notice of the dispute on August 9, 2001; Petitioner submitted a letter dated August 23, 2001, to the MRD, but the letter was not received by the MRD until August 27, 2001, making the response untimely.
- Petitioner attempted to deny the claim for sterile whirlpool treatment as unnecessary medical treatment in its response dated August 23, 2001, arguing that the treatment was not necessary because the same type of heat treatment (ultrasound) had already been provided to Claimant.
- Petitioner had not previously informed First Rio Valley that it was denying reimbursement because the whirlpool treatment was not necessary.
- On September 28, 2001, Petitioner appealed the MRD’s decision.
- On November 12, 2001, the Commission sent a notice of hearing to the parties. The notice contained a statement of the time and place of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular section of the statutes and rules involved; and a short plain statement of the matters asserted.
- The hearing on the merits was convened on September 9, 2002. Attorney Shannon Butterworth represented Petitioner. Although attorney William Maxwell had entered his appearance on behalf of Respondent, no one appeared at the hearing for Respondent. The hearing concluded on September 9, 2002 and the record closed on that date.
IV. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. §413.031.
- 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(k) of the Act; Tex. Gov’t Code Ann. ch. 2003, and 28 Tex. Admin. Code chs. 148 and 149.
- Petitioner timely appealed the MRD’s decision, pursuant to 28 TAC § 148.3.
- The Commission sent a notice of hearing that complied with the requirements of Tex. Gov’t Code § 2001.052 and 28 TAC § 148.4(b).
- Petitioner had the burden of proof to show by a preponderance of the evidence that it should prevail in this matter, pursuant to §413.031 of the Act and 28 TAC §148.21(h) and (i).
- Section 408.021 of the Act and 28 TAC § 134.1, provide that health care providers shall bill carriers only for treatments and services rendered that are medically necessary to treat the compensable injury, and in accordance with Commission rules and guidelines.
- Section 408.027 of the Act provides that a carrier is to pay health care providers for such services within a specified period unless the claim is disputed. If a carrier disputes the claim, it is required to provide the health care provider and the injured worker with an explanation of the reason or reasons for denial or reduction of the claim within a specified time period.
- If a carrier has not informed the health care provider of a particular reason for denial prior to the provider’s request for medical dispute resolution, the carrier cannot change or add a denial code after a dispute is at the MRD for review or at a contested case hearing before SOAH. § 408.027(d) of the Act and 28 TAC §133.304(a).
- Petitioner failed to show that sterile whirlpool treatment was bundled under the ultrasound procedure (CPT Code 97035), so that denying reimbursement for the treatment was proper under the Global denial code.
It is hereby ordered that Liberty Mutual Insurance Company shall reimburse First Rio Valley Medical $40 plus interest for the sterile whirlpool treatment provided Claimant on December 7, 2000.
Signed this 4th day of October, 2002.
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- Ms. Butterworth advised the ALJ that she received a motion for continuance from First Rio Valley’s attorney the Friday afternoon before the Monday hearing. The motion had been faxed to the Attorney General’s office, where Ms. Butterworth used to work. Someone at that office had recognized her name and had faxed it to her current employment. Ms. Butterworth argued the motion should be denied for numerous reasons. First, the motion had not been filed with SOAH or with opposing counsel at the correct address. Second, SOAH rule 1 TAC §'155.29(f) requires that a motion for continuance be filed at least five days prior to the scheduled hearing and that the movant confer with opposing party regarding the requested continuance. Because Petitioner did not comply with the rule, the motion should be denied. The ALJ agreed and denied the motion for continuance.↑
- The MRD did not consider Liberty Mutual’s response when it reviewed the dispute in this case because it found that the response was dated September 23, 2001, and received on September 27, 2001. In fact, according to the certified record, the Petitioner received notice of the request for dispute resolution on August 9, 2001; Petitioner’s letter responding to the dispute was dated August 23, 2001, 14 days after receipt of the notice which would make the response timely. However, the response was date-stamped “August 27, 2001” at the Commission, indicating it was received four days late. (Emphasis added).↑
- The proposition that, absent some extenuating circumstances, a carrier may not change denial codes at the MRD proceeding or at the SOAH hearing is well established and reflected in the following SOAH decisions: Docket Nos. 453-00-1570.M5 (Oct. 20, 2000, ALJ Smith); 453-99-2021.M5 (July 20, 2000, ALJ Rusch); 453-99-3399.M5 (May 18, 2000, ALJ Pacey).↑