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At a Glance:
Title:
453-02-0666-m4
Date:
May 21, 2004
Status:
Medical Fees

453-02-0666-m4

May 21, 2004

DECISION AND ORDER

Texas Mutual Insurance Company (Carrier) appealed the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) ordering Carrier to pay $2,696 to Boyd Chiropractic Center (Provider) for services billed under CPT Codes 97110, 97545-WC, and 97546-WC. After considering the evidence and arguments presented, the Administrative Law Judge (ALJ) concludes that Provider is entitled to no reimbursement, and Carrier is not required to reimburse Provider under the MRD order in this docket.

I. BACKGROUND FACTS AND PROCEDURAL HISTORY

Claimant _____ suffered a work-related injury to his lower back on ________. Claimant began receiving treatment from Provider. As part of his treatment, Claimant underwent therapeutic exercises and work conditioning. The specific dates of service for the treatments that are in dispute in this case are August 4, 2000, through September 8, 2000. For treatment during that time period, Provider billed under CPT Codes 97110 (one-on-one therapeutic exercises), and 97545-WC and 97546-WC for work conditioning. Carrier denied reimbursement for the treatment and Provider requested medical dispute resolution by the Commission. The Commission’s MRD reviewed the matter and determined that Provider was entitled to additional reimbursement of $2,696 for 40 units of one-on-one therapy and 36 hours of work conditioning. Carrier then requested a hearing before SOAH, resulting in this proceeding.

II. DISCUSSION AND ANALYSIS

The issues in this case are (1) whether services billed under CPT Code 97110 were properly provided and, if they were, whether they were medically necessary; and (2) whether work conditioning was properly provided and, if it was, whether it was medically necessary.

First, as to services billed under CPT Code 97110, the ALJ concludes that one-on-one therapy was not properly provided. Therefore, the Provider is not entitled to reimbursement for services billed under that code. The medical and legal authority is amply clear that CPT Code 97110 is to be used only when the health care provider has worked directly one-on-one with the patient in regard to that patient’s therapy alone. Carrier cites to numerous previous decisions that recognize this principle and which cite to the American Medical Association’s billing guidelines for CPT codes.[1] The ALJ agrees with this authority and concludes that Provider is entitled to reimbursement under CPT Code 97110 only if one-on-one direct therapy was provided.

In this case, the evidence establishes that Provider’s staff generally did not provide one-on-one therapy to Claimant. Instead, Provider’s staff usually supervised several people at one time, all of whom would be exercising in the same area.[2] Although there may have been times where one-on-one therapy was provided, there is no clear delineation from the evidence of when that occurred. The Claimant clearly testified that the supervising therapist was frequently monitoring other patients at the same time. Because CPT code 97110 is used only for one-on-one therapy-and the evidence does not show that one-on-one therapy was properly provided to Claimant for the time periods in issue-Provider is not entitled to recover for services billed under CPT Code 97110. Moreover, from a review of the evidence, the ALJ also agrees that one-on-one therapy would not have been medically necessary treatment for Claimant. Rather, Claimant’s condition warranted a home exercise program or, at most, a group exercise program.[3] For these reasons, the ALJ concludes that Provider is not entitled to reimbursement for treatment billed under CPT Code 97110.

Next, the ALJ turns to the work conditioning services provided to Claimant. Carrier argues that Provider did not properly document work conditioning for Claimant. Carrier notes that Provider’s treatment documentation is the same as that used for therapeutic services billed under CPT Code 97110. Moreover, Carrier alleges that there are discrepancies in the time billed for services, asserting Provider billed for 4 hours of work conditioning even though Claimant performed virtually the same exercises that were completed (and billed under CPT Code 97110) in less than 2 hours on other dates of service.[4] For example, Carrier points out that, on August 16, 2000, Claimant performed the exact same exercises with the same number of repetitions as he performed on September 1, 2000. The only apparent difference is that Claimant also spent 15 additional minutes on the treadmill on September 1, 2000. Despite this, there is nearly a 3-hour billing difference between August 16, 2000, and September 1, 2000. Carrier argues that this cannot be correct and reflects improper billing by Provider. Further, Carrier argues that the treatment notes show only basic physical therapy exercises being provided and does not reflect true work conditioning or any therapy directly related to Claimant’s job as a welder. For these reasons, Carrier argues that Provider is not entitled to reimbursement for work conditioning.[5]

After considering the arguments and evidence presented, the ALJ finds that the significant discrepancies in Provider’s records cause the ALJ to doubt the validity of the treatment provided. In particular, Carrier is correct in noting that Provider’s records show that the work conditioning program was exactly the same in many instances as the one-on-one therapy that was billed, with the exception that work conditioning was billed for greater periods of time, even though the exercises and repetitions involved were similar. Provider has given no explanation for this.

Moreover, the ALJ finds that the treatments provided do not conform to the Commission’s requirements for work conditioning. The Commission’s rules define work conditioning as “a highly structured, goal oriented, individualized treatment program using real or simulated work activities in conjunction with conditioning tasks.”[6] One of the entrance criteria is that the injured worker be a person whose current level of functioning interferes with their ability to carry out specific identifiable tasks required in the workplace. In this case, the records do not show that any individualized treatment program was designed for Claimant, taking into account his specific work-related skills. The records do not reflect that “real or simulated work activities” relevant to Claimant’s work were used in Claimant’s treatment program. Rather, Provider used a generic “work simulation activity sheet” as the basis for Claimant’s exercises, with most of the exercises having no relationship whatsoever to Claimant’s job.[7] In his deposition, Claimant identified only one task, pushing carts with heavy weights that had any relationship to his work.[8] Every other task he was required to perform in work conditioning, he did not perform at his work.[9]

In total, the records reflect little more than an ongoing exercise and physical therapy program, which does not meet the criteria for work conditioning. For this reason, the ALJ concludes that Provider did not provide the services as billed and is not entitled to reimbursement. In support of the determinations stated above, the ALJ makes the following findings of fact and conclusions of law.

III. FINDINGS OF FACT

  1. _____ (Claimant) suffered a compensable, work-related injury to his back on______.
  2. Claimant began receiving treatment for his injury from Boyd Chiropractic Center (Provider).
  3. As part of his treatment, Claimant underwent therapy and purported work conditioning.
  4. The specific dates of service for the treatments in dispute in this case are August 4, 2000, through September 8, 2000.
  5. For treatment provided to Claimant between August 4, 2000, and September 8, 2000, Provider billed under CPT Codes 97110 (one-on-one therapeutic exercises), and 97545-WC and 97546-WC for work conditioning.
  6. Texas Mutual Insurance Company (Carrier) denied reimbursement for the treatments referenced above.
  7. Provider requested medical dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD).
  8. On September 7, 2001, after conducting medical dispute resolution, MRD issued an order determining that Provider was entitled to additional reimbursement of $2,696 for 40 units of one-on-one therapy and 36 hours of work conditioning.
  9. Carrier received the MRD decision on September 21, 2001.
  10. On October 5, 2001, Carrier requested a hearing on the MRD decision and the case was referred to the State Office of Administrative Hearings (SOAH).
  11. The hearing convened on December 10, 2003, with ALJ Craig R. Bennett presiding. Carrier appeared through its attorney, Katie Kidd. Provider appeared through its attorney, Reynaldo Garza, III. The record closed on May 7, 2004, after the parties filed written arguments.
  12. No parties have raised challenges to notice or jurisdiction.
  13. Provider’s staff generally did not provide one-on-one therapy to Claimant. Instead, Provider’s staff usually supervised several people at one time, all of whom would be exercising in the same area.
  14. Claimant’s condition warranted a home exercise program or, at most, a group exercise program, and one-on-one physical therapy was not necessary for treatment of Claimant’s injury.
  15. The work conditioning program provided to Claimant by Provider was exactly the same in many instances as the one-on-one therapy that was billed under CPT Code 97110, with the exception that work conditioning was billed for greater periods of time, even though the exercises and repetitions involved were similar.
  16. Provider did not develop an individualized treatment program designed for Claimant, taking into account his specific work-related skills.
  17. The records do not show that "real or simulated work activities" relevant to Claimant’s work were used in Claimant’s work conditioning treatment program. Rather, Provider used a generic "work simulation activity sheet" as the basis for Claimant’s exercises, with most of the exercises having no relationship whatsoever to Claimant’s job.
  18. Although Claimant’s last job was as a welder, the work simulation sheet used by Provider was preprinted and included activities such as "sled," dolly," "boxes," "balance beam," etc.
  19. Provider did not get a description of Claimant’s job from Claimant’s employer.
  20. Except for pushing carts with heavy weights, the tasks Claimant performed in work conditioning were tasks that he did not do in his job.

IV. CONCLUSIONS OF LAW

  1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers’ Compensation Act (the Act), specifically Tex. Labor Code Ann. §413.031 and Tex. Gov’t Code Ann. ch. 2003.
  2. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001, and 28 Tex. Admin. Code ch. 148.
  3. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code § 148.3.
  4. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
  5. Carrier has the burden of proof in this matter. 28 Tex. Admin. Code §§ 148.21(h) and 133.308(v).
  6. Under the American Medical Association’s billing guidelines for CPT codes, CPT Code 97110 is to be used only when the health care provider has worked directly one-on-one with the patient in regard to that patient’s therapy alone. See SOAH Docket No. 453-01-1188.M5 (April 3, 2002)(ALJ Smith); SOAH Docket No. 453-00-2051.M4 (December 1, 2000)(ALJ O’Malley); SOAH Docket No. 453-01-1081.M4 (May 25, 2001)(ALJ Smith); SOAH Docket No. 453-01-1492.M5 (July 23, 2001)(ALJ Cunningham).
  7. Carrier established, by a preponderance of the evidence, that Provider did not properly provide one-on-one physical therapy, as required for treatments billed under CPT Code 97110.
  8. The Commission’s rules define work conditioning as "a highly structured, goal oriented, individualized treatment program using real or simulated work activities in conjunction with conditioning tasks." 1996 Medical Fee Guideline, Medicine Ground Rule II.D.
  9. Carrier established, by a preponderance of the evidence, that Provider did not properly provide work conditioning, as required for treatments billed under CPT Code 97545-WC and 97546-WC.
  10. Provider is not entitled to reimbursement for the disputed services.

ORDER

IT IS, THEREFORE, ORDERED that Texas Mutual Insurance Company is not required to reimburse Boyd Chiropractic Center for services rendered to Claimant _____ between August 4, 2000, and September 8, 2000, billed under CPT Codes 97110, 97545-WC, and 97546-WC.

Signed May 21, 2004.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. See SOAH Docket No. 453-01-1188.M5 (April 3, 2002)(ALJ Smith); SOAH Docket No. 453-00-2051.M4 (December 1, 2000)(ALJ O’Malley); SOAH Docket No. 453-01-1081.M4 (May 25, 2001)(ALJ Smith); SOAH Docket No. 453-01-1492.M5 (July 23, 2001)(ALJ Cunningham); see also Carrier Ex. 7 (AMA’s CPT Assistant).
  2. Carrier Ex. 5, at 14-15, 26, 31-32;
  3. Carrier Ex. 3, at 17-19; also testimony of Dr. Defoyd.
  4. Comparing treatment notes for 8/16/00 to 9/1/00, and 8/14/00 to 8/28/00 and 9/6/00.
  5. Carrier also asserts that work conditioning was not medically necessary. However, Carrier did not deny reimbursement initially on this ground, rather Carrier denied reimbursement on the basis of Code “F” C that the documentation does not support the service billed. Because of this, the ALJ will not consider Carrier’s medical necessity arguments.
  6. 1996 Medical Fee Guideline, Medicine Ground Rule II.D.
  7. Although Claimant was a welder, the work simulation sheet was preprinted and included activities such as “sled,” “dolly” “boxes,” “balance beam,” etc. Nothing in the records indicates that Provider developed any tasks actually related to Claimant’s job. In fact, Provider concedes that it did not get a job description from Claimant’s employer. Ultimately, Claimant did not even return to work, but instead took a job selling cars in Mexico.
  8. Carrier Ex. 5, at 25-26.
  9. Id.
End of Document
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