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At a Glance:
Title:
453-02-0971-m4
Date:
June 28, 2002
Status:
Medical Fees

453-02-0971-m4

June 28, 2002

DECISION AND ORDER

This case concerns whether SCD Back & Joint Clinic, Ltd. (SCD) should be reimbursed for three 15-minute units of muscle testing conducted on a workers= compensation claimant. The testing was conducted on a single body area of the claimant on two separate dates of service; the gist of the dispute is whether muscle testing on one body area must be reimbursed as a single unit, regardless of the time spent, or in 15-minute increments. The amount in dispute is $129.00.

The Administrative Law Judge concludes the Medical Fee Guideline allows reimbursement for muscle testing on a single body area in 15-minute increments. Therefore he orders the additional reimbursement.

I. Discussion

SCD performed various disputed medical services for the Claimant from January 31, 2001, through March 2, 2001. In a decision issued November 5, 2001, the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (the Commission) ordered additional reimbursement of $208.00. The remaining dispute is over muscle testing performed on the Claimant's right knee on February 20 and February 22, 2001.

Regarding muscle testing, the Commission's 1996 Medical Fee Guideline (MFG), states:

Muscle testing (97750-MT) requires a report identifying the service provided, results, and interpretation of the test and shall be reimbursed per body area (see section (I)(D)(1) of the ground rules for this section). If two or more contiguous areas are injured and if testing requires no additional tasks, then reimbursement shall be allowed for only one body area. Muscle testing shall not be reimbursed in addition to a functional capacity evaluation (FCE). Muscle testing may be used to replace any six components of the functional abilities test and shall be reimbursed (by time required) as a component of the FCE, not exceeding the MAR for an FCE.

1996 MFG, page 35.

The MFG describes CPT code 97750 s Aphysical performance test or measurement (e.g musculoskeletal, functional capacity) with written report, each 15 minutes . . . . 1996 MFG, page 60.

There is no factual issue in this case. SCD performed two isometric muscle tests on the Claimant's right knee, for a total of 45 minutes, on February 20, 2001. It performed another test on the knee, for 30 minutes, on February 22, 2001. The question is how much reimbursement the MFG allows for that testing. SCD seeks reimbursement for each 15-minute unit, at $43.00 per unit. American Home Assurance (the Carrier) has reimbursed it only for $43.00 for each session. The difference is three 15-minute units, at $43.00 per unit, or $129.00.

The MFG's verbige is not very clear. However, the logical starting point is the definition of muscle testing found on page 35, which requires reimbursement Aper body area. That restriction prevents a provider from attempting to be reimbursed for each muscle tested within a body area. In this case, the relevant body area is listed under section (I)(D)(1)(b)(i): AHip/Knee. A provider could not charge for administering the same test to both the hip and the knee. However, a provider could charge for more than one testing unit within that area, with reimbursement limited to the MAR level.

The MAR level allows 15-minute increments of testing, as long as those tests are otherwise reasonable and necessary. In this case, there is no dispute about the reasonableness of the tests. Therefore, the provider is allowed to charge for each 15-minute unit of testing within the body area. In this instance, SCD should be reimbursed the additional $129.00, along with interest as required.

II. Findings of Fact

  1. The Claimant sustained a compensable knee injury on (date of injury) and sought treatment from SCD Back & Joint Clinic, Ltd. (SCD).
  2. SCD performed various disputed medical services for the Claimant from January 31, 2001, through March 2, 2001.
  3. In a decision issued November 5, 2001, the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (the Commission) ordered additional reimbursement of $208.00.
  4. SCD filed a timely appeal of the MRD decision.
  5. Notice of the hearing was sent December 4, 2001.
  6. 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.
  7. The hearing was held April 10, 2002, with Administrative Law Judge Henry D. Card presiding and representatives of SCD and American Home Assurance (the Carrier) participating. The hearing was adjourned the same day.
  8. SCD performed 45 minutes of muscle testing on the Claimant's right knee on February 20, and 30 minutes of testing on that knee on February 22, 2001, and requested $215.00 in reimbursement.
  9. The Carrier reimbursed SCD $43.00 for each date of service, leaving $129.00 in dispute.

III. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq.
  2. 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.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov=t Code Ann. '2001.052.
  4. SCD has the burden of proof in this matter. 28 Tex. Admin. Code '148.21(h).
  5. The Commission's 1996 Medical Fee Guideline allows a health care provider to charge for each 15-minute unit of testing within each body area.
  6. SCD should be reimbursed the additional $129.00, along with interest as required.

ORDER

IT IS, THEREFORE, ORDERED that American Home Assurance shall reimburse SCD Back & Joint Clinic, Ltd. $129.00, plus applicable interest, for muscle testing conducted on the Claimant on February 20 and 22, 2001.

Signed June 28th, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

End of Document
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