DECISION AND ORDER
This case is a dispute over whether the charge for the presence of an assistant surgeon during Claimant’s back surgery should be reimbursed, when the assistant surgeon’s presence for 70 percent of the operation time was not documented in the operative report as required by the Medical Fee Guidelines (MFG). The amount in controversy is $531.00.
The Administrative Law Judge (ALJ) concludes the Petitioner -- through the assistant surgeon’s testimony -- met its burden of proving the assistant surgeon was present for 70 percent of the time during the surgery in question. Therefore, reimbursement of $531.00 is ordered.
Findings of Fact
- (Claimant) suffered a compensable workers’ compensation injury on___________.
- Floyd Hardimon, D.O., of East Harris County Orthopedic Associates, P.A. (Petitioner) performed back surgery on Claimant on September 14, 2000.
- During the September 14, 2000, back surgery, Dr. Hardimon was assisted by Eric Scheffey, M.D.
- Dr. Scheffey’s presence was necessary because the by-laws of the hospital in which Claimant’s surgery was performed require the presence of an assistant surgeon during surgery.
- Petitioner billed Transportation Insurance Company (Respondent) $250.00 using CPT Code 20975-80 and $1,000.00 using CPT Code 22830-80, for a total of $1,250.00 for procedures performed during Claimant’s back surgery.
- The Maximum Allowable Reimbursement (MAR) for CPT code 20975-80 (invasive electrical stimulation to aid bone healing) is $113.75 and for CPT Code 22830-80 (exploration of spinal fusion) is $417.25, for a total of $531.00.
- Respondent denied reimbursement on the grounds that the procedure was incidental to the related primary procedure billed, and the procedure was not payable to an assistant surgeon.
- Petitioner filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement of $531.00.
- On October 25, 2001, the Commission’s Medical Review Division (MRD) denied the request for reimbursement because Petitioner’s operative report did not state the assistant surgeon was present for 70 percent of the time during surgery.
- Petitioner filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
- Notice of the hearing was sent December 4, 2001.
- 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.
- The hearing was held February 4, 2002, with ALJ Sharon Cloninger presiding and representatives of Transportation Insurance Company and East Harris County Orthopedic Associates, P.A. participating. The hearing adjourned and the record closed the same day.
- Under the MFG, for charges billed under CPT Code 20975-80 and/or CPT Code 22830-80, documentation shall substantiate the attendance of the assistant surgeon 70 percent of the time during one operative session.
- While Petitioner’s operative report did not document that Dr. Scheffey was present for 70 percent of the time during the back surgery performed on September 14, 2000, Dr. Scheffey testified at the hearing that he was present for between 70 percent and 90 percent of the time during Claimant’s back surgery.
- Assistant surgeon Dr. Scheffey was present for between 70 percent and 90 percent of the time during Claimant’s back surgery performed on September 14, 2000.
Conclusions of Law
- 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.
- 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.
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
- The Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
- East Harris County Orthopedic Associates, P.A., met its burden of proving it was entitled to reimbursement.
- East Harris County Orthopedic Associates, P.A.’s request for reimbursement should be granted.
IT IS, THEREFORE, ORDERED that $531.00 be paid by Transportation Insurance Company to East Harris County Orthopedic Associates, P.A., for the charges billed under CPT Code 20975-80 and CPT Code 22830-80.
Signed February 8, 2002.
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS