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At a Glance:
Title:
453-02-1004-m5
Date:
April 19, 2002
Status:
Retrospective Medical Necessity

453-02-1004-m5

April 19, 2002

DECISION AND ORDER

This case is a dispute over whether Respondent Billing R Us should receive additional reimbursement from Petitioner TASB Risk Management Fund (“TASB”) for the administration of monitored anesthesia (MAC) by Dr. Sherolyn Simmons during an Intra Discol Electro Therapy (IDET) procedure for lumbar discogenic pain and disc disruption. The Administrative Law Judge (ALJ) concludes Billing R Us is entitled to additional reimbursement in the amount of $360.00.

The hearing was held February 20, 2002, with Administrative Law Judge (ALJ) Nancy N. Lynch presiding. Jane Lipscomb Stone appeared representing TASB; Debi Martinez appeared by telephone for Billing R Us. The hearing was adjourned the same day.

I. DISCUSSION

Petitioner’s Position

TASB initially denied Billing R Us’s claim (twice), based on lack of medical necessity. After Billing R Us requested medical dispute resolution, TASB decided the anesthesia was medically necessary and paid partial reimbursement. However, it then argued that the procedure involved only a “simple injection” and CPT Code 00630, used by Billing R Us, was inappropriate because it was intended for more invasive procedures under general anesthesia. TASB argued that there is no CPT Code for monitored anesthesia care (MAC), and therefore, pursuant to 28 TAC § 133.304(i) TASB was required to “establish and consistently apply the methodology for determination of fair and reasonable” reimbursement. This it did by turning to a TWCC Problem Solver issued in 1994, based on the 1991 Medical Fee Guideline. Based on its “fair and reasonable” methodology, TASB found it appropriate to pay $240.00 for six time units (90 minutes) multiplied by the conversion factor of $40.00 plus interest of $15.17. As Petitioner, TASB has the burden of proof. 28 Tex. Admin. Code (TAC) §148.21(h).

Respondent’s Position

Billing R Us maintained CPT Code 00630 was appropriate by straightforward application of its terms: “Anesthesia for procedures in lumbar region; not otherwise specified.” This procedure was in the lumbar region, and monitored anesthesia care is not otherwise specified in the CPT Codes. The Anesthesia Ground Rules, at page 193, specifically includes monitored anesthesia case in its definition of anesthesia: “Anesthesia care may include but is not limited to general, regional, or monitored anesthesia care, supplementation of local anesthesia, or other supportive services in order to afford the patient the anesthesia care deemed optimal by the anesthesiologist or Certified Registered Nurse Anesthesiologist (CRNA) during any procedure.” (emphasis added)

Medical Review Division

The MRD found in favor of Billing R Us and ordered an additional payment of $360.00, allowing eight RVUs as provided for CPT Code 00630 and one unit risk factor in addition to the six time units used by TASB to calculate its previous reimbursement. It rejected the Carrier’s use of the 1994 Problem Solver issued by TWCC relating to its 1991 Medical Fee Guideline because the services were performed according to the 1996 Medical Fee Guideline.

ALJ’s Conclusion

The ALJ concludes that CPT Code 00630 applies to this procedure by its terms. This interpretation is consistent with the definition of anesthesia in the Anesthesia Ground Rules of the 1996 Medical Fee Guideline and the way other forms of anesthesia are handled in the CPT Codes.

II. FINDINGS OF FACT

  1. On ______, Claimant___, diagnosed with lumbar discogenic pain and disc disruption, underwent Intra Discol Electro Therapy (IDET) in the lumbar region.
  2. Sherolyn Simmons, M.D., provided professional monitored anesthesia care to Claimant, while another doctor performed the IDET.
  3. Billing R Us sought reimbursement for Dr. Simmons’s services under CPT Code 00630, the code for “Anesthesia for procedures to lumbar region; not otherwise specified.”
  4. Billing R Us filed a request for medical dispute resolution based on TASB’s finding of no medical necessity.
  5. After twice rejecting the claim based on lack of medical necessity, TASB paid $240 plus interest, claiming the CPT Code used by Billing R Us did not apply to this procedure, that there was no CPT Code in the Medical Fee Guideline that did apply to it, and that its $240 reimbursement was fair and reasonable according to its methodology.
  6. The Commission’s Medical Review Division (MRD) found in favor of Billing R Us.
  7. TASB filed a timely appeal of the MRD decision.
  8. Notice of the hearing was sent November 30, 2001.
  9. 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.
  10. The hearing was held February 20, 2002, with Administrative Law Judge (ALJ) Nancy N. Lynch presiding and representatives of TASB and Billing R Us participating. The hearing was adjourned the same day.
  11. The 1996 Medical Fee Guideline, Anesthesia Ground Rules, General Information and Instructions, subpart A, specifically included monitored anesthesia care in its description of anesthesia care and procedures:

Anesthesia care may include but is not limited to general, regional, or monitored anesthesia care, supplementation of local anesthesia, or other supportive services in order to afford the patient the anesthesia care deemed optimal by the anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) during any procedure.

  1. CPT Code 00630, “anesthesia for procedures in lumbar region; not otherwise specified,” covers monitored anesthesia care for procedures in the lumbar region.
  2. Monitored anesthesia care is anesthesia “not otherwise specified.”
  3. The anesthesia in this case was for a procedure in the lumbar region.
  4. Other anesthesia CPT codes do not differentiate between “general, regional, or monitored anesthesia care, supplementation of local anesthesia, or other supportive services.”
  5. The appropriate reimbursement for anesthesia care in this case is determined by adding the basic value associated with the CPT Code, plus time units, plus any risk units, and multiplying the total number of units by the dollar conversion factor. 1996 MFG, Anesthesia Ground Rules, General Information and Instructions.
  6. The relative value unit (RVU) assigned to CPT Code 00630 in the 1996 MFG is eight.
  7. The administration of anesthesia began at 4:10 p.m. and ended at 5:36 p.m. for a total of 86 minutes, or six time units.
  8. One risk unit was assigned to this patient who had a history of hypertension and migraine headaches, and there was a risk that movement during the procedure could result in unnecessary and serious complications.
  9. The number of units for this procedure was fifteen, comprised of eight relative value or “base” units, six time units, and one risk unit.
  10. The conversion factor for anesthesiologists under the 1996 MFG Anesthesia Ground Rules was $40.00 per unit.
  11. The appropriate total reimbursement for this procedure was $600.00.
  12. TASB has paid $240 plus interest to Billing R Us.
  13. Billing R Us is entitled to further reimbursement of $360.00 plus interest.

III. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction over this matter pursuant to § 413.031 of the Texas Workers’ Compensation Act. Tex. Labor Code Ann. ch. 401 et seq.
  2. The State Office of Administrative Hearings has jurisdiction to issue a decision and order, pursuant to Tex. Labor Code Ann. 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann.§§2001.051 and 2001.052.
  4. TASB, Petitioner herein, had the burden of proof in this matter. 28 Tex. Admin. Code (TAC) § 148.21(h).
  5. TASB did not prove that CPT Code 00630 does not apply to the services rendered by Billing R Us.
  6. The administration of monitored anesthesia was appropriately billed under CPT Code 00630 of the 1996 Medical Fee Guideline as an anesthesia procedure “not otherwise specified.”
  7. TASB is required to reimburse to Billing R Us as set out in the Findings of Fact and Conclusions of Law.

ORDER

IT IS, THEREFORE, ORDERED that TASB Risk Management Fund shall pay Billing R Us additional reimbursement in the amount of $360.00 plus accrued interest within 30 days of the date of this order.

Signed this 19th day of April, 2002.

Nancy N. Lynch
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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