DECISION AND ORDER
The issue in this proceeding is whether Highpoint Pain Management (Highpoint) is entitled to $700 in reimbursement from Liberty Mutual Insurance (Liberty) for fluoroscopy and epidurography, services that were provided with an epidural steroid injection (ESI). The Administrative Law Judge (ALJ) finds that Highpoint failed to carry its burden of proving it is entitled to reimbursement in the amount of $700. The ALJ finds, however that Highpoint is entitled to reimbursement of $88.
I. JURISDICTION, NOTICE AND PROCEDURAL HISTORY
There were no contested issues of jurisdiction or notice. Therefore, those issues are addressed in the findings of fact and conclusions of law without further discussion here.
The hearing on the merits was conducted by ALJ Katherine Smith on February 20, 2002. The record closed the same day. Highpoint was represented by Connie Morgan and Terri Flinn. Liberty was represented by Mahon B. Garry, Jr., an attorney. The Texas Workers’ Compensation Commission (Commission) did not participate.
Claimant __suffered a compensable injury on____. Deborah Westergaard, M.D., treated Claimant with an ESI at Highpoint on April 24, 2001, at the request of Claimant’s treating doctor, Johann Van Beest, D.C. Dr. Westergaard used a fluoroscope to guide the placement of the needle and epidurography to confirm the spread of the steroid. Dr. Westergaard was reimbursed separately for her services. Highpoint billed Liberty $400 for the fluoroscopy and $300 for the epidurography, using CPT Code 76499 for both procedures. Liberty denied the reimbursement. The Clinic requested dispute resolution. The Commission’s Medical Review Division (MRD) upheld the denial due to improper coding and lack of documentation of medical necessity. Highpoint appealed the decision.
According to Ms. Morgan, who is a certified adjuster at Highpoint, the correct CPT codes for the services at issue, 76005 (fluoroscopic guidance and localization of needle for spine or paraspinous diagnostic or therapeutic injection procedures) and 72275 (epidurography, radiologic supervision and interpretation) are not listed in the Commission’s 1996 Medical Fee Guideline (MFG). Relying on a recommendation from the Commission that Highpoint use a generic code from the MFG, Highpoint used CPT Code 76499, which is defined as an unlisted diagnostic procedure, for both procedures. Ms. Morgan argues that using CPT Code 76000, which is in the MFG, to bill for the fluoroscopy would not reflect what had been preauthorized and would not be fair and reasonable. Highpoint usually bills at $300 to $400 for the use of the fluoroscope to compensate for the radiology equipment, which costs $100,000 and requires $7000 in maintenance. Highpoint asserts that the payment requested is reasonable because carriers have been willing to pay the full amount. Relying on an American Society of Anesthesiologists Newsletter, Ms. Morgan also testified that Highpoint was entitled to bill separately for the epidurography as long as a hard copy of the epidurogram and a written report are available.
Liberty notes that the MFG incorporates usage of the American Medical Association’s 1995 CPT codes and instructs health care providers to select the CPT code that most accurately identifies each service performed. Liberty points out that Dr. Westergaard used CPT Code 76000 when she billed for the fluoroscopic guidance and CPT Code 72010 when she billed for the epidurography. CPT Code 76000 (which refers to fluoroscopy) provides for payment of $88 for the technical component of the procedure. CPT Code 72010 (which refers to a radiologic exam of the spine, entire, survey study, anteroposterior and lateral) provides for a payment of $67 for the technical component. Liberty argues that Highpoint ignored the most appropriate CPT Code 76000 so that it could charge more than the Commission determined was fair and reasonable. Liberty also argues that the MRD correctly found that the Spine Treatment Guideline (STG) does not recognize the need for epidurography during an ESI and that deviation from the STG requires documentation of medical necessity. Relying on TWCC Advisory 97-01, Liberty also asserts that to be reimbursed for fluoroscopic assistance, the provider must include documentation of medical necessity. Pointing to the same American Society of Anesthesiologists Newsletter referred to by Highpoint, Liberty argues that epidurography is not be billed with fluoroscopy.
Although CPT Code 76000 may not specifically delineate how a fluoroscope was used in the medical procedure at issue, it is sufficiently descriptive and generic. It is the fee that TWCC determined is fair and reasonable for the use of a fluoroscope. It should not be ignored just because it may not reimburse the provider for what it believes to be fair and reasonable. CPT Code 76499 is to be used only when the service provided is not specifically listed or is unusual or too variable to have an assigned maximum allowable reimbursement. There is nothing in the record indicating that an ESI with fluoroscopic guidance is an unusual or variable procedure.
The next issue is whether Highpoint should be reimbursed for the epidurography. Ms. Morgan argues that CPT Code 72010 is not an appropriate code because it refers to a radiologic exam of the entire spine, which was not done in this case. Ms. Morgan may have a point. But use of CPT Code 76499 requires documentation of procedure as to the need for the service. But for Dr. Van Beest using the phrase “medical necessity for epidural steroid injections nos. 2 and 3 with epiduragram” in a letter dated April, 16, 2001, there is no documentation establishing the need for the epidurography. Dr. Westergaard’s operative notes also provide no basis for the need for epidurography.
The ALJ finds that Highpoint failed to carry its burden of proving it is entitled to reimbursement in the amount of $700. The ALJ finds, nevertheless, that Highpoint is entitled to reimbursement in the amount of $88.
IV. FINDINGS OF FACT
- Claimant___ suffered a compensable injury on_____, and was employed at the time by an employer carrying workers’ compensation insurance underwritten by Liberty Mutual Insurance (Liberty).
- On April 24, 2001, Deborah Westergaard, M.D., used the facilities of Highpoint Pain Management (Highpoint) to treat Claimant with a fluoroscopically-guided epidural steroid injection (ESI).
- Using CPT Code 76449, Highpoint requested reimbursement from Liberty of $400 for the fluoroscopy and $300 for the epidurography, services that were provided with the ESI.
- Liberty denied the payment.
- Highpoint submitted a request for dispute-resolution on September 21, 2001, to the Texas Workers’ Compensation Commission (Commission).
- On November 8, 2001, the Commission’s Medical Review Division (MRD) issued its Findings and Decision denying reimbursement because of improper coding and lack of documentation of medical necessity.
- Highpoint filed a timely appeal of the MRD decision on November 13, 2001, and the Commission issued its Notice of Hearing on December 10, 2001.
- Administrative Law Judge Katherine Smith convened the hearing on February 20, 2002. Highpoint was represented by Connie Morgan and Terri Flinn. Liberty was represented by Mahon B. Garry, Jr., an attorney. The Commission did not participate.
- CPT Code 76000 from the Commission’s 1996 Medical Fee Guideline is the appropriate billing code for the use of a fluoroscope during an ESI.
- Highpoint is entitled to reimbursement of $88 pursuant to CPT Code 76000 for the use of the fluoroscope during the ESI.
- Use of CPT Code 76449, which has no maximum allowable reimbursement, requires documentation of procedure outlining the medical necessity of the procedure.
- Highpoint failed to provide sufficient documentation of procedure outlining the medical necessity for epidurography during the fluoroscopically guided ESI.
V. CONCLUSIONS OF LAW
- The Commission has jurisdiction over this matter pursuant to the Texas Workers’ Compensation 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 Tex. Lab. Code Ann. § 413.031(d) and Tex. Gov’t Code Ann., ch. 2003.
- Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann.§§ 2001.051 & 2001.052.
- Highpoint had the burden of proving by a preponderance of the evidence that it was entitled to reimbursement. 28 Tex. Admin. Code (TAC) § 148.21(h).
- Highpoint failed to show that its reimbursement request complied with the Commission’s 1996 Medical Fee Guideline, 28 TAC §134.201.
IT IS, THEREFORE, ORDERED that Highpoint Pain Management’s request for reimbursement from Liberty Mutual Insurance of $700 is denied, but Liberty Mutual Insurance is ORDERED to reimburse Highpoint Pain Management of $88.
Signed this 22nd day of April, 2002.
KATHERINE L. SMITH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- CPT codes are five-digit codes obtained from the Physicians’Current Procedural Terminology, Fourth Edition, Copyright 1994, by the American Medical Association, which lists descriptive terms and numeric identifying codes for reporting medical services and procedures.↑
- Medical Fee Guideline, 28 Tex. Admin. Code (TAC) § 134.201.↑
- Highpoint Ex. 2.↑
- American Society of Anesthesiologists Newsletter, Vol. 65, No. 4 (April 2001) in Highpoint Ex. 3 and Liberty Ex. 1 at 19.↑
- Medical Fee Guideline, General Instructions I.A & B.↑
- Spine Treatment Guideline, 28 TAC§134.1001.↑
- TWCC Advisory 97-01 in Liberty Ex. 1 at 20.↑
- Medical Fee Guideline, General Instructions III.↑
- Liberty Ex. 1 at 25.↑
- Id. at 29.↑