DECISION AND ORDER
I. PROCEDURAL HISTORY
Petitioner Waco Ortho Rehab seeks reimbursement from the Phoenix Insurance Company (the Carrier) for the medical services it rendered to a worker’s compensation Claimant from February 1, 2001, through July 10, 2001. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) ordered partial reimbursement for some of the claims and denied certain other claims, indicating the proper documentation had not been submitted to the MRD. Petitioner appealed the MRD’s decision and seeks reimbursement for the entire claim.
The Administrative Law Judge (ALJ) convened and concluded the hearing on March 4, 2002. Attorney Scott Hilliard represented Petitioner, and Dan Flanagan appeared for the Carrier.
II. EVIDENCE AND BASIS FOR DECISION
The evidence consists of the 62-page certified record (C.R.) of the MRD proceeding and the testimony of David Bailey, D.C., who testified by telephone. Dr. Bailey testified the MRD reviewer had found Petitioner’s documentation substantiated the services had been rendered on February 1, May 15, and July 10, 2001, but believed the reviewer had misinterpreted the guideline for CPT Code 97750-MT, which provides that muscle testing (MT) can be done in 15-minute timed units. The reviewer allowed for only one unit of MT, whereas CPT Code 97750-MT allows up to three 15-minute units of MT, which is what Petitioner provided and billed. (See Physical Medicine Ground Rules I (C) (1), I (D) (4) and I (E) (3), which relate to MT). Section I (E) (3) of the Physical Medicine Ground Rule for 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. . . . 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.
The explanation for CPT Code 97750 indicates it is used to bill for “physical performance test or measurement (e.g., musculoskeletal, functional capacity), with a written report, each 15 minutes. . . .” The maximum allowable reimbursement (MAR) is $43, presumably for each 15-minute unit.
Dr. Bailey also testified Petitioner had properly submitted documentation to the Carrier related to the services provided on April 9, 2001, and July 10, 2001, but the Carrier did not respond to those billings, even after they were resubmitted. (See C.R. pp.16 -19). The Carrier sent no explanation of benefits (EOBs) to explain why the services were not paid, and that is why no EOBs were attached to those claims when they were submitted to the MRD. Ultimately, Petitioner filed a complaint with the Commission’s enforcement division in efforts to get EOBs on the claims. Petitioner argued the Carrier should not be rewarded by having the claims disallowed when the Carrier had ignored the Commission’s rule that requires Carriers to timely respond to providers’ claims and sent no EOBs to Petitioner for those claims.
Based on the evidence, the ALJ finds the documentation submitted by Petitioner complied with the Commission’s requirements as set out in 28 TAC §133.305(e)(1) and substantiated that the services were provided. The ALJ further concludes Petitioner’s entire claim should be approved. The particular facts, reasoning, and legal analysis in support of this decision are set out below in the Findings of Fact and Conclusions of Law.
III. FINDINGS OF FACT
- On______, Claimant suffered a compensable injury that resulted in an injured right hand. Claimant wasemployed by__________, which had workers' compensation coverage with the Phoenix Insurance Company (Carrier) at that time.
- Petitioner treated Claimant’s injured right-hand beginning on ___, with physical medicine services to help the injured right hand improve and prepare Claimant to return to work.
- Petitioner received preauthorization from the Carrier for active physical therapy three times per week for four weeks on May 23, 2001.
- Pursuant to preauthorization, Petitioner provided Claimant the following services on June 11 and 12, 2001: therapeutic procedures (CPT Code 97150), myofascial release (CPT Code 97250), and joint mobilization (CPT Code 97265), and therapeutic procedures on June 21, 2001.
- The Carrier refused to pay Petitioner for the services set out in Finding No. 4, indicating the services were not preauthorized.
- On May 15, 2001, and July 10, 2001, Petitioner conducted muscle testing (CPT Code 97750-MT) and range of motion (ROM) testing (CPT Code 95851) to determine Claimant’s clinical prognosis, treatment plan, and current return-to-work status and determine if any ROM impairment existed in the wrist. A ROM test was also conducted on February 1, 2001.
- Petitioner detailed the test results in patient office-visit reports and submitted claims to the Carrier for the testing services ($129 for three units of MT at $43 each and $36 for one ROM test) for the visits on May 15, 2001, and July 10, 2001. The documentation substantiated that forty-five minutes of muscle testing (three 15-minute units) was performed on Claimant on those dates.
- The Carrier paid $129 (3 x $43) for the three units of muscle testing on May 15, 2001, and July 10, 2001, but declined to pay for the ROM tests on February 1, 2001, May 15, 2001, and July 10, 2001, because it considered the ROM tests part of a global charge.
- Petitioner submitted the charges for the services provided Claimant between April 9, 2001, and July 10, 2001, that had not been paid (amounting to $409) to the Carrier. (C.R. pp. 8 and 18).
- The Carrier denied payment of some of the charges referenced in Findings 4, 6 and 7. Petitioner resubmitted the claim and described the Carrier’s reasons for denial as follows: the services were timed procedures and exceeded treatment guidelines, denial code S; preauthorization was not obtained, denial code J; the procedure was part of a global charge, denial code L; and the Carrier had not explained its reason for denial, denial code E.
- Although Petitioner submitted claims for the services provided Claimant on April 9, 2001, (office visit) and (ROM test) on July 10, 2001, the Carrier did not respond to those specific claims. Petitioner resubmitted claims for reconsideration on August 31, 2001, including those for services provided on the dates stated above, but the Carrier again failed to send any explanation to Petitioner as to why those specific claims were denied.
- Petitioner wrote to the Commission’s enforcement division, asking it to order the Carrier to send Petitioner explanation of benefits (EOBs) as to the services provided on April 9 and July 10, 2001.
- Petitioner requested dispute resolution by the Commission’s Medical Review Division (MRD) on September 28, 2001, seeking reimbursement for the services provided between February 1, 2001, and July 10, 2001. Petitioner supplied MRD no EOBs for the services provided on April 9 and July 10, 2001, because it had received none from the Carrier.
- On November 12, 2001, the MRD issued a decision ordering payment for all of the claims submitted, except for those dated April 9, 2001, and July 10, 2001.
- The MRD found the Carrier had paid $129 for muscle testing (CPT Code 97750-MT on February 1, 2001, and May 15, 2001), but determined that only $86 (reimbursement for one unit at $43 for each day because the testing involved only one body part) was allowed. It, therefore, ordered $172 be refunded to the Carrier and deducted that amount from the $409 total sought by Petitioner.
- The MRD dismissed the claims for services on April 9 and July 10, 2001, specified in Finding No. 11, finding the documentation in the request for dispute resolution did not include “all medical audit summaries and/or explanations of benefits,” as required by Commission rule 133.305(e)(1)(C).
- On November 15, 2001, Petitioner appealed the MRD’s decision.
- On December 12, 2001, the Commission sent a notice of hearing to the parties. The notice contained a statement of the time and place of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular section of the statutes and rules involved; and a short plain statement of the matters asserted.
- The explanation of CPT Code 97750 under “Tests and Measurements” indicates it is to be used to bill for: “Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with a written report, each 15 minutes (see Medicine G.R. I (E) (2) for reimbursement amounts for functional Capacity Evaluations).” The maximum allowable reimbursement (MAR) for CPT Code 97750 is $43.
- Medicine Ground Rule I (E) (2) provides the MAR for a Functional Capacity Evaluation (FCE) is $100 per hour, not to exceed five hours, for a total of $500 for the initial test, and two hours ($200) for an interim or discharge test.
- Medicine Ground Rule I (E) (3) provides: “Muscle testing (97750-MT) requires a report identifying the service provided, results, and interpretation of the test and shall be reimbursed per body area . . . . 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.”
IV. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (the 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 §413.031(d) of the Act; Tex. Gov't Code Ann. ch. 2003 (Vernon 2000), and 28 Tex. Admin. Code (TAC) chs. 148 and 149 (2001).
- Petitioner timely appealed the MRD’s decision, pursuant to 28 TAC §148.3.
- The notice of hearing sent by the Commission complied with the requirements of Tex. Gov’t Code §2001.052 and 28 TAC §148.4(b).
- Petitioner had the burden of proof to show by a preponderance of the evidence that it should prevail in this matter, pursuant to §413.031 of the Act and 28 TAC §148.21(h) and (i).
- Pursuant to 28 TAC §133.304(c), when a Carrier denies payment of a claim, it is required to send, in the form and manner prescribed by the Commission, an explanation of benefits (EOBs) that includes the correct payment exception codes as required by the Commission to sufficiently explain to the provider the reason(s) for the Carrier’s denial.
- Because the Carrier did not send EOBs as required by 28 TAC §133.304 (c) related to the claims’ dated April 9, 2001, and July 10, 2001, Petitioner had no EOBs to submit to the MRD for those claims. Therefore, those claims should not have been dismissed from Petitioner’s claim.
- The documentation related to the muscle testing performed on February 1, 2001, and May 15, 2001, substantiated that three units of muscle testing on each date were provided to Claimant to determine functional abilities, as is permitted in Medicine Fee Guidelines, Ground Rule I (E) (3) and were properly billed under CPT Code 97750-MT.
- Therefore, the MRD’s offset of $172 for the muscle testing on those dates was incorrect.
- The documentation submitted by Petitioner when it sought medical dispute resolution substantiates its claim for reimbursement of $409, which included the claims of April 9, 2001, and July 10, 2001.
- Based upon the foregoing Findings of Fact and Conclusions of Law, Petitioner's request for reimbursement should be approved.
It is hereby ordered that the Carrier is ordered to reimburse Petitioner $409.00 plus interest for the services rendered to the Claimant from February 1, 2001, through July 10, 2001.
Signed this 25th day of March 2002.
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS