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At a Glance:
Title:
453-02-1236-m5
Date:
March 27, 2002
Status:
Retrospective Medical Necessity

453-02-1236-m5

March 27, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Lois M. Hansen, M.A., L.P.C. (Petitioner or Provider) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (TWCC) denying reimbursement from Connecticut Indemnity Company (Carrier) for medical services provided to ____ (Claimant). This decision orders the Carrier to reimburse the Provider $3,755.00 for biofeedback provided under CPT Codes 90889 (report preparation), 90900 (biofeedback session-EMG modality), 90906 (biofeedback session-temperature modality), and 90908 (report preparation).

The Administrative Law Judge convened a hearing on February 28, 2002. The hearing was concluded and the record closed on March 4, 2002. The Provider appeared by telephone. The Carrier was represented by Robert F. Josey, attorney.

II. EVIDENCE AND BASIS FOR DECISION

The issues presented in this preceding are: (1) did the Provider double bill the Carrier by billing 60 minutes, each, for two modalities completed within the same one hour period; (2) did the Provider fail to document the time spent in the preparation of reports, and (3) did the Provider fail to document 60 minutes for each biofeedback modality as billed.

The documentary record in this case consisted of the 142-page certified record of the MRD proceeding (Exh. 1), a one-page letter with eight separate explanation of benefit forms attached (Exh. 2), and a one-page response to Exhibit 2 (Exh. 3).

Based on the evidence, the ALJ concludes that Petitioner’s appeal should be granted. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law.

III. FINDINGS OF FACT

  1. On_______(Claimant) suffered a compensable injury to his back when he jumped from a machine after completing his job task.
  2. Claimant’s injury is covered by workers’ compensation insurance written for Claimant’s employer by Connecticut Indemnity Company (Carrier).
  3. Petitioner Lois M. Hansen, M.A., L.P.C. (Provider) treated the Claimant’s injury with biofeedback modalities during office visits from November 30, 2000, through January 31, 2001.
  4. The Provider obtained pre-authorization to treat the Claimant with the biofeedback modalities referenced in Finding of Fact No. 3.
  5. The Provider treated the Claimant’s back injury with two biofeedback modalities during each 60 minute session during the office visits referenced in Finding of Fact No. 3.
  6. Two biofeedback modalities may be reimbursed for each 60 minute session.
  7. The Provider did not double bill the Carrier.
  8. The Provider properly documented the time expended for each 60 minute session on the HCFA 1500 forms filed with the Carrier.
  9. The Provider prepared reports documenting treatment provided to the Claimant.
  10. The Provider properly documented the time expended in the preparation of the reports on the HCFA 1500 forms filed with the Carrier.
  11. The Provider timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  12. The MRD issued its findings and decision on November 5, 2001, concluding that the disputed expenses should not be paid, and the Provider timely appealed this decision.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’Compensation Commission (TWCC) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §413.031.
  2. 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. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov’t Code §2001.052 in that it 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 section of the statutes and rules involved; and a short plain statement of the matters asserted.
  4. The Provider has the burden of proving by a preponderance of the evidence that she should prevail in this matter. Tex. Labor Code §413.031.
  5. The Mental Health Treatment Guideline provides that no more than two biofeedback modalities will be reimbursed per session. 28 Tex. Admin. Code (TAC) §134.1000 (f) (6) (B) (I) and (ii).
  6. Based on Findings of Fact Nos. 3 - 8 and Conclusion of Law No. 5, the Provider proved that reimbursement for biofeedback modalities should be allowed.
  7. The Mental Health Treatment Guideline provides for the preparation of reports but does not require that the time spent in report preparation be contained in the report. 28 TAC §§ 134.1000 (g) (4) and (h) (6).
  8. Based on Findings of Fact Nos. 9 and 10 and Conclusion of Law No. 7, the Provider proved that reimbursement of report preparation should be allowed.
  9. The Carrier should reimburse the Provider for providing treatment to Claimant in the amount of $3,755.00 plus interest.

ORDER

IT IS, THEREFORE, ORDERED that Connecticut Indemnity Company reimburse Lois M. Hansen, M.A., L.P.C. for fees incurred in treating the Claimant in the amount of $3,755.00.

Issued this 27th day of March, 2002.

MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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