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At a Glance:
Title:
453-02-1876-m4
Date:
October 7, 2002
Status:
Medical Fees

453-02-1876-m4

October 7, 2002

DECISION AND ORDER

I. SUMMARY

Back and Joint Clinic (Petitioner) appealed a decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) denying partial reimbursement from Fidelity & Guaranty Insurance Company (Carrier) for medical services provided to ____ (Claimant). Based on the evidence, the Administrative Law Judge (Judge) concludes Carrier should reimburse Petitioner $207.00 for the disputed services.

Judge Carol Wood convened a hearing on this matter on July 31, 2002, at the State Office of Administrative Hearings (SOAH) facility in Austin, Texas. Petitioner appeared through its attorney, Scott Hilliard. Attorney Steve Tipton represented Carrier. The Commission did not appear. The record closed that same day.

II. DISCUSSION

Claimant sustained a compensable worker’s compensation injury to his left knee on_____. Carrier denied Petitioner payment for treatments and services provided to Claimant from March 28, 2001, to April 26, 2001. Petitioner appealed Carrier’s determination to MRD. After considering the medical records presented in the certified record (Exhibit No. 1), MRD ordered Carrier to pay Petitioner $219.00 of Petitioner’s claim for $516.00. Petitioner appealed MRD’s decision, and the matter was referred to SOAH.

At the hearing on the matter, Petitioner requested reimbursement for only $207.00 for the following disputed claims:

$ 35.00Current Procedural Terminology (CPT) Code 97110 [therapeutic procedures, 15 minutes, one-to-one supervision]; service provided on April 11, 2001

$172.00CPT Code 97250 [myofascial release]; treatments to Claimant’s left knee provided on March 28, March 30, April 9, and April 11, 2001

CPT Code 97110

Carrier denied reimbursement with the Denial Code T (“Treatment guidelines”) for one unit (15 minutes) of therapeutic procedures provided to Claimant on April 11, 2001, and billed at $35.00. Carrier, however, approved reimbursement of $245.00 for seven units (1 hour and 45 minutes) provided to Claimant that same day. MRD did not recommend reimbursement of the one unit ($35.00) because, “[a]lthough the documentation is signed, it does not support that the services were rendered for one-on-one therapy.”

Petitioner argues that, because Carrier approved reimbursement for seven of the eight units billed for the same date of service, Carrier should reimburse Petitioner for the remaining unit. Additionally, Petitioner asserts there is no evidence Petitioner did not provide one-on-one therapy.

Carrier concurs with the MRD decision and asserts Petitioner must prove the therapeutic procedures were provided one-to-one.

The Judge finds that the evidence shows Petitioner provided the therapeutic procedures to Claimant on a one-to-one supervised basis. The “patient office visit report” regarding Claimant and dated April 11, 2001, states the following:

THERAPEUTIC PROCEDURES: (97110, per TWCC MFG, p.32. One to One Setting): LOWER EXTREMITIES. DURATION: 2 hours. [Exhibit No. 1, p. 35]

Because the preponderance of the evidence--indeed, the only evidence--in the record is that Petitioner provided the therapeutic procedures to Claimant with one-to-one supervision, Petitioner is entitled to reimbursement of $35.00 for the service.

CPT Code 97250

With the Denial Code T, Carrier denied reimbursement to Petitioner for four myofascial release treatments to Claimant’s left knee, provided on the dates noted above and billed at $43.00 per treatment. MRD did not recommend reimbursement based on the following:

Documentation does not support that the services were rendered. SOAP [Subjective/Objective Assessment Plan/Procedure] notes are not signed by a licensed HCP [health care provider]. As a result, it is not known who provided the services billed.

Petitioner argues that, at the time these treatments were provided, there were no rules requiring SOAP notes to be signed. Petitioner contends Advisory 2002-03B, signed by the Commission’s executive director on March 14, 2002, and entitled “Medical Fee Dispute Resolution - Identification of Health Care Provider,” became effective nearly a year after the four treatments were provided. Carrier concurs with the MRD decision and argues Advisory 2002-03B is only a clarification of Commission rules.

The Judge finds the evidence demonstrates that the four myofascial release treatments to Claimant’s left knee were provided Claimant by Petitioner on the dates noted above and that Sam Liscum, D.C., was the health care provider who rendered the treatments. The request for preauthorization for the treatments (dated March 9, 2001) was signed by Dr. Liscum (see Exhibit No. 1, p. 11); all the claims for reimbursement were signed by Dr. Liscum; and all the patient office visit reports regarding Claimant described the treatments in detail and contained the notation that they were “originally attached to the bill when submitted to the carrier.” Because the evidence establishes that Petitioner provided the treatments and the health care provider was identified, Petitioner is entitled to reimbursement of $172.00 for the four myofascial release treatments.

FINDINGS OF FACT

  1. On_______, Claimant _____ sustained a compensable worker’s compensation injury to his left knee.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by Fidelity & Guaranty Insurance Company (Carrier).
  3. Back and Joint Clinic (Petitioner) provided services and treatments to Claimant, including therapeutic procedures and myofascial release treatments, from the period of March 28, 2001, through April 26, 2001.
  4. After Carrier denied Petitioner payment of $516.00 for the treatments and services provided to Claimant, Petitioner filed a request for medical dispute resolution with the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) on October 11, 2001.
  5. MRD issued its decision and findings on December 11, 2001, and ordered Carrier to reimburse Petitioner $219.00.
  6. Petitioner requested a hearing regarding MRD’s decision, and the matter was referred to the State Office of Administrative Hearings (SOAH).
  7. Notice of the hearing was sent to the parties on February 27, 2002. The notice contained a statement of the time, place, and nature of the hearing; and a statement of the legal authority and jurisdiction under which the hearing was to be held. On July 26, 2002, the Commission sent the parties a short, plain statement of the matters asserted. The Commission’s statement of matters asserted included references to the particular statutes and rules involved.
  8. A hearing was held on July 31, 2002, at SOAH’s hearings facility in Austin, Texas, and the record closed that same day.
  9. At the hearing, Petitioner requested reimbursement of only $207.00 for the following disputed claims:

$ 35.00Current Procedural Terminology (CPT) Code 97110 [therapeutic procedures, 15 minutes, one-to-one supervision]; service provided on April 11, 2001

$172.00CPT Code 97250 [myofascial release]; treatments provided on March 28, March 30, April 9, and April 11, 2001

  1. Carrier denied reimbursement with the Denial Code T (“Treatment guidelines”) for one unit (15 minutes) of therapeutic procedures provided to Claimant on April 11, 2001, and billed at $35.00, but approved reimbursement of $245.00 for seven units (1 hour and 45 minutes) provided to Claimant that same day.
  2. Petitioner’s “patient office visit report” regarding Claimant and dated April 11, 2001, states the following:

THERAPEUTIC PROCEDURES: (97110, per TWCC MFG, p.32. One to One Setting): LOWER EXTREMITIES. DURATION: 2 hours. [Exhibit No. 1, p. 35]

  1. Petitioner provided the therapeutic procedures to Claimant on April 11, 2001, with one-to-one supervision.
  2. With the Denial Code T, Carrier denied reimbursement to Petitioner for four myofascial release treatments to Claimant’s left knee rendered on March 28, March 30, April 9, and April 11, 2001, and billed at $43.00 per treatment.
  3. The request for preauthorization for the services and treatments to be provided Claimant, dated March 9, 2001, was signed by Sam Liscum, D. C. [Exhibit No. 1, p. 11]
  4. All the claims for reimbursement from Carrier for the services and treatments provided Claimant were signed by Dr. Liscum.
  5. All of Petitioner’s “patient office visit reports” regarding Claimant contained the notation that they were “originally attached to the bill when submitted to the carrier.”
  6. Dr. Liscum was the health care provider who rendered the treatments and services to Claimant during the period of March 28, 2001, to April 26, 2001.

CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to TEX. LABOR CODE (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 an order, pursuant to Labor Code §413.031(k) and TEX. GOV’T CODE (Gov’t Code) ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code §§ 2001.051 and 2001.052.
  4. The hearing was conducted pursuant to the Administrative Procedure Ace, Gov’t Code ch. 2001 and the Commission’s rules, 28 TEX. ADMIN. CODE § 133.305.
  5. Petitioner has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Labor Code §413.031.
  6. Based on Findings of Fact Nos. 11 and 12, Petitioner is entitled to further reimbursement from Carrier of $35.00 under CPT Code 97110.
  7. Based on Findings of Fact Nos. 14 - 17, Petitioner is entitled to further reimbursement from Carrier of $172.00 under CPT Code 97250.

ORDER

IT IS ORDERED that Fidelity & Guaranty Insurance Company reimburse Back and Joint Clinic the amount of $207.00, plus all accrued interest due.

Issued this 7th day of October, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CAROL WOOD
Administrative Law Judge

End of Document
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