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At a Glance:
Title:
453-02-2026-m5
Date:
June 19, 2002
Status:
Retrospective Medical Necessity

453-02-2026-m5

June 19, 2002

DECISION AND ORDER

This case concerns whether Petitioner, Lois M. Hansen, M.A., L.P.C., should be reimbursed $670.00 for services she provided to Claimant ___in 2001.

___sustained a compensable injury to her right foot on______, when she was hit by a forklift while at her job at ______. The injuries to her foot included sprain/strain and a bone fracture. William Langeland, D.C., referred ___to Ms. Hansen for a psychophysiological evaluation. Ms. Hansen, a licensed professional counselor with a masters degree in counseling, interviewed ___and prepared a written report. She billed her work under CPT Codes 90801 (psychiatric diagnostic interview), 90825 (psychiatric review of medical records), and 90889 (preparation of report of patient’s psychiatric status). She billed a total of $670.00 for these services. American Home denied reimbursement on the grounds that the services provided were not related to the compensable injury.

The Administrative Law Judge (ALJ) concludes that Ms. Hansen is entitled to recover for the disputed services.

I. Jurisdiction, Notice, and Procedural History

The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq. The State Office of Administrative Hearings (SOAH) has jurisdiction over 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.

The Commission’s Medical Review Division (MRD) issued its decision December 19, 2001. Ms. Hansen filed a timely request for hearing. Proper and timely notice of the hearing was issued March 6, 2002. The hearing was convened May 23, 2002, with ALJ Shannon Kilgore presiding. Kenda Dalrymple appeared for Ms. Hansen, and Dan Kelley appeared for Respondent American Home Assurance Company (American Home). The Commission did not participate in the hearing. The hearing was adjourned the same day, but the record was kept open for the submission of written post-hearing arguments. The record closed June 14, 2002.

II. Discussion

There are three primary issues in this case:

Were the services provided related to the compensable injury?

Following her accident, ___had complained of pain in parts of her body other than her right foot B her ankle, knee, hip, and low back. TWCC Ex. 1, pp. 11, 19. The Commission subsequently determined that the scope of___’s compensable injury was limited to her right foot. Respondent Ex. 1, 2. Because Dr. Langeland’s referral and Ms. Hansen’s report reference pain in these other areas, American Home argues that the psychophysiological evaluation was not related enough to the foot injury to be reimbursable.

The ALJ finds that the disputed services were related to the foot injury. Ms. Hansen’s report states that at the time of the evaluation___ was in a “cam walker”cast on her right foot to the knee. TWCC Ex.1, p. 12. She reported an inability to play with her stepchildren, jog, engage in sports, and do yard work - limitations that were surely related to the foot injury and the necessity of wearing a cast. Id., pp. 12 - 13. While the report does refer to pain and disability related to other body areas, it is clear that the foot injury played a part in Ms. Hansen’s emotional difficulties. Id. The evidence shows a sufficient nexus between the compensable injury and Ms. Hansen’s evaluation.

Must the amount of time spent be recorded in the provider’s report?

The CPT codes under which Ms. Hansen billed her services are “timed codes,” and the amount of reimbursement for each service depends on the amount of time spent in rendering the service. Ms. Hansen’s report described her findings and recommendations. Id., pp. 11 - 15. The report did not include the amount of time she spent in interviewing__, reviewing her records, and preparing the report. Those amounts of time were, however, recorded on Ms. Hansen’s claim form, the “HCFA 1500” form. Id., p. 10 (120 minutes for the interview, 45 minutes for the review of medical records, and 110 minutes for the preparation of the report). American Home repeated the number of minutes on its own explanation of benefits. Id., p. 16.

The MRD determined that Ms. Hansen was not entitled to reimbursement because her time spent was not set out in the report. Id., pp. 1 - 4. The MRD cited to 28 Tex. Admin. Code § 134.1000(f)(2)(B)(E).[1] Id., p. 3. The ALJ cannot find anything in this section or sections requiring that time be recorded in a provider’s report. Nor has American Home pointed to any other section of the Commission’s rules in support of such a requirement. The section of the Commission’s Mental Health Treatment Guideline entitled “Documentation Requirements for Assessment/Evaluation” does not require that the time spent in the evaluation and report preparation be included in the report itself. 28 Tex. Admin. Code §134.1000(g)(4).

Since Ms. Hansen did document and provide to American Home the amount of time she spent in each activity for which she billed, she is entitled to reimbursement.

Can a licensed professional counselor be reimbursed for “psychological services”?

American Home argues that in order for Ms. Hansen’s services to be covered “health care”under the Labor Code, she must characterize them as “psychological services.” Tex. Labor Code § 401.011(19)(C). However, the Psychologists’ Licensing Act prohibits non-psychologists from describing their services as “psychological services.” Tex. Occ. Code §§501.004, 501.251. Therefore, according to American Home, Ms. Hansen cannot recover for the disputed services.

Ms. Hansen objects that American Home has waived this argument. American Home did not make this argument when it denied reimbursement and issued its explanation of benefits. See TWCC Ex. 1, p. 16. It did not raise this argument before the MRD, either. Seeid., p. 2. American Home first made this argument at the SOAH hearing.

In general, it is established at SOAH that a carrier is limited to the explanation or explanations it provides when denying a claim, and cannot raise new reasons before the MRD or at SOAH. See, e.g., Docket No. 453-96-1446.M4 (Nov. 12, 1996, ALJ Corbitt); Docket No. 453-97-0973.M4 (May 14, 1998, ALJ Card); Docket No. 453-01-0309.M5 (February 7, 2001, ALJ Doherty). The ALJ will not, therefore, address the issue of whether a licensed professional counselor can be reimbursed for mental health services provided to a workers’ compensation claimant.

III. Findings of Fact

  1. The workers’ compensation claimant in this case, ___, sustained a compensable injury to her right foot on_____. The injury included sprain/strain and a bone fracture.
  2. William Langeland, D.C., referred___ to Lois M. Hansen, M.A., L.P.C. (Ms. Hansen) for a psychophysiological evaluation.
  3. Ms. Hansen is a licensed professional counselor with a masters degree in counseling.
  4. Ms. Hansen interviewed___, reviewed her medical records, and prepared a written report. She billed her work under CPT Codes 90801 (psychiatric diagnostic interview), 90825 (psychiatric review of medical records), and 90889 (preparation of report of patient’s psychiatric status). She billed a total of $670.00 for these services.
  5. The carrier, American Home Assurance Company (American Home), denied reimbursement on the grounds that the services provided were not related to the compensable injury.
  6. After unsuccessfully resubmitting her claims, Ms. Hansen filed a Request for Medical Dispute Resolution with the Commission’s Medical Review Division (MRD).
  7. The MRD denied the request on the grounds that Ms. Hansen did not set out, in her report, the amount of time she spent on each activity.
  8. Ms. Hansen filed a timely request for hearing.
  9. Notice of the hearing was issued March 6, 2002.
  10. 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.
  11. The hearing was convened May 23, 2002, with ALJ Shannon Kilgore presiding. Kenda Dalrymple appeared for Ms. Hansen, and Dan Kelley appeared for American Home. The Commission did not participate in the hearing. The hearing was adjourned the same day, but the record was kept open until June 14, 2002, for the submission of written post-hearing arguments.
  12. At the time of Ms. Hansen’s examination, ___ was in a “cam walker” cast on her right foot to the knee.
  13. In her interview with Ms. Hansen, ___ reported an inability to play with her stepchildren, jog, engage in sports, and do yard work - limitations that were related to the foot injury and the necessity of wearing a cast.
  14. The foot injury played a part in Ms. Hansen’s emotional difficulties.
  15. The services provided by Ms. Hansen were related to__’s compensable right foot injury.
  16. Ms. Hansen did not record in her report how much time she spent on each activity; however, she did include that information on her claim for reimbursement.

IV. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. SOAH has jurisdiction over 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.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  4. Ms. Hansen has the burden of proof in this matter. 28 TAC §148.21(h).
  5. Based on Findings of Fact Nos. 1 and 12 - 15, Ms. Hansen met her burden of proving that the services she provided were medically necessary for the treatment of claimant’s compensable injury, within the meaning of Tex. Labor Code § 408.021.
  6. The Commission’s Mental Health Treatment Guideline, in effect at all times relevant to this case, does not require that evaluation reports include the amount of time spent in evaluation and report preparation. 28 Tex. Admin. Code § 134.1000(g)(4).
  7. Based on Finding of Fact No. 16, Ms. Hansen’s documentation met the requirements of the applicable Commission’s rules.
  8. Since American Home did not originally cite Ms. Hansen’s status as a licensed professional counselor, as opposed to a psychologist, as grounds for denial of payment, it may not raise that issue for the first time at hearing. See, e.g., Docket No. 453-96-1446.M4 (Nov. 12, 1996, ALJ Corbitt); Docket No. 453-97-0973.M4 (May 14, 1998, ALJ Card); Docket No. 453-01-0309.M5 (February 7, 2001, ALJ Doherty).
  9. Ms. Hansen is entitled to reimbursement of $670.00 for the services in question.

ORDER

IT IS, THEREFORE, ORDERED that American Home Assurance Company reimburse Lois M. Hansen, M.A., L.P.C., $670.00 for services rendered to the workers’ compensation claimant___ in 2001.

Signed this 19th of June, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Shannon Kilgore
Administrative Law Judge

  1. There is some uncertainty about the current status of the Commission’s Mental Health Treatment Guideline, 28 Tex. Admin. Code § 134.1000. The Guideline was abolished by statute effective January 1, 2002, but the administrative repeal of the Commission’s rule has not yet been adopted. 27 Tex. Reg. 1661 - 1662. However, at all times relevant to this case, the Guideline was in effect.
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