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At a Glance:
Title:
453-02-2313-m5
Date:
September 20, 2002
Status:
Retrospective Medical Necessity

453-02-2313-m5

September 20, 2002

DECISION AND ORDER

I. Summary

Petitioner, J.C. Penney Company, Inc., appeals from a decision of the Texas Worker’s Compensation Commission’s (TWCC) Medical Review Division (MRD) that ordered it to reimburse First Rio Valley Medical (Respondent or Provider) for ten office visits that were made in conjunction with physical therapy treatment provided to Claimant,____. The amount of the office visits totaled $ 263.00.[1] Based on the evidence, the ALJ concludes that Petitioner’s claim that the office visits were not medically necessary should be denied and that reimbursement is due to the Respondent. The Administrative Law Judge convened a hearing on these issues on July 22, 2002, and the record closed the same day.

II. Evidence

The evidence in this case consisted of the certified records of the MRD proceedings as follows:

Exhibit 1TWCC No. __________ SOAH Docket No. 453-02-2313.M5

Exhibit 2TWCC No. __________ SOAH Docket No. 453-02-1860.M5

Exhibit 3TWCC No. _________ SOAH Docket No. 453-02-2174.M5

Exhibit 4TWCC No. _________ SOAH Docket No. 453-02-1294.M5

Exhibit 5TWCC No. _________ SOAH Docket No. 453-02-1294.M5

Exhibit 6TWCC No. _________ SOAH Docket No. 453-02-1294.M5

III. DISCUSSION

Claimant____ incurred a back sprain/strain on___________, when he lifted a trash bag while working for ___________. He began seeing Dr. Sam Allen, a physician employed by Respondent, on October 7, 1999, and was under his care during the relevant time period.

The ten office visits in issue were billed as follows:

CPT Code

MAR

Date

Description[2]

99211

$ 18

04-09-01

04-16-01

04-30-01

05-16-01

05-18-01

05-21-01

05-25-01

05-30-01

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually the presenting problem(s) are minimal. Typically, 5 min. are spent performing or supervising these services.

99213

$ 48

05-28-01

Office of other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face to face with the patient and/or family.

99214

$ 71

06-20-01

Office or other outpatient visit

For the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face to face with the patient and/or family.

Petitioner denied payment of the office visits, claiming that they were not medically necessary in conjunction with the physical therapy treatment. Petitioner argued that the number of office visits was excessive and not necessary each time Claimant received physical therapy services. Petitioner relied on a chiropractic peer review for the proposition that the medical services were not necessary; however, Carrier continued to pre-authorize and pay for those services, including those provided on the same dates of the office visits in issue. The peer review did not address the question of whether the office visits in question were medically necessary.

There was no evidence in the record of what the appropriate number of office visits, if any, should have been. The only evidence in the record demonstrates that Petitioner’s objections to paying for the office visits were, in reality, directed to the treatment provided to Claimant, and not whether or not an office visit as minimal as five minutes or less was necessary prior to providing the treatment. See Exhibit 5, pp. 49-50. While the number of office visits may well be excessive and unnecessary, there is not sufficient evidence in the record to find that they were not medically necessary.

The Provider argued that the eight office visits of minimal duration and conducted by someone other than a physician were necessary because it was important to ascertain if there were changes in Claimant’s condition which could affect treatment. The record contains sufficient documentation of the office visits.[3] Respondent also argued that the two office visits involving two physicians were sufficiently documented.

On May 28, 2001, Dr. Sam Allen reviewed Claimant’s electrodiagnostic testing results with the Claimant. The test was performed on May 19, 2001. Additionally, the medical notes and report contained an expanded problem focused history, an expanded problem focused examination, and medical decision making of low complexity.[4] This visit met the requirements of CPT Code 99213.

Dr. Patrick McAllister prepared a letter of medical necessity after Claimant’s examination on June 20, 2001. The report indicates that Dr. McAllister performed a detailed examination and that the visit involved medical decision making of moderate complexity. Dr. McAllister concluded that Claimant appeared to have numerous personality traits associated with the risk of developing chronic pain and noted that his condition had not responded well to standard treatment methods. Dr. McAllister’s letter was written as a request for authorization of a behavioral pain management intervention to determine whether Claimant was a good candidate for a multi-disciplinary chronic pain management program. The documentation of this visit met the requirements of CPT Code 99214.

After considering all the evidence contained within the MRD certified records, the ALJ finds that Petitioner failed to meet its burden of proof in this case.

IV. FINDINGS OF FACT

  1. On_______,____ (Claimant) suffered the compensable injury of a lower back sprain/strain.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer, _____________, by Liberty Mutual Insurance Company (Carrier).
  3. Provider billed Carrier for the following office visits:

4-09-01CPT Code 99211 $ 18.00

4-16-01CPT Code 99211 $ 18.00

4-30-01CPT Code 99211 $ 18.00

5-16-01CPT Code 99211 $ 18.00

5-18-01CPT Code 99211 $ 18.00

5-21-01CPT Code 99211 $ 18.00

5-25-01CPT Code 99211 $ 18.00

5-28-01CPT Code 99213 $ 48.00

5-30-01CPT Code 99211 $ 18.00

6-20-01CPT Code 99214 $ 71.00

  1. Carrier denied payment for these claims on the ground that the office visits were not medically necessary.
  2. Petitioner timely requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD) for each of these dates of service.
  3. The MRD officer found that Provider had established medical necessity for the office visits and ordered reimbursement accordingly.
  4. The office visits with Claimant were conducted by persons other than a physician on all dates except May 28 and June 20, 2001.
  5. There was documentation for the office visits for CPT Code 99211 on April 9, 16, 30, May 16, 18, 21, 25, and 30, 2001.
  6. There is no specific requirement under the Medical Fee Guidelines for documenting an office visit billed under CPT Code 99211.
  7. On May 28, 2001, Claimant was seen by Dr. Sam Allen in an office visit to explain the results of Claimant’s recent electrodiagnostic test.
  8. The documentation for the office visit on May 28, 2001, billed as CPT Code 99213, contained an expanded problem focused history, an expanded problem focused examination, and medical decision making of low complexity.
  9. On June 20, 2001, Claimant was seen by Dr. Patrick McAllister in an office visit to evaluate Claimant’s progress and response to treatment.
  10. The documentation for the office visit on June 20, 2001, billed as CPT Code 99214, contained a detailed examination and medical decision making of moderate complexity.

V. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction over this matter pursuant to the Texas Worker’s Compensation Commission Act (Act), 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 §§ 402.073(b) and 413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by the Commission 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. As the party appealing from an adverse decision of the Commission’s Medical Review Division, Petitioner has the burden of proving, by a preponderance of the evidence, that it should prevail in this matter. Tex. Labor Code § 413.031.
  5. Under Tex. Labor Code §408.021(a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.
  6. Pursuant to the MFG, CPT Code 99211 applies to an office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising those services.
  7. Under the TWCC’s Medical Fee Guideline (MFG), services billed under CPT Code 99211 are reimbursed at the maximum rate of $18 per hour. Medical Fee Guideline 1996; adopted by reference at 28 TAC § 134.201(a).
  8. Pursuant to the MFG, CPT Code 99213 applies to an office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face to face with the patient and/or family.
  9. Under the TWCC’s Medical Fee Guideline (MFG), services billed under CPT Code 99213 are reimbursed at the maximum rate of $ 48 per hour. Medical Fee Guideline 1996; adopted by reference at 28 TAC § 134.201(a).
  10. Pursuant to the MFG, CPT Code 99214 applies to an office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face to face with the patient and/or family.
  11. Under the TWCC’s Medical Fee Guideline (MFG), services billed under CPT Code 99214 are reimbursed at the maximum rate of $ 71 per hour. Medical Fee Guideline 1996; adopted by reference at 28 TAC § 134.201(a).
  12. Petitioner did not prove by a preponderance of the evidence that the office visits provided to Claimant on the dates at issue were not medically necessary.
  13. Based on Findings of Fact Nos. 1, 2, 3, 7, 8, and 9, and Conclusions of Law Nos. 5, 6, and 7, the Petitioner incorrectly denied the Respondent’s request for payment of office visits under CPT Code 99211 in the amount of $ 144.00.
  14. Based on Findings of Fact Nos. 1, 2, 3, 10,and 11, and Conclusions of Law Nos. 5, 8, and 9, the Petitioner incorrectly denied the Respondent’s request for payment of office visits under CPT Code 99213 in the amount of $ 48.00.
  15. Based on Findings of Fact Nos. 1, 2, 3, 12, and 13, and Conclusions of Law Nos. 5, 10, and 11, the Petitioner incorrectly denied the Respondent’s request for payment of an office visit under CPT Code 99214 in the amount of $ 71.00.
  16. Based on the foregoing Findings of Fact and Conclusions of Law, the Petitioner shall pay the Respondent an additional $ 263.00 for office visits provided to Claimant.

ORDER

The claim by Petitioner, ___________, that the office visits by Respondent were medically unnecessary is denied and Petitioner is ordered to pay Respondent $ 263.00, plus accrued interest.

Signed this 20th day of September, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

SUZANNE FORMBY MARSHALL
Administrative Law Judge

  1. This dispute only involves the charges for the office visits; the treatment itself during each of the visits is not in dispute and was paid by the Carrier. The treatments provided to Claimant included massage therapy, electric muscle stimulation, therapeutic exercises, and ultrasound.
  2. TWCC Medical Fee Guideline (MFG) 1996; adopted by reference at 28 Tex. Admin. Code (TAC) '134.201(a).
  3. Exhibit 2, pp. 35-36; Exhibit 3, pp. 95-103; Exhibit 4, pp. 35-36; Exhibit 5, pp. 35-37; Exhibit 6, pp. 37-39. Further, the Medical Fee Guidelines do not set forth specific documentation requirements for CPT Code 99211.
  4. Exhibit 3, pp. 89-94.
End of Document
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