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At a Glance:
Title:
453-02-2930-m5
Date:
October 15, 2002
Status:
Retrospective Medical Necessity

453-02-2930-m5

October 15, 2002

DECISION AND ORDER

This case involves a dispute over whether Petitioner Curtis Adams, D.C., should be reimbursed $1,400.00 for five visits for physical therapy provided during August 2000. Respondent Zurich American Insurance Co. denied payment for these visits based on lack of preauthorization. Zurich states that it preauthorized only twelve visits for physical therapy, but Petitioner billed for seventeen visits. In response, Petitioner argues that Zurich improperly counted five office visits for other non-physical-therapy services that did not require preauthorization against the twelve preauthorized visits, and then refused to pay for the remaining five physical therapy visits that Zurich had preauthorized.

The Administrative Law Judge (ALJ) finds the Zurich improperly denied payment for the five physical therapy visits in question. Therefore the ALJ grants Dr. Adams’ appeal and orders Zurich to pay additional reimbursement of $1,400.00.

I. Procedural History

The hearing in this case was held August 19, 2002. There were no contested issues of jurisdiction or notice. Curtis Adams, D.C. was represented by Mr. Rick Muniz. Attorney Steven Tipton represented Zurich American Insurance Company. The hearing concluded and the record closed the same day.

II. Discussion

The Claimant sustained a compensable injury on_________, in the course of his employment with________. On July 31, 2000, Zurich Services gave written preauthorization for Dr. Curtis Adams to provide Claimant with “PHYSICAL THERAPY CERVICAL” during the period “08/01/00 TO 09/01/00 (12 VISITS).” Dr. Adams provided these and other services to Claimant with designated CPT Codes as listed below. The dates showing payment are the visits that Zurich counted against the twelve physical therapy visits it preauthorized:

DateCPT CodesAmt. BilledAmt. Paid

8/2/00 97110 $140.00 $ 0.00

8/2/00 97530 $140.00 $ 0.00

8/3/00 97110 $140.00 $140.00

8/3/00 97530 $140.00 $140.00

8/4/00 97110 $140.00 $140.00

8/4/00 97530 $140.00 $140.00

8/7/00 97110 $140.00 $140.00

8/7/00 97530 $140.00 $140.00

8/8/00 97110 $140.00 $ 0.00

8/8/00 97530 $140.00 $ 0.00

8/9/00 97110 $140.00 $ 0.00

8/9/00 97530 $140.00 $ 0.00

8/14/00 97110 $140.00 $ 0.00

8/14/0097530 $140.00 $ 0.00

8/15/00 97110 $140.00 $ 0.00

8/15/0097530 $140.00 $ 0.00

8/16/00 97110 $140.00 $140.00

8/16/0097530 $140.00 $140.00

  1. 8/17/00 99213 $ 48.00 $ 48.00
  2. 8/18/00 99213 $ 48.00 $ 48.00
  3. 8/21/00 97110 $140.00 $140.00

8/21/0097530 $140.00 $140.00

8/22/00 97110 $140.00 $140.00

8/22/0097530 $140.00 $140.00

8/23/00 97110 $140.00 $140.00

8/23/0097530 $140.00 $140.00

  1. 8/24/00 99213 $ 48.00 $ 48.00
  2. 8/25/00 99213 $ 48.00 $ 48.00
  3. 8/28/00 99213 $ 48.00 $ 48.00

The CPT Codes contained in these billings are for the following procedures:

97110:Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

97530:Therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes.

99213:Office visit with manipulation.

At hearing, the parties agreed that CPT Codes 97110 and 97530 are physical therapy procedures that require preauthorization, but services under CPT Code 99213 do not require preauthorization.

On its Notice of Medical Payment Dispute (TWCC-62) dated November 10, 2000, Zurich stated the following:

*A* PREAUTHORIZATION NOT OBTAINED

12 VISITS FROM 8/1-9/1/00 WERE CERTIFIED. THE FOLLOWING DATES OF SERVICE (12) HAVE ALREADY BEEN PAID: 8/3, 8/4, 8/7, 8/18, 8/22, 8/23, 8/24, 8/25, 8/28.

Dates of service 8/2, 8/8, 8/9, 8/14, 8/15 will NOT be paid as only 12 visits were authorized and only 12 visits will be paid!

Petitioner did not call a witness, but instead relied on the official record. Petitioner states that Zurich improperly counted five “office visits with manipulation” that did not require preauthorization (CPT Code 99213 - dates of service 8/17, 18, 24, 25, & 28) against the twelve preauthorized physical therapy visits. Therefore, Petitioner states that it is entitled to $1,400.00 reimbursement for the five unpaid physical therapy visits listed above.

Zurich’s counsel also relied on the record and did not call a witness. The carrier argues that it properly denied payment based on lack of preauthorization, lack of medical necessity, and lack of documentation of one-on-one services.

Concerning lack of preauthorization, the Carrier concedes that office visits with chiropractic manipulation do not require preauthorization, but it argues that these visits are classified as “physical medicine” and therefore should count against the preauthorized visits for “physical therapy.” If those five visits are counted against the twelve preauthorized physical therapy visits, the Carrier sates, then it has made proper payment and owes no additional reimbursement.

On medical necessity, the Carrier contends that the ALJ should look beyond the mere preauthorization and should determine whether the services provided were proper. It argues that Petitioner offered insufficient evidence to establish medical necessity for the services provided.

Finally, the Carrier points out that CPT Code 97530 requires one-on-one supervision by the physical therapy provider, but it argues that Petitioner provided inadequate documentation to establish one-on-one supervision.

In response to Carrier’s arguments, Petitioner reiterates its position that the Carrier improperly counted services that do not require preauthorization against the services that the Carrier preauthorized. Further, Petitioner argues that “physical therapy” is a distinct service with specific CPT codes, while “physical medicine” is a general category of treatment. Thus, merely because an office visit with manipulation is characterized as physical medicine does not make it physical therapy.

On the medical necessity question, Petitioner notes that the Carrier paid for seven visits of physical therapy without questioning the medical necessity. And in the official record, Petitioner cited TWCC Rule 133.301, which provides:

The insurance carrier shall not retrospectively review the medical necessity of a medical bill for treatment(s) and/or service(s) for which the health care provider has obtained pre-authorization under Chapter 134 of this title.

Finally, on the one-on-one supervision argument, Petitioner refers to the SOAP Notes for the disputed dates of service contained in the official record. Each of these contains a description of the services and exercises performed, with a concluding statement that “Mr. AB B B worked out for 2 hours today one on one with the therapist.”[1]

III. ALJ’s Analysis

The ALJ grants Dr. Adams’ appeal and orders that Zurich reimburse him $1,400.00 for the disputed five physical therapy visits. Based on the TWCC-62, it is clear that Zurich counted five “office visits with manipulation” against the twelve physical therapy visits that Zurich had preauthorized. But the parties agree that Petitioner’s “office visits with manipulation” did not require preauthorization. In addition, although an office visit with manipulation may be considered physical medicine, it is a distinct service with a separate CPT Code than the physical therapy preauthorized by Zurich. Therefore, the ALJ concludes that Zurich improperly counted five office visits with manipulation against the twelve preauthorized visits for physical therapy, and that Petitioner did not provide more physical therapy services than preauthorized by Zurich.

The ALJ also rejects the Carrier’s medical necessity argument. First, it is not clear to the ALJ that this reason for denial was stated in the applicable TWCC 62. The original TWCC 62 dated November 10, 2000, only listed lack of preauthorization as the reason for denying payment. Another TWCC 62 dated February 6, 2001, lists denial codes T – “Not according to treatment guidelines;” and N – “Not documented.” However, the Carrier’s narrative statement in this TWCC 62 refers only to work conditioning services.[2] Therefore, the ALJ finds that this TWCC 62 is not related to the services that are the subject of the present proceeding. And this is bolstered by the fact that the Carrier paid for seven of the preauthorized physical therapy visits provided by Petitioner without ever questioning the medical necessity. Further, as noted by Petitioner, TWCC Rule 133.301 precludes Zurich from retrospectively raising a medical necessity issue for preauthorized services.

The ALJ also questions whether the Carrier ever raised the issue of documentation of one-on-one services prior to hearing. But in any event, the ALJ agrees with Petitioner that the SOAP Notes expressly state that the services were provided with one-on-one supervision, and no evidence has been presented to call into doubt the accuracy of that documentation.

In summary, the ALJ finds that the physical therapy services in dispute were properly preauthorized; that the Carrier improperly counted five non-physical therapy visits against the number of preauthorized physical therapy visits; that one-on-one supervision of the physical therapy services was properly documented; and that the Carrier is precluded by TWCC rules from retrospectively challenging medical necessity for the preauthorized services. Therefore, the ALJ grants Dr. Adams’ appeal and orders Zurich to reimburse him for an additional $1,400.00 for the services in issue.

IV. Findings of Fact

  1. The Claimant sustained a compensable injury on______, in the course of his employment with______.
  2. Respondent Zurich American Insurance Company (Zurich) was the workers’ compensation insurance carrier and provides coverage for Claimant’s injury.
  3. On July 31, 2000, Zurich gave written preauthorization for Petitioner Curtis Adams, D.C., to provide twelve visits of physical therapy for Claimant’s cervical spine during the period August 1, 2000, to September 1, 2000.
  4. Petitioner provided physical therapy services for Claimant’s cervical spine on the following dates: August 2, 3, 4, 7, 8, 9, 14, 15, 16, 21, 22, and 23, 2000. On each date, Petitioner billed his services under CPT Codes 97110 and 97530. For each date, Petitioner charged $280.00 for the physical therapy services, for a grand total of $3,360.00.
  5. Petitioner provided one-on-one supervision for the physical therapy services described in Finding of Fact No. 4.
  6. Zurich paid Petitioner for the physical therapy he provided to Claimant on the following dates of service: August 3, 4, 7, 16, 21, 22, and 23, 2000. For these services, Zurich paid $280.00 for each date, for a grand total of $1,960.00.
  7. On August 17, 18, 24, 25, and 28, 2000, Petitioner provided Claimant with an office visit with manipulation. He billed Zurich $48.00 for each of these visits using CPT Code 99213. Services provided under CPT Code 99213 do not require preauthorization.
  8. An office visit with manipulation under CPT Code 99213 is not “physical therapy” as described in CPT Codes 97110 and 97530. Zurich improperly counted the office visits described in Finding of Fact No. 7 against the twelve visits of physical therapy preauthorized as described in Finding of Fact No. 3.
  9. The physical therapy services provided by Petitioner to Claimant on August 2, 8, 9, 14, and 15, 2000, as described in Finding of Fact No. 4, were properly preauthorized and were properly documented.
  10. Zurich refused to pay for physical therapy services provided by Petitioner to Claimant on the following dates: August 2, 8, 9, 14, and 15, 2000. Petitioner billed $280.00 for the physical therapy services provided on each of these dates, for a total of $1,400.00.
  11. Zurich denied payment for the services described in Finding of Fact No. 10 based on Denial Code A - lack of preauthorization.
  12. Petitioner timely appealed Zurich’s denial of payment to the Commissions Medical Review Division (MRD).
  13. MRD found in favor of Zurich and denied additional reimbursement.
  14. Petitioner timely appealed of the MRD decision.
  15. Notice of the hearing was sent May 15, 2002. 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.
  16. The hearing was held August 19, 2002, with Administrative Law Judge (ALJ) Thomas H. Walston presiding, and representatives of Petitioner and Zurich participating. The hearing adjourned and the record closed the same day.

V. 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. Curtis Adams, D.C., has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  5. Curtis Adams, D.C., established that he is entitled to additional reimbursement from Zurich in the amount of $1,400.00 for physical therapy services provided on August 2, 8, 9, 14, and 15, 2000.

ORDER

IT IS, THEREFORE, ORDERED that Curtis Adam, D.C.’s request for reimbursement of $1,400.00 from the Zurich American Insurance Company for physical therapy services provided on August 2, 8, 9, 14, and 15, 2000, is GRANTED, and Curtis Adams, D.C., shall have and recover $1,400.00 of and from Zurich American Insurance Company for the claims brought in this proceeding, plus interest at the rate and for the time allowed by law.

Signed October 15, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

THOMAS H. WALSTON
Administrative Law Judge

  1. See Official Record at pp. 59-68.
  2. Official Record at p. 529.
End of Document
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