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At a Glance:
Title:
453-02-3319-m5
Date:
December 20, 2002
Status:
Retrospective Medical Necessity

453-02-3319-m5

December 20, 2002

DECISION AND ORDER

The Back & Joint Clinic (Provider) and the National Fire Insurance Company of Hartford (Carrier) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (TWCC) denying reimbursement for medical services provided to ____(Claimant). This decision orders the Carrier to reimburse the Provider $1,144.00 for physical therapy provided under CPT Codes 97265 (joint mobilization), 97250 (myofascial release), 97150 (group therapy exercises) and 97110 (individual exercises). Additionally, this decision orders the Carrier to reimburse the Provider $834.00 for services provided under CPT Codes 99213 (office visit), 99215 (extended office visit), 99080-73 (work status report), 95851 (range of motion testing), 97750 (muscle testing), 99214 (office visit), and 99070 (analgesic balm for pain relief).

I. PROCEDURAL HISTORY

There are no contested issues of notice or jurisdiction in this proceeding. Therefore, these matters are addressed in the findings of fact and conclusions of law without further discussion here.

The Administrative Law Judge convened a hearing on November 5, 2002. The Provider was represented by Scott Hilliard, attorney. The Carrier was represented by Kyle Hensley, attorney. The record was closed at the conclusion of the hearing.

II. EVIDENCE AND BASIS FOR DECISION

The issues presented in this proceeding are: (1) did the last week of physical therapy exceed the eight week limit on physical therapy before preauthorization was required; and (2) were the other services provided to the Claimant medically necessary.

The documentary record in this case consisted of the 122-page certified record of the MRD proceeding (Exh. 1), a 16-page timeline of the services provided to the Claimant and charts (Exh. 2), the curriculum vitae of Dr. Michael A. Bhatt, D.C., Carrier’s expert witness (Carrier’s Exh. 1) and the 128 pages of records reviewed by Dr. Bhatt (Carrier’s Exh. 2).

Eight Weeks of Physical Therapy.

The Claimant was provided medical services by the Provider during nine of ten weeks beginning on January 22, 2001, and concluding on March 30, 2001. During the week of February 5, 2001, the Claimant was not treated by the Provider. During the week of February 12, 2001, the Claimant did not receive physical therapy, but was provided other medical services by the Provider, including range of motion and muscle testing. The Claimant received eight weeks of physical therapy during the ten week period.

The Provider argued that the medical services received by the Claimant during the week of February 12, 2001, including range of motion and muscle testing, should not count toward the eight week limitation on physical therapy before preauthorization becomes necessary. The Carrier argued that the services provided during the week in question required that the last week of physical therapy be preauthorized. The Carrier offered the testimony of Michael A. Bhatt, D.C., a practicing and consulting chiropractor. Dr. Bhatt reviewed the Claimant’s medical records and testified that in his opinion the Provider should have obtained preauthorization for the eighth week of physical therapy.

The Medicine Ground Rules provide instructions pertaining to physical medicine modalities and testing. The Ground Rules do not include the CPT Codes for range of motion and muscle testing under physical medicine care or therapy. The medical services provided to the Claimant during the week of February 12, 2002, should not be counted as physical therapy.

B. Medical Necessity of Other Services.

  1. CPT Code 99213. This code is used for standard, usual office visits for the evaluation and management of an established patient. During this office visit, the Provider should document two of three key components consisting of expanded problem focused history, expanded problem focused examination, and medical decision making of low complexity. Physicians typically spend 15 minutes face-to-face with the patient. The Claimant was seen by the Provider for three office visits in one week. Dr. Bailey testified that the nature of the injury required this level of management and evaluation of the patient. The office visits were well documented in the record. (Exh. 1, pages 22-24) The MRD ordered reimbursement and the Carrier did not present evidence sufficient to show that the office visits were not medically necessary and reasonably required.
  2. CPT Code 99214. This code is used for office visits for the evaluation and management of an established patient. During this office visit, the Provider should document two of three components consisting of a detailed history, a detailed examination, and medical decision making of moderate complexity. Physicians typically spend 25 minutes face-to-face with the patient. Dr. Bailey testified that he spent between 20 and 25 minutes with the Claimant and explained recent evaluation results. A detailed report was prepared indicating that the patient was also examined, and the Claimant was provided with updated instructions for his home exercise program. (Exh. 1, page 26) Dr. Bhatt testified that medical necessity was not shown for this visit because the Provider did not document review of six systems or body areas during the examination. The MRD did not recommend reimbursement, but the Provider did present evidence sufficient to show that the office visit was medically necessary and reasonably required.
  3. CPT Code 99215. This code is used for an extended office visit for the evaluation and management of an established patient. During this office visit, the Provider should document two of three key components consisting of a comprehensive history, a comprehensive examination, and medical decision making of high complexity. Physicians typically spend 40 minutes face-to-face with the patient. The office visit included physical capacity and muscular testing, cervical and lumbar spine testing, shoulder strength testing, and preparation of a treatment plan. (Exh. 1, pages 45-58) The Carrier argued, based on the testimony of Dr. Bhatt, that this is the highest level of office visit and it requires examination of nine of the 14 body systems. The Provider argued that time is also a component to be considered in making a determination. The MRD did not recommend reimbursement, but the Provider established that the office visit was medically necessary and reasonably required.
  4. CPT Code 99080-73. This code is used for preparation of a work status report, TWCC 73. Medical necessity was established for the office visit on the same date discussed in item number 3 above. Therefore, the carrier should reimburse the Provider for preparation of the work status report during that office visit.
  5. CPT Code 95851. This code is used for range of motion testing. The Claimant was tested on February 13, 2001, and again on April 17, 2001. The Carrier argued that the second test was not medically necessary. Dr. Bailey testified that when comparing the results of the two tests, substantial improvement was found. Medical necessity was established for the second test to measure the Claimant’s improvement.
  6. CPT Code 97750-MT. This code is used for muscle testing.Dr. Bhatt testified that the Provider should have charged for only four units instead of seven units. Medical necessity was shown based on the same rationale as discussed in CPT Code 95851 above, and the Carrier should reimburse the Provider for these services.
  7. CPT Code 99070. This code was used to document application of analgesic balm to provide pain relief for the Claimant. The MRD recommended reimbursement, and the Carrier did not present evidence to show that this service was not medically necessary and reasonably required.

Based on the evidence, the ALJ concludes that the Carrier should reimburse the Provider for the services rendered in the treatment of the Claimant.

III. FINDINGS OF FACT

  1. On _________________(Claimant) suffered a compensable injury to his back, neck, and shoulder when a hinge broke allowing a 70 pound door to fall on the left side of his head and shoulders.
  2. Claimant’s injury is covered by workers’ compensation insurance written for Claimant’s employer by National Fire Insurance Company of Hartford (Carrier).
  3. The Back & Joint Clinic (Provider) treated the Claimant’s injury with physical therapy and other modalities, including the contested dates of service from March 26, 2001, through April 19, 2001.
  4. Pre-authorization of eight weeks of physical therapy was not necessary.
  5. The Claimant was provided eight weeks of physical therapy during a 10 week period.
    1. The Claimant did not receive any treatment during the third week of the 10 week period of treatment.
    2. The Claimant was not treated with physical therapy during the fourth week of the 10 week period of treatment.
    3. Range of motion and muscular testing, and office visits were provided to the Claimant during the fourth week of the 10 week period of treatment.
  6. The Carrier denied payment for the eighth week of physical therapy because it was not pre-authorized.
  7. The services referred to in Finding of Fact No. 5 (c) are not physical therapy.
  8. In addition to services referred to in Finding of Fact No. 5, the Provider billed for services provided under CPT Codes 99213, 99214, 99215, 99080-73, 95851, 97750-MT, and 99070.
  9. The Carrier denied payment for the services referred to in Finding of Fact No. 8 for not being medically necessary.
  10. The Provider properly documented the office visits billed under CPT Codes 99213, 99214, and 99215.
  11. The TWCC 73 billed under CPT Code 99080-73 was prepared during an office visit to document work status.
  12. Range of motion and muscular testing billed under CPT Codes 95851 and 97750-MT documented substantial improvement over the results of the first tests.
  13. Analgesic balm billed under CPT Code 99070 was supplied to relieve the Claimant’s level of pain.
  14. The Provider timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  15. The MRD issued its findings and decision on May 8, 2002, concluding that the disputed expenses billed under CPT Codes 99213 and 99070 should be paid. Reimbursement was not ordered for CPT Codes 97265, 97250, 97150, 97110, 99214, 99215, 99080-73, 99851, and 07750-MT.
  16. Both the Carrier and the Provider filed a request for hearing on the MRD’s decision.
  17. The Commission sent notice of hearing to the parties on June 13, 2002. The hearing notice informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
  18. At the hearing on November 5, 2002, the Provider appeared by telephone and was represented by Scott C. Hilliard, attorney. The Carrier was represented at the hearing by Kyle Hensley, attorney.

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 it should prevail in this matter on reimbursement of services billed under CPT Codes 97265, 97250, 97150, 97110, 99214, 99215, 99080-73, 95851, and 97550-MT. Tex. Labor Code §413.031.
  5. The Carrier has the burden of proving by a preponderance of the evidence that it should prevail in this matter on reimbursement of services billed under CPT Codes 99213 and 99070. Tex. Labor Code Ann. §413.031.
  6. Based on Findings of Fact Nos. 4, 5, and 7, the Claimant was provided eight weeks of physical therapy and pre-authorization was not required. 28 Tex. Admin. Code §134.600.
  7. Based on Findings of Fact Nos. 10 - 12, the Provider established that the treatment provided was medically necessary for treatment of the Claimant’s compensable injury. Tex. Labor Code Ann.§408.021.
  8. Based on Findings of Fact Nos. 4, 5, 7 and 10-12, and Conclusions of Law Nos. 6 and 7, the Provider proved that reimbursement should be allowed for the CPT Codes referred to in Conclusion of Law No. 4.
  9. Based on Findings of Fact Nos. 10 and 13, the Carrier failed to prove that reimbursement for CPT Codes 99213 and 99070 should be disallowed.
  10. The Carrier should reimburse the Provider for providing treatment to Claimant in the amount of $1,978.00 plus interest.

ORDER

IT IS, THEREFORE, ORDERED that National Fire Insurance Company of Hartford reimburse the Back & Joint Clinic for fees incurred in treating the Claimant in the amount of $1,978.00.

Issued this 20th day of December 2002.

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

End of Document
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