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At a Glance:
Title:
453-02-3344-m4
Date:
November 22, 2002
Status:
Medical Fees

453-02-3344-m4

November 22, 2002

DECISION AND ORDER

Texas Imaging and Diagnostic (Texas Imaging) challenges a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denying requested reimbursement of $150.00 for fluoroscopic assistance (fluoroscopy) provided in conjunction with an epidural steroid injection (ESI). Reimbursement is not warranted. The Findings of Fact and Conclusions of Law detail the reasons for this conclusion.

I. Discussion

A. Background

In September 2000, Texas Imaging provided fluoroscopic assistance to an injured worker in conjunction with an ESI. Texas Imaging billed separately for the two procedures, including $150.00 for the fluoroscopy, for which it seeks reimbursement in this proceeding. The carrier, Highmark Casualty Insurance Company, refused to make reimbursement for the fluoroscopy, arguing that it was a part of the ESI and, as such, not separately reimbursable. The determinative issue in this case is straightforward: Whether a provider is entitled to reimbursement for a fluoroscopy performed in conjunction with an ESI.

B. Billing for Fluoroscopy

Texas Imaging argues that the ESI and fluoroscopic procedures can be billed separately, as separate procedures, pursuant to TWCC Advisory 9701, which, in pertinent part, provides:

If a health care provider believes fluoroscopic assistance (fluoroscopy) is medically necessary when performing an injection on a particular patient, and it is not included in the procedure, the provider shall bill the appropriate CPT code for the injection and the appropriate CPT Code for the fluoroscopic assistance.

Highmark disagrees, citing §134.1001(e)(2)(T)(1) of the Commission’s Spine Treatment Guideline in support of its argument that because fluoroscopy must be performed in conjunction with an ESI, it is part of the ESI procedure and not reimbursable as a separate procedure.

The ALJ agrees with Highmark. Section 134.1001(e)(2)(T)(1) is straightforward in addressing the disputed issue: “ESIs must be performed under fluoroscopic control.” Fluoroscopy, therefore, is a necessarysupport service for all ESIs. Because TWCC Advisory 9701 permits reimbursement for fluoroscopy only when it is not included in an injection procedure, Texas Imaging is not entitled to reimbursement.

C. Timeliness of Request for Hearing

The parties disputed whether Texas Imaging requested a hearing within 20 days of receiving the Medical Dispute Resolution Findings and Decision. The stamped date of receipt is not visible on one of the Commission’s two date stamps appearing on the hearing request, although a handwritten date was inserted, and the other date stamp reflects a date more than 20 days after issuance of the Findings and Decision. Consequently, the evidence is inconclusive on this issue, and the ALJ considers the request to have been timely filed.

II. Findings of Fact

  1. On September 21, 2000, Texas Imaging and Diagnostic (Texas Imaging) provided fluoroscopic assistance (fluoroscopy) to an injured worker in conjunction with an Epidural Steroid Injection (ESI).
  2. Texas Imaging billed the workers’ compensation insurance carrier, Highmark Casualty Insurance Company (Highmark), separately for the fluoroscopy and ESI. Highmark refused to reimburse Texas Imaging for the fluoroscopy.
  3. ESIs must be performed under fluoroscopic control.
  4. Upon requesting medical dispute resolution from the Texas Workers’ Compensation Commission’s Medical Review Division and receiving the medical dispute resolution officer’s decision denying reimbursement for the fluoroscopy, Texas Imaging timely filed a request for hearing before the State Office of Administrative Hearings.
  5. Notice of the hearing was sent to the parties on June 18, 2002.
  6. The notice of hearing 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.
  7. The hearing at the State Office of Administrative Hearings was held on September 24, 2002.

III. Conclusions of Law

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issue presented pursuant to the Texas Workers' Compensation Act (the Act), Tex. Labor Code Ann. §413.031 (Vernon Supp. 2002).
  2. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to §413.031(D) of the Act and Tex. Code Ann. ch. 2003 (Vernon 2002).
  3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 (Vernon 2002) and 28 Tex. Admin. Code (TAC) §§133.305.
  4. Texas Imaging has the burden of proof in this matter. 28 TAC §148.21(h).
  5. Pursuant to TWCC Advisory 9701, a health care provider shall bill the appropriate CPT code for an ESI and the appropriate CPT code for fluoroscopy when the provider believes fluoroscopy is medically necessary and when it is not included in the ESI procedure.
  6. Pursuant to 28 TAC § 134.1001(e)(2)(T)(1), fluoroscopy is included in the ESI procedure.
  7. Texas Imaging failed to meet its burden of proof that it is entitled to separate reimbursement for the fluoroscopy.
  8. Texas Imaging is not entitled to reimbursement from Highmark.

ORDER

IT IS ORDERED that Provider, Texas Imaging & Diagnostic Center, is not entitled to reimbursement from Carrier, Highmark Casualty Insurance Company, for the September 21, 2000, fluoroscopy provided to the injured worker.

Signed this 22nd day of November, 2002.

GARY W. ELKINS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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