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At a Glance:
Title:
453-02-3375-m4
Date:
October 21, 2002
Status:
Medical Fees

453-02-3375-m4

October 21, 2002

DECISION AND ORDER

I. INTRODUCTION

Texas Property & Casualty Insurance Guaranty Association for United Pacific Insurance Company (Carrier) appealed the decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) ordering Carrier to reimburse Spencer Sloane, D.C. (Provider) $13,489.00 in partial payment for services provided to____ (Claimant) from October 18, 2000, through May 25, 2001. The treatments and services were billed under 17 different Current Procedural Technology (CPT) codes. Carrier seeks a decision disallowing any and all payment for these services.

The MRD decision was also appealed by Provider, who seeks $17,192.40 in full payment for the disputed services, rather than the partial payment that was ordered.

The Administrative Law Judge (ALJ) finds that some of the disputed services were properly documented and some were not. Therefore, Carrier is to reimburse Provider $12,516.00 for the properly documented services.

II. PROCEDURAL HISTORY

ALJ Sharon Cloninger convened the hearing on August 22, 2002, in the William Clements Building, 300 West 15th Street, Austin, Texas. Carrier was represented by Kyle Hensley, attorney. H. Douglas Pruett represented Provider, who also appeared. The Texas Workers’ Compensation Commission (the Commission) did not participate in the hearing. The parties did not contest notice or jurisdiction, which are addressed in the Findings of Fact and Conclusions of Law below. After evidence was presented, the hearing concluded and the record closed that same day.

III. BACKGROUND

On_________, Claimant, a 74-year-oldmachine operator employed by________., in________, Texas, sustained a compensable injury when his right hand was crushed by a machine. Claimant underwent surgery at RHD Memorial Medical Center on July 7, 2000, for repair of a complex laceration, open management of multiple open fractures of the metacarpals[1] at the little and ring fingers, and a repair of extensor tendons avulsions [2] of the right hand times five. (Carrier’s Ex. 2 at 144 and 250). Claimant next underwent some conservative post-operative management and, in September 2000, underwent a repeat extensor tendon release surgery. (Id. at 250).

Beginning October 17, 2000, Claimant was treated by Provider, who used passive manipulative techniques, myofascial release, joint mobilization, and supervised therapeutic hand exercises. During the course of treatment, Claimant’s pain level dropped from seven out of ten on October 18, 2000, to one out of ten by January 2001. Physical medicine modalities were pre-authorized for three times a week from October 24, 2000, through December 15, 2000. (Provider’s Exhibits 3 and 4). Provider treated Claimant with physical medicine modalities on 13 dates of service during that period.

Provider referred Claimant to James Laughlin, M.D., an orthopedic surgeon (Carrier’s Ex. 2 at 250). On October 26, 2000, Dr. Laughlin evaluated Claimant to have marked limitation of motion in the entire hand and in the wrist. There was evidence of sensory nerve disruption in the ulnar distribution of the hand. There was also extensor lag of the ring and little fingers.

In November 2000, repeat radiographs revealed a fourth metacarpal fracture that had not healed, but there is no indication that any additional surgeries occurred. (Id. at 250).

Provider referred Claimant to Ergos Work Recovery, Inc., for a functional capacity evaluation (FCE) which was conducted onJanuary 15, 2001. The FCE report contains start and end times, as required by Commission guidelines regarding documentation. The summary states Claimant did not meet maximum medium level Department of Labor requirements for the static push cart, the static lift knuckle height, static lift bench height, dynamic lift bench height center, dynamic lift shelf height center, or carrying. (Carrier’s Ex. 3 at 86).The report also indicates Claimant’s whole body range of motions and standing work tolerance were below the competitive level, as was keyboarding (Id. at 94, 97 and 99). Claimant’s wrist flexion/extension was well below the physical demand level for his job. (Id. at 100). His forearm pronation/supination strength also was below the level required for his job. (Id. at 101).

Following the FCE, Claimant was enrolled in Provider’s work hardening programfor five-and-a-half weeksfrom January 22, 2001, through March 2, 2001.

A follow-up FCE conducted on February 28, 2001, indicates increases by percentage in Claimant’s ability to perform job-related activities such as lifting, carrying, pushing, pulling, kneeling, crouching, reaching and fingering. Detailed documentation regarding Claimant’s current safe work capacity, static strength, range of motion, work endurance, standing work tolerance, keyboarding, fingering/handling performance, hand grip static strength, flexion/extension static strength of right and left wrists, forearm pronation/supination, and an assessment for job placement considerations are included in the report. The summary contains start and end times, as required by Commission guidelines regarding FCE documentation. (Provider’s Ex. 4).

On March 20, 2001, Claimant was seen by M. Raper, D.C., for an Independent Medical Evaluation. Dr. Raper gave Claimant a whole body impairment rating of six percent. (Carrier’s Ex. 2 at 143).

In a peer review letter dated September 28, 2001, Kate Blanchette, M.D., stated that Provider’s conservative chiropractic treatment of Claimant’s hand following Claimant’s surgery was reasonable and appropriate during the post-operative phase, which should have lasted no more than three months, with a January 2001 treatment end point. She said the chiropractic treatment to that point was well within normal Commission guidelines. She found the work hardening to be unnecessary for Claimant. (Carriers Ex. 2 at 250-253).

IV. DISCUSSION

A. Treatments and services at issue

The following treatments and services are in dispute in this proceeding, and are listed by CPT code, in numerical order. Included in the list is the maximum allowable reimbursement (MAR), if applicable, for each treatment or service, as listed in the MFG.

  • 95851 (Range of motion measurements and report. MAR’$36.00) Provider billed Carrier $72.00 for range of motion measurements occurring on October 18, 2000, and November 6, 2000.
  • 95860 (Needle electromyography, two extremities and related paraspinal areas. MAR’$113.00)Provider billed Carrier $113.00 for services occurring January 12, 2001.
  • 95900 (Nerve conduction, velocity and/or latency study; motor, each nerve. MAR = $64.00) Provider billed Carrier $128.00 for a nerve conduction study with a date of service of January 12, 2001.
  • 95904 (Sensory, each nerve. MAR = $64.00)Provider billed Carrier $192.00 for services provided January 12, 2001.
  • 95935 (AH” or AF” reflex study, by electrodiagnostic testing. MAR = $53.00) Provider billed Carrier $106.00 for electrodiagnostic testing with a date of service of January 12, 2001.
  • 97110 (Therapeutic procedures one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. MAR’$35.00 for each 15 minutes) Provider billed $105.00 per disputed date, or for three units per session, for a total of $ 2,730.00[3] for 26dates of service from October 18, 2000, through January 12, 2001.
  • 97122 (Manual traction. MAR’$35.00)Provider billed Carrier $ 490.00 for 14 treatments occurring between December 11, 2000, and January 12, 2001.
  • 97250-59 (Myofascial release/soft tissue mobilization, one or more regions. MAR = $43.00)Provider billed Carrier $1,032.00 for 24 treatments occurring from October 19, 2000, through January 12, 2001.
  • 97265 (Joint mobilization, one or more areas, peripheral or spinal. MAR’$43.00)Provider billed Carrier $ 989.00[4] for 23 joint mobilizations occurring from October 19, 2000, through January 12, 2001.
  • 97545-WH[5] (Work hardening/conditioning: initial two hours. MAR’$ 64.00 perhour) Provider billed Carrier $0, or $51.20 per hour, for each of 28 dates of service occurring from January 22, 2001, through March 2, 2001, for a total of $2,176.00.
  • 97546-WH (work hardening, each additional hour beyond two hours. MAR’$64.00 per hour) Provider billed Carrier $6,336.00 for additional hours of work hardening occurring on 27 dates from January 22, 2001, through February 28, 2001.
  • 97750-FC[6] (Physical performance test or measurement such as FCE with written report, each 15 minutes. Medicine Ground Rule I. E. 2. states FCEs are to be billed at $100 per hour for up to five hours for the first FCE, and for up to two hours for an interim or discharge FCE) Provider billed Carrier $700.00 for FCEs occurring January 15, 2001, and February 28, 2001.
  • 97750-MT[7] (Physical performance tests or measurement with written report, each 15 minutes. MAR = $43.00)Provider billed Carrier $129.00 for three physical performance tests or evaluations, with dates of service of October 18, 2000, November 13, 2000, and December 27, 2000.
  • 99082 (Unusual travel such as transportation and escort of patient. Requires documentation of procedure so there is no MAR). Provider billed Carrier $ 969.00 for 57 occasions at $17.00 each of unusual travel occurring from October 19, 2000, through March 9, 2001.
  • 99090 (Analysis of information, such as ECGs, blood pressures, hematologic data, stored in computers. MAR = $108.00)Provider billed Carrier $ 432.00 for four analyses, with dates of service of October 18, November 6, November 13, and December 27, 2000.
  • 99213 (Office or 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. . . . Physicians typically spend 15 minutes face-to-face with patient. MAR’$48.00)
  • Provider billed Carrier $1,056.00 for 22 office visits occurring from October 19, 2000, through May 25, 2001.
  • 99213-MP[8] (Office visit: first manipulation. MAR’$48.00) Provider billed Carrier $ 528.00 for 11 office visits with first manipulations occurring from October 18, 2000, through January 12, 2001.

B. Applicable Law

Because Claimant’s compensable injury is to his hand, the Commission’s Upper Extremities Treatment Guideline (UETG) applies. The UETG requires treatment of a work-related injury to be documented by the health care provider to determine the level of care to be provided and the necessity for that care. 28 Tex. Admin. Code (TAC) § 134.1002(e)(3)(B).

UETG Rule (f)(6)(V) applies to the issues in this case. The rule states in relevant part that the duration of a the primary level of care for a crush injury to the hand should last up to three months, and that treatment interventions may include but are not limited to outpatient evaluation and therapy such as attended modalities and procedures. The expected outcome is that the patient will return to unrestricted work or reach Maximum Medical Improvement (MMI).

Also applicable to this case is Medicine Ground Rule (I)(A)(10)(a) found in the Commission’s Medical Fee Guideline (MFG), which states:

A physical medicine session is defined as any combination of four modalities (97010-97039), procedures (97110-97150) and/or physical medicine activities and training (97220-97541). The maximum amount of time allowed per session is two hours. If additional time is required to complete the treatment rendered in a session, a maximum of one additional hour may be allowed. DOP is required for time exceeding the two hour maximum. . . .”

Medicine Ground Rule I.E.2.a. applies to functional capacity evaluations, and states:

FCEs are allowed a maximum of three times for each injured worker. FCEs shall be billed as code 97750-FC. FCEs shall be reimbursed at $100 per hour for a maximum of five hours ($500) for the initial test and two hours ($200) for an interim and/or discharge test. A summary report for each FCE is required and shall not be reimbursed in addition to the evaluation charge. Required documentation includes the start and end time for the FCE.

The Commission has adopted rules governing work hardening programs. The rules, found in the MFG, relate to, among other things, what documentation is required of work hardening providers. Work hardening is defined in the Commission’s Medical Fee Guideline (MFG) at Medicine Ground Rule II.E. as:

a highly structured, goal-oriented, individualized treatment program designed to maximize the ability of the persons served to return to work. Work Hardening programs are interdisciplinary in nature with a capability of addressing the functional, physical, behavioral, and vocational needs of the injured worker. Work Hardening provides a transition between management of the initial injury and return to work while addressing the issues of productivity, safety, physical tolerance, and work behaviors. Work Hardening programs use real or simulated work activities in a relevant work environment in conjunction with physical conditioning tasks. These activities are used to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, behavioral, attitudinal, and vocational functioning of the person served.

Work hardening documentation requirements are found at Medicine Ground Rule II.E.8, which states:

Daily treatment and patient response to treatment shall be documented and reviewed to ensure continued progress.

Therapeutic services billed under CPT Code 97110 must meet the requirements of Medicine Ground Rule I.C.9, which states:

If any of the procedures (97110-97139) are performed with two or more individuals, then 97150 is reported. . . .

Carrier’s reasons for denial of payment

For each CPT code billed, Carrier denied payment using denial code “T,” which is used when the insurance carrier is reducing or denying payment because the treatments and/or services fall outside the parameters set in the appropriate Commission treatment guideline, and there is not sufficient documentation to support the medical necessity of providing those treatments or services. However, an insurance carrier cannot deny payment solely because a treatment or service falls outside the parameters of a treatment guideline. (Provider’s Ex. 1).

In addition to using denial code “T,” Carrier also denied payment for CPT code 99082 (unusual travel) using denial code “N,” which is used when the insurance carrier is reducing or denying payment because the provider did not submit Commission-required documentation with the bill.

Use of this code must include an explanation of the missing documentation sufficient to allow the provider to correct the error when requesting reconsideration. See 28 TAC §§ 133.1(a)(3), 133.300(a), and 133.301. (Provider’s Ex. 1).

Carrier used denial code “F” as well as “T” in refusing to reimburse provider for charges billed under CPT codes 97545-WH and 97546-WH, related to Claimant’s work hardening. Denial code “F” is used when the insurance carrier is reducing payment from the billed amount in accordance with the MAR as set out in the appropriate Commission guideline, here the MFG. This denial code is not used for reductions based on a lack of documentation. (Provider’s Ex. 1).

D. Evidence and argument

Carrier offered the 256-page certified record of the MRD proceeding (Carrier’s Ex. 2), an Ergos Evaluation Summary Report (Carrier’s Ex. 3), and the curriculum vitae of Carrier’s witnessWilliam D. Defoyd, D.C., all of which were admitted.Dr. Defoyd testified. Provider offered four exhibits, all of which were admitted, and asked the ALJ to take official notice of three documents, which was done.

Medical necessity is not an issue in this proceeding

As a preliminary matter, Provider argued that Carrier could not, at the hearing before SOAH, raise lack of medical necessity as a reason for payment denial, because lack of medical necessity was not raised as an issue before the MRD.[9] Carrier argued that medical necessity could be raised. In support of its argument, Provider cited several prior SOAH decisions, which were reviewed by the ALJ after the hearing. The ALJ agrees with Provider’s argument, and will not consider medical necessity as an issue in this proceeding.

The ALJ adopts the reasoning set forth in SOAH Docket No. 453-99-2021.M5, decided by ALJ Renee Rusch on July 20, 2000, as follows:

At the hearing, the Carrier attempted to assert new reasons for denying Provider’s claims, in addition to those it asserted on the Form TWCC-62 and presented to the MRD. For the reasons set forth below, the ALJ concludes that the Carrier waived any grounds for reimbursement that it did not assert before the request for medical dispute resolution was filed.

Tex. Labor Code Ann. § 408.027(d):

If an insurance carrier disputes the amount of payment or the health care provider’s entitlement to payment, the insurance carrier shall send to the commission, the health care provider, and the injured employee a report that sufficiently explains the reasons for the reduction or denial of payment for health care service provided to the employee. The insurance carrier is entitled to a hearing as provided by Section 413.031(d).

The Carrier must explain the reasons for denial of payment on Form TWCC-62, Notice of Medical Payment Dispute, or its equivalent. 28 TAC § 133.304(a). Tex. Labor Code Ann. § 413.031 provides for medical dispute resolution at the Commission, and Commission Rules 133.301 - 133.304 implement the dispute resolution process. Review at the MRD consists of a paper review of documents submitted by the disputing parties. The documents submitted define the scope of the dispute at the MRD.

It is the Commission’s position that a carrier may not assert, at the MRD, reasons for denial which it did not raise before the matter was filed with the MRD. Several SOAH ALJs have agreed.[10] It follows, therefore, that a carrier may not raise, for the first time, in the SOAH proceeding, a basis for denying payment that it did not even present to the MRD.[11]

In the current proceeding, Carrier did not raise medical necessity as a reason for denial before the matter was filed with the MRD, or at the MRD. Therefore, the ALJ will not consider medical necessity as a basis for denying reimbursement to Provider.

V. ANALYSIS AND CONCLUSION

A. Documentation does not support reimbursement for charges billed under CPT code 99082, and denied by Carrier under payment exception codes “T” and “N”

Transportation and escort of Claimant is not documented by Provider, except to the extent that it is an itemized charge in Provider’s bills to Carrier. (Carrier’s Ex. 2 at 112, 114-119, 121-126, 128, 131-133, and 135-139). The record contains no information regarding where or why Claimant was transported, or who escorted him.

The ALJ finds no evidence in the record to support transportation and escort of Claimant. The ALJ upholds Carrier’s denial of reimbursement for Provider’s failure to document this service.

B.Documentation does not support reimbursement for therapeutic services billed under CPT code 97110, and denied under payment exception code “T”, but does support reimbursement for therapeutic services under CPT code 97150

Provider billed Carrier for three 15-minute units of therapy at $35.00 per unit per visit, for a total of $2,730.00, for 26 sessions between October 18, 2000, and January 12, 2001. The documentation indicates that all therapy sessions were supervised, but except for one instance, does not state if the supervision was one-on-one. If the therapy was in a group setting, it should have been billed under CPT code 97150, which has a MAR of $27.00 and is not a timed code so would only be billed once per session. Pursuant to Medicine Ground Rule I.C.9, therapeutic services should be billed under 97150, because documentation does not support one-on-one treatment in this case. Accordingly, the ALJ orders payment of $35.00 for one unit of one-on-one therapy, and 26 sessions of group therapy, for a total of $737.00.

C. Documentation does not support reimbursement for office visits billed under CPT code 99213 and 99213-MP

Provider billed Carrier $1,056.00 under CPT code 99213 for 22 office visits occurring from October 19, 2000, through May 25, 2001. According to the MFG, an office visit can only be billed if two of the three elements are satisfied: an expanded problem focused history, an expanded problem focused examination, or medical decision making of low complexity. The evidence in this case does not indicate that the requirements of CPT code 99213 were met. Carrier sustained its burden of proof on this issue and will not be required to reimburse Provider for the office visits.

Provider billed Carrier $528.00 for 11 office visits with first manipulations occurring from October 18, 2000, through January 12, 2001. The dates of service do not overlap with dates of service billed under CPT code 99213, above. However, the documentation does not support the requirements of CPT code 99213, nor does it state what first manipulation occurred on these visits. The ALJ finds the documentation to be inadequate to support payment for this treatment.

D. Documentation does not support reimbursement for treatments and/or services billed under 95860, 95900, 95904, 95935, 97750-MT, and 99090, and denied by Carrier under payment exception code “T”

The record contains no evidence of physical evaluations conducted on October 18, November 13, or December 27, 2000.

There is nothing in the record to support that analysis of information stored in a computer occurred at any time, including on the disputed dates of service. There is no evidence that Claimant underwent electrodiagnostic testing, a nerve conduction study, nerve sensory testing, or needle electromyography on January 12, 2001. Therefore, Provider is not entitled to reimbursement from Carrier for charges billed under CPT codes 95860, 95900, 95904, 95935, 97750-MT and 99090.

E. Documentation supports reimbursement for treatments and/or services billed under CPT codes 95851, 97122, 97250-59 and 97265, and denied by Carrier under payment exception code “T”

Carrier should reimburse Provider $1,032.00 for myofascial release treatments, which are supported by documentation in the record. Documentation supports payment to Provider of $490.00 for 14 treatments using manual traction. There is documentation for one of the two range of motion measurements at issue, so reimbursement of $36.00 is ordered for this service. The medical records in this case indicate joint mobilization procedures were performed on all the disputed dates, with no more than one session per day, so Carrier is to reimburse Provider $989.00 for these treatments.

F.Documentation supports reimbursement for charges billed under CPT code97750-FC, and denied by Carrier under payment exception code “T”

Provider billed Carrier $700.00 for FCEs occurring January 15, 2001, and February 28, 2001. The FCE reports meet the documentation requirements of Medicine Ground Rule (I)(E)(2), in that the start and end times of each FCE are included in the reports. Conducting an FCE is within the parameters of Commission guidelines. Therefore, Carrier did not prove that denial of reimbursement was proper based on payment exception code “T”. The ALJ orders reimbursement of $700.00 from Carrier to Provider for charges billed under CPT code 97750-FC.

G. Documentation supports reimbursement for charges billed under CPT codes 97545-WH and 97546-WH, and denied by Carrier under payment exception codes “T” and “F”

Provider billed Carrier $102.40 for the initial two hours of work hardening for each of 28 dates of service occurring from January 22, 2001, through March 2, 2001, for a total of $2,176.00. Provider billed Carrier $6,336.00 for 99 additional hours of work hardening occurring on 27 dates from January 22, 2001, through February 28, 2001. Documentation supports that Claimant participated in work hardening for the number of hours billed by Provider. Carrier did not prove work hardening for Claimant fell outside the parameters of the UETG, thus requiring documentation to justify it. Full payment is ordered, with no reduction in the amount.

H. Conclusion

Carrier met its burden of proof in showing that reimbursement should be denied for CPT codes 99082 (unusual travel), 97110 (therapeutic services: one-on-one), 99213 (office visits) and 99213-MP (office visits with first manipulation).

Provider met its burden of proof in showing that reimbursement should be ordered for CPT codes 95851 (range of motions measurement) in the amount of $36.00, 97122 (manual traction) in the amount of $490.00, 97250-59 (myofascial release) in the amount of $1,032.00, 97265 (joint mobilization) in the amount of $989.00, 97750-FC (functional capacity evaluation) in the amount of $700.00, 97545-WH (work hardening: initial two hours) in the amount of $2,176.00 and 97546-WH (work hardening: additional hours) in the amount of $6,336.00. In addition, reimbursement of $737.00 is warranted for group therapeutic services under CPT code 97150. Accordingly, the ALJ orders a total reimbursement of $12,516.00.

VII. FINDINGS OF FACT

  1. ____ (Claimant) sustained a compensable work-related injury on_________, while employed with__________., whose workers’ compensation insurance carrier was Texas Property & Casualty Insurance Guaranty Association for United Pacific Insurance Company (Carrier).
  2. Claimant’s initial treatment consisted of surgery to repair his hand on July 7, 2000, and again in September 2000.
  3. Spencer Sloane, D.C., (Provider) began treating Claimant’s hand on October 17, 2001. He used passive manipulative techniques including myofascial release, joint mobilization, and supervised hand exercises.
  4. Provider referred Claimant to Ergos Work Recovery, Inc., for a functional capacity evaluation (FCE), which was conducted on January 15, 2001.
  5. The FCE evaluation report dated January 15, 2001, contains start and end times. The summary states Claimant did not meet maximum medium level Department of Labor requirements for the static push cart, the static lift knuckle height, static lift bench height, dynamic lift bench height center, dynamic lift shelf height center, or carrying. The report also indicates Claimant’s whole body range of motions and standing work tolerance were below the competitive level, as was keyboarding. Claimant’s wrist flexion/extension was well below the physical demand level for his job. His forearm pronation/supination strength also was below the level required for his job.
  6. Following the FCE, Claimant participated in Provider’s work hardening program from January 22, 2001, through March 2, 2001.
  7. The daily work hardening notes indicate the start and stop times; which exercises and activities Claimant performed and the purposes of each exercise and activity; and Claimant’s level of effort, endurance and pain.
  8. A follow-up FCE was conducted on February 28, 2001. The report contains start and end times. It indicates increases by percentage in Claimant’s ability to perform job-related activities such as lifting, carrying, pushing, pulling, kneeling, crouching, reaching and fingering. Detailed documentation regarding Claimant’s current safe work capacity, static strength, range of motion, work endurance, standing work tolerance, keyboarding, fingering/handling performance, hand grip static strength, flexion/extension static strength of right and left wrists, forearm pronation/supination, and an assessment for job placement considerations are included in the report.
  9. Provider sought reimbursement of $17,192.40 from Carrier for services rendered to Claimant, and billed under the following CPT codes:
    • 95851 (Range of motion measurements and report. MAR-$36.00) Provider billed Carrier $72.00 for range of motion measurements occurring on October 18, 2000, and November 6, 2000.
    • 95860 (Needle electromyography, two extremities and related paraspinal areas. MAR-$113.00)Provider billed Carrier $113.00 for services occurring January 12, 2001.
    • 95900 (Nerve conduction, velocity and/or latency study; motor, each nerve. MAR - $64.00) Provider billed Carrier $128.00 for a nerve conduction study with a date of service of January 12, 2001.
    • 95904 (Sensory, each nerve. MAR - $64.00)Provider billed Carrier $192.00 for services provided January 12, 2001.
    • 95935 (AH” or AF” reflex study, by electrodiagnostic testing. MAR - $53.00) Provider billed Carrier $106.00 for electrodiagnostic testing with a date of service of January 12, 2001.
    • 97110 (Therapeutic procedures one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. MAR-$35.00 for each 15 minutes) Provider billed $105.00 per disputed date, or for 45 minutes per session, for a total of $ 2,730.00 for 26therapeutic procedures occurring from October 18, 2000, through January 12, 2001.
    • 97122 (Manual traction. MAR-$35.00)Provider billed Carrier $ 490.00 for 14 treatments occurring between December 11, 2000, and January 12, 2001.
    • 97250-59 (Myofascial release/soft tissue mobilization, one or more regions. MAR - $43.00). Provider billed Carrier $1,032.00 for 24 treatments occurring from October 19, 2000, through January 12, 2001.
    • 97265 (Joint mobilization, one or more areas, peripheral or spinal. MAR-$43.00) Provider billed Carrier $ 989.00 for 23 joint mobilizations occurring from October 19, 2000, through January 12, 2001.
    • 97545-WH (Work hardening/conditioning: initial two hours. MAR-$64.00 per hour) Provider billed Carrier $102.40Bor $51.20 per hourBfor each of 28 dates of service occurring from January 22, 2001, through March 2, 2001.
    • 97546-WH (work hardening, each additional hour beyond two hours. MAR-$64.00 per hour) Provider billed Carrier $6,336.00 for additional hours of work hardening occurring on 27 dates from January 22, 2001, through February 28, 2001.
    • 97750-FC (Physical performance test or measurement such as functional capacity with written report, each 15 minutes) Provider billed Carrier $700.00 ($100 per hour) for FCEs conducted January 15, 2001, and February 28, 2001. The amount billed comports with Medicine Ground Rule I.E.2.a.
    • 97750-MT (Physical performance tests or measurement with written report, each 15 minutes. MAR - $43.00)Provider billed Carrier $129.00 for three physical performance tests or evaluations, with dates of service of October 18, 2000, November 13, 2000, and December 27, 2000.
    • 99082 (Unusual travel such as transportation and escort of patient. Requires documentation of procedure). Provider billed Carrier $ 969.00 for 57 occasions at $17.00 each of unusual travel occurring from October 19, 2000, through March 9, 2001.
    • 99090 (Analysis of information, such as ECGs, blood pressures, hematologic data, stored in computers. MAR - $108.00)Provider billed Carrier $ 432.00 for four analyses, with dates of service of October 18, November 6, November 13, and December 27, 2000.
    • 99213 (Office or 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. . . . Physicians typically spend 15 minutes face-to-face with patient. MAR-$48.00)Provider billed Carrier $1,056.00 for 22 office visits occurring from October 19, 2000, through May 25, 2001.
    • 99213-MP (Office visit: first manipulation. MAR-$48.00) Provider billed Carrier $ 528.00 for 11 office visits with first manipulations occurring from October 18, 2000, through January 12, 2001.
  10. Carrier refused to reimburse Provider for the above services using payment exception codes AT” for all of them. Carrier also used payment exception code “N” for CPT code 99082 (unusual travel) and payment exception code “F” for CPT codes 97545-WH (work hardening: initial two hours) and 97546-WH (work hardening: additional hours). Payment exception code “T” indicates lack of documentation to support treatment outside parameters of the Commission’s guidelines. Payment exception code “N” indicates failure to document a treatment or service altogether. Payment exception code “F” is used when Carrier reduces an amount billed so that the amount comports with Commission fee guidelines.
  11. The record contains no documentation regarding CPT code 99082 (unusual travel). The record is silent as to where, why and by whom Claimant was escorted.
  12. Except for one instance, the record does not state that therapeutic services billed under CPT code 97110 were provided in a one-on-one setting, although it is documented that therapeutic services were provided on 26 dates of service.
  13. Documentation for office visits billed under CPT code 99213 does not set out that two of the following three services were provided during each visit: an expanded problem focused history, an expanded problem focused examination, or medical decision making of low complexity.
  14. Documentation for office visits billed under CPT code 99213-MP does not set out two of the following three services were provided during each visit: an expanded problem focused history, an expanded problem focused examination, or medical decision making of low complexity. The documentation does not state how the Afirst manipulation” modifier of this code was met.
  15. The record contains no evidence of physical evaluations conducted on October 18, November 13, or December 27, 2000, and billed under CPT code 97750-MT.
  16. The record contains no evidence of an analysis of information stored in a computer, on any date, and billed under CPT code 99090.
  17. There is no evidence in the record that Claimant underwent needle electromyography (CPT code 95860), a nerve conduction study (CPT code 95900), nerve sensory testing (CPT code 95904) or electrodiagnostic testing (CPT code 95935) on January 12, 2001.
  18. The record contains evidence that myofascial release treatments billed under CPT code 97250-59 were performed on 24 dates between October 19, 2000, and January 12, 2001.
  19. Documentation supports that manual traction (CPT code 97122) occurred on 14 dates between December 11, 2000, and January 12, 2001.
  20. Documentation supports that one range of motion measurement (CPT code 95851) occurred on a disputed date of service.
  21. Documentation supports that joint mobilization (CPT code 97265) was performed by Provider on 23 dates of service from October 19, 2000, through January 12, 2001.
  22. On September 10, 2001, Provider filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission’s Medical Review Division (MRD), asking for reimbursement of $17,192.40 for the above-described services.
  23. On May 15, 2001, the MRD ordered Carrier to reimburse Provider $13,489.00 of the requested $17,192.40.
  24. On May 21, 2002, Provider appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH), seeking full, rather than partial, payment.
  25. On May 29, 2002, Carrier appealed the MRD’s decision to SOAH, seeking that any and all payment be disallowed.
  26. On June 24, 2002, notice of the hearing was mailed to Carrier, Provider, and the Commission’s APA Litigation Section. 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 statues and rules involved.
  27. On August 22, 2002, SOAH Administrative Law Judge Sharon Cloninger held a hearing on the cross appeal by Carrier and Provider in the William Clements Building, Fourth Floor, 300 West 15th Street, Austin, Texas. Representatives of the Carrier and Provider attended the hearing. The hearing concluded and the record closed that same day.

VIII. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented in this case, pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Labor Code Ann. §413.031.
  2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this case, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. §413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. In this cross-appeal, Carrier and Provider each timely filed notice of appeal of the decision of TWCC’s Medical Review Division (MRD), as specified in 28 Tex. Admin. Code (TAC) § 148.3.
  4. Proper and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052 and 28 TAC § 148.4(b).
  5. As parties appealing the MRD decision, Carrier and Provider each had the burden of proving the case by a preponderance of the evidence, pursuant to 28 TAC §148.21(h) and (i).
  6. `The Upper Extremities Treatment Guideline (UETG) found at 28 TAC § 134.1002 applies to treatment of Claimant’s compensable injury.
  7. Based on the above Findings of Fact, Provider failed to meet documentation requirements of for CPT codes 99082 (unusual travel), 97110 (therapeutic services: one-on-one), 99213 (office visits), 99213-MP (office visit with first manipulation), 95860 (needle electromyography), 95900 (nerve conduction), 95904 (sensory, each nerve), 95935 (electrodiagnostic testing), 97750-MT (physical performance tests), and 99090 (analysis of information stored in computers), and should not be reimbursed for those services and treatments.
  8. Based on the above Findings of Fact and Conclusions of Law, Provider met its burden of proof regarding reimbursement for CPT code 97150 (therapeutic services in a group setting), pursuant to Medicine Ground Rule I.C.9.
  9. Based on the above Findings of Fact and Conclusions of Law, Provider met its burden of proof regarding payment for one range of motion measurement, billed under CPT code 95851.
  10. Based on the above Findings of Fact and Conclusions of Law, Provider met its burden of proof for CPT codes 97250-59 (myofascial release), 97122 (manual traction) and 97265 (joint mobilization).
  11. Based on the above Findings of Fact and Conclusions of Law, Provider met its burden of proof for documentation of CPT code 97750-FC (functional capacity evaluation) pursuant to Medicine Ground Rule I.E.2.a.
  12. Based on the above Findings of Fact and Conclusions of Law, Provider met its burden of proof for charges billed under CPT codes 97545-WH (work hardening: initial two hours) and 97546-WH ( work hardening: additional hours), pursuant to Medicine Ground Rule II.E.8.
  13. Based on the above Findings of Fact and Conclusions of Law, each party’s appeal should be granted in part and denied in part, and Carrier should reimburse Provider $12,516.00.

ORDER

Because each party appealed the MRD decision, each party had the burden of proving its case at the SOAH hearing. Neither party entirely met its burden. Each party met its burden in part. IT ISORDERED THAT Carrier is to reimburse Provider $12,516.00.

Signed this 21st day of October, 2002.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. A metacarpal is any bone of the metacarpus of the human hand. The metacarpus is the part of the human hand between the carpus and the phalanges that contains five elongated bones. Merriam-Webster’s Medical Dictionary, 1995, p. 413. The carpus is the wrist. Id. at 98.
  2. A tendon is a tough cord or band of dense white fibrous connective tissue that unites a muscle with some other part, and transmits the force which the muscle exerts. Id. at 691. An extensor is a muscle tending to extend a bodily part. Id. at 223. Avulsions are a tearing away of the body part either accidentally or surgically. Id. at 58.
  3. The MRD recommended full payment, but stated the amount of reimbursement for all 26 sessions was $140.00, with no further explanation.
  4. The MRD only recommended a total of $569.00 in payment for the 23 joint mobilization procedures, but multiplying 23 treatments times the $43.00 per treatment MAR, results in $989.00.
  5. The WH modifier is used with CPT Codes 97545 and 97546 when work hardening, as opposed to work conditioning, is performed. (MFG at 44).
  6. The FC modifier is used with CPT Code 97750 when a functional capacity evaluation is performed.
  7. The MT modifier is used with CPT Code 97750 when muscle testing is performed. (MFG at 43).
  8. The MP modifier is added to the evaluation and management code when the first manipulation for the visit is performed. (MFG at 43).
  9. If Carrier had wished to deny reimbursement based on lack of medical necessity, payment exception codes “U” or “V” should have been used instead of payment exception codes “T,” “N”and “F,” which do not relate to lack of medical necessity.
  10. E.g., Docket Nos. 453-99-3399.M5 (ALJ Pacey); 453-96-1446.M4 (ALJ Corbitt); and 453-97-0973.M4 (ALJ Card).
  11. See SOAH Docket Nos. 453-96-1446.M4 and 453-96-0817.M4 (ALJ Corbitt); 453-97-0973.M4 (ALJ Card); 453-96-0175.M2 (ALJ Lynch); and 453-97-1189.M2 (ALJ Hunn).
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