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At a Glance:
Title:
453-03-1319-m4
Date:
February 19, 2003
Status:
Medical Fees

453-03-1319-m4

February 19, 2003

DECISION AND ORDER

I. Introduction

Brian Randall, D.C. (Provider) sought a contested-case hearing concerning a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) regarding medical services for ____ (Claimant). The MRD found the Provider furnished inadequate documentation to support the level of services that he provided to the Claimant from June 13, through June 15, 2001, and for which he thereafter billed $555 to National Fire Insurance Co. (Carrier). The Parties agree that the Provider has the burden of proof.

The only disputed issues are:

  • Was each of the provided services adequately documented to support the level of reimbursement requested?
  • Did the Carrier timely submit an explanation of benefit (EOB) to the Provider denying payment for service because they were not adequately documented to support the level of reimbursement requested?
  • If the Carrier did not timely submit an EOB, did the inadequate-documentation issue lie outside the scope of the case, such that the Carrier may not now make that argument?

As set out below, the Administrative Law Judge (ALJ) finds that the Carrier submitted an EOB denying reimbursement because the services were not adequately documented, hence that issue lies within the scope of the case. The ALJ also finds that some of the Disputed Services were adequately documented and some were not. He finds that the Carrier should reimburse the Provider $202.00

II. A Service-Not-Documented EOB Was Sent

The evidence includes an undated EOB from the Carrier to the Provider denying reimbursement for the services and alleging that they were not adequately documented. The Provider denies having ever received the EOB and argues the lack of a date on the EOB suggests it may never have been sent. The notes of the Provider’s billing representative, Amanda Sumlin, were admitted into evidence to show what others said. In those notes, Ms. Sumlin notes that the EOB stated the services were “not documented.” The ALJ concludes that the Carrier sent the Provider an EOB denying reimbursement for services and alleging that they were not documented.

III. Adequacy of Service Documentation

Originally, 14 services provided from June 13, through June 15, 2001, were in dispute. At the hearing, however, the Provider conceded that there was no documentation for two of those services, Current Procedural Terminology (CPT) Codes 97265 and 97540 provided on June 13, 2001, and withdrew the request for their reimbursement.

What remains in dispute are the following medical services (Disputed Services):

DATES CPS CODES SERVICE DESCRIPTIONS AMOUNT

%1-%2-199205 Office visit for evaluation; new $140.00

patient, which requires comprehensive history; a comprehensive examination; and medical decision making of high complexity

6-13-01 97124 Massage $30.00

6-14-01 99212 Office visit for evaluation and $35.00

management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-14-01 97250 Myofacial release. $45.00

6-14-01 97035 Ultrasound $25.00

6-14-01 97014 Electric stimulation $20.00

6-14-01 97010 Hot or cold pack $20.00

6-15-01 99213 Office visit for evaluation and $50.00 management of an established patient, which requires two of the following: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity.

6-15-01 97250 Myofacial release. $45.00

6-15-01 97035 Ultrasound. $25.00

6-15-01 97014 Electric stimulation $20.00

6-15-01 97010 Hot or cold pack. $20.00

TOTAL $475.00

A. Office Visits

On June 13, 2001, the Provider first examined the Claimant and prepared an Initial Report, though it was dated June 14, 2001. For that first visit, the Provider billed the Carrier for the highest level of initial visit complexity and reimbursement, under CPT Code 99205. That Code is for an initial visit that includes the taking of a comprehensive history; performing a comprehensive examination; and medical decision making of high complexity. However, the Initial Report indicates only a short patient interview and chiropractic examination was conducted. For example, there is no evidence that the Claimant’s family health, prior work history, or then-current drug use were discussed or that her vital signs were noted. Nor is there any indication that highly complex medical decision making was involved. The Provider routinely prescribed a physical therapy program. The ALJ cannot conclude that the June 13 CPT Code 99205 billing was adequately documented to support that level of service.

The Claimant also visited the Provider on June 14 and 15, 2001. The only documentation for those visits is a generic card on which the Claimant’s pain and the Provider’s observations are noted. That minimal documentation does not adequately explain the higher-priced, June 15, CPT Code 99213 office visit, which requires two of the following: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. Without more documentation, the ALJ cannot reasonably conclude that an expanded history was taken or an expanded problem focused exam occurred. However, the ALJ finds that minimal documentation was adequate to explain the lower-priced, June 14, CPT Code 99212 office visit, which Code requires two of the following: problem focused history; a problem focused examination; and straightforward medical decision making.

In fact, the ALJ concludes that the Initial Report and card are adequate documentation to support reimbursement of all three of the office visits under CPT Code 99212 and orders the Carrier to so reimburse the Provider.

B. Other Disputed Services

The Provider’s Initial Report indicated that the Claimant was suffering pain due to her injury and that the Claimant would be given a “ice pack” for home pain control. The ALJ can reasonably infer that the CPT Code 97010 cold pack was the “ice pack”and that very common treatment was necessary for pain control.

Also, the ALJ can reasonably infer that the CPT Code 97250 myofacial release was necessary to treat the Claimant’s “acute post-traumatic myofascitis,” which the Provider included as a diagnosis in his Initial Report. The ALJ concludes that those services were adequately documented.

It may well be that the other services were also necessary to treat the Claimant, but the Provider’s documentation fails to show that. The massage and ultrasound were not even mentioned except to note that they were given. The Initial Report indicates that the Claimant would be given a transcutaneous electrical nerve stimulator (TENS) unit. Possibly, that led the Provider to bill for electric stimulation, but the ALJ cannot be sure and the documentation does not explain why that service would be necessary. The ALJ cannot conclude that the massage, ultra sound, or electric stimulation services were adequately documented to support their being reimbursed.

IV. Summary

The ALJ concludes that the Provider has adequately documented the Claimant’s need for the following services and that the Carrier should be ordered to reimburse the Provider the maximum allowable reimbursement (MAR) for them:

DATES CPS CODES SERVICE DESCRIPTIONS MAR

6-13-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-14-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-15-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-14-01 97250 Myofacial release $42.00

6-14-01 97010 Hot or cold pack $11.00

6-15-01 97250 Myofacial release $42.00

6-15-01 97010 Hot or cold pack. $11.00

TOTAL $202.00

The ALJ concludes that the Provider has not adequately documented the level of billing for the other services and that his request to be reimbursed for them should be denied.

V. Findings of Fact

  1. On____,____. (Claimant) sustained a work-related injury: a strain of her back, neck, and shoulders.
  2. On the date of injury, the Claimant’s employer was______., and its workers’ compensation insurance carrier was National Fire Insurance Co. (Carrier).
  3. On June 13, 2001, Brian Randall, D.C. (Provider) first examined the Claimant and prepared an initial report, which indicated a short patient interview and routine chiropractic examination were conducted and the Provider routinely prescribed a physical therapy program.
  4. The Provider’s Initial Report indicated that the Claimant was suffering pain due to her injury and that the Claimant would be given an “ice pack” for home pain control.
  5. In his Initial Report, the Provider reasonably diagnosed the Claimant as suffering from “acute post-traumatic myofascitis” as part of the Compensable Injury.
  6. The Claimant also visited the Provider on June 14 and 15, 2001. The only documentation for those dates is a generic Treatment Card on which the Claimant’s pain, the Provider’s observations, and the services provided were noted.
  7. Between them, the Treatment Card and Initial Report documented that the Claimant was provided the services that the Provider coded and for which he sought reimbursement as follows from the Carrier:

DATES CPS CODES SERVICE DESCRIPTIONS AMOUNT BILLED

%1-%2-199205 Office visit for evaluation; new $140.00

patient, which requires comprehensive history; a comprehensive examination; and medical decision making of high complexity

6-13-01 97124 Massage $30.00

6-14-01 99212 Office visit for evaluation and $35.00

management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-14-01 97250 Myofacial release. $45.00

6-14-01 97035 Ultrasound $25.00

6-14-01 97014 Electric stimulation $20.00

6-14-01 97010 Hot or cold pack $20.00

6-15-01 99213 Office visit for evaluation and $50.00 management of an established patient, which requires two of the following: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity.

6-15-01 97250 Myofacial release. $45.00

6-15-01 97035 Ultrasound. $25.00

%1-%2-197014 Electric stimulation $20.00

6-15-01 97010 Hot or cold pack. $20.00

TOTAL $475.00

  1. The Carrier sent an explanation of benefit (EOB) to the Provider denying the requested reimbursement for the services because that they were not adequately documented.
  2. The Provider filed a request for medical dispute resolution with the TWCC.
  3. TWCC’s Medical Review Division (MRD) found that the documents submitted did not support the level of services billed and recommended no reimbursement.
  4. After the MRD order was issued, the Provider asked for a contested-case hearing by a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ).
  5. Notice of a February 12, 2003, contested-case hearing concerning the dispute was mailed to the Carrier, and the Provider on December 10, 2002.
  6. On February 12, 2003, SOAH ALJ William G. Newchurch held a hearing on this dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded and the record closed on that same day.
  7. The Carrier appeared at the hearing through its attorney, James Loughlin.
  8. The Provider appeared at the hearing through his associate, Dr. Marjan Malekzadeh.

VI. Conclusions of Law

  1. 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 Ann. (Labor Code) §§ 402.073(b) and 413.031(k) (West 2002) and Tex. Gov’t Code Ann. (Gov’t Code) ch. 2003 (West 2001).
  2. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code §§ 2001.051 and 2001.052.
  3. SOAH’s Chief ALJ has jurisdiction to adopt procedural rules for SOAH hearings, and a referring agency’s procedural rules govern a hearing only to the extent that SOAH’s rules adopt them by reference. Gov’t Code § 2003.050 (a) and (b).
  4. Under TWCC’s rules, the party seeking relief has the burden of proof. 28 Tex. Admin. Code (TAC) §148.21(h) (2002).
  5. The Chief ALJ has not adopted TWCC’s burden-of-proof rule, and no statute requires the use of that rule.
  6. In determining the burden of proof, the referring agency’s documented policy is to be considered, but it must be modified to consider the parties’ access to and control over pertinent information and so that no party is required to prove a negative. 1 TAC § 155.41(b).
  7. Based on the above Findings of Fact, Conclusions of Law, and TWCC’s documented policy set out in its rules, Provider should have the burden of proof in this matter.
  8. 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. Labor Code § 408.021 (a).
  9. CPT Code 99205 is for an initial office visit that requires a comprehensive history; a comprehensive examination; and medical decision making of high complexity.
  10. CPT Code 99213 is for an office visit that requires two of the following: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity.
  11. CPT Code 99212 is for an office visit that requires two of the following: problem focused history; a problem focused examination; and straightforward medical decision making.
  12. The Provider did not document that the June 13, 2001, office visit with the Claimant was a CPT Code 99205 service that included a comprehensive history, a comprehensive examination, and medical decision making of high complexity.
  13. The Provider did not document that the June 15, 2001, office visit with the Claimant was a CPT Code 99213 service that included an expanded problem focused history or an expanded problem focused examination.
  14. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request to be reimbursed under CPT Code 99205 for the June 13, 2001, office visit and under CPT Code 99213 for the June 15, 2001, office visit should be denied.
  15. Based on the above Findings of Fact, the Provider documented that the June 13, 14, and 15, 2001, office visits were CPT Code 99212 visits, and he should be so reimbursed for them.
  16. Based on the above Findings of Fact, the Provider documented that the June 14 and June 15, 2001, cold packs were “ice packs,” which were necessary for pain control, and he should be so reimbursed under CPT Code 97010 for them.
  17. Based on the above Findings of Fact, the Provider documented that the June 14 and 15, 2001, myofacial releases were necessary to treat the Claimant’s “acute post-traumatic myofascitis,” and he should be reimbursed under CPT Code 97250 for them.
  18. The Commission’s Medical Fee Guideline (MFG) sets a maximum allowable reimbursement (MAR) for certain medical services. Medical Fee Guideline 1996; adopted by reference at 28 TAC § 134.201(a).
  19. The MFG also provides that an “insurance carrier will reimburse the lesser of the billed charge, or the MAR.” MFG, General Instructions, VI. Reimbursement.
  20. Based on the above Findings of Fact and Conclusions of Law, the Carrier should be required to reimburse the Carrier the following MARs for the following services:

DATES CPS CODES SERVICE DESCRIPTIONS MAR

6-13-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-14-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-15-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-14-01 97250 Myofacial release $42.00

6-14-01 97010 Hot or cold pack $11.00

6-15-01 97250 Myofacial release $42.00

6-15-01 97010 Hot or cold pack. $11.00

TOTAL $202.00

  1. The Provider did not adequately document that the other services that he provided the Claimant from June 13 through June 15, 2001, were CPT Code 97124, 97035, and 97014 services.
  2. Based on the above Findings of Fact and Conclusions of Law, the Carrier should not reimburse the Provider for the alleged CPT Code 97124, 97035, and 97014 services provided from June 13 through June 15, 2001.

ORDER

IT IS ORDERED THAT:

The Carrier shall reimburse the Carrier the following MARs for the following services:

DATES CPS CODES SERVICE DESCRIPTIONS MAR

6-13-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-14-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-15-01 99212 Office visit for evaluation and $32.00 management of an established patient, which requires two of the following: problem focused history; a problem focused examination; straightforward medical decision making.

6-14-01 97250 Myofacial release $42.00

6-14-01 97010 Hot or cold pack $11.00

6-15-01 97250 Myofacial release $42.00

6-15-01 97010 Hot or cold pack. $11.00

TOTAL $202.00

  1. The Carrier shall not reimburse the Provider for the following services:
  2. DATES SERVICE DESCRIPTIONS
  3. 6-13-01 Massage
  4. 6-14-01 Ultrasound
  5. 6-14-01 Electric stimulation
  6. 6-15-01 Ultrasound.
  7. 6-15-01 Electric stimulation.

Signed February 19, 2003.

WILLIAM G. NEWCHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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