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At a Glance:
Title:
453-03-1529-m4
Date:
April 22, 2003
Status:
Medical Fees

453-03-1529-m4

April 22, 2003

DECISION AND ORDER

I. INTRODUCTION

Brian K. Randall, D.C., (Provider) of West Houston Chiropractic and Associates, P.C., appealed the decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denying reimbursement of $3,232[1] and approving $15 in payment for services provided to ___ (Claimant) from August 3, 2001, through October 31, 2001. Provider submitted bills for the treatments and services under nine different Current Procedural Technology (CPT) codes. National Fire Insurance Company (Carrier) denied payment. The Administrative Law Judge (ALJ) finds that some, but not all, of the disputed treatments should be reimbursed. Therefore, Carrier is to reimburse Provider $557.

II. PROCEDURAL HISTORY

ALJ Sharon Cloninger convened and closed the hearing on February 20, 2003, in the William P. Clements Building, 300 West 15th Street, Fourth Floor, Austin, Texas. Provider was represented by his associate, Marjan Malekzadeh, D.C., who appeared by telephone. Carrier was represented by James Loughlin, attorney. 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.

III. BACKGROUND

On_________, Claimant was a cutter employed by____, a sewing factory in_____, Texas, when she sustained a compensable injuryto her back and right shoulder while pulling some material down. Provider began treating Claimant at least as early as July 9, 2001. On August 15, 2001, she was seen by Trent A. Carlyle, M.D., in an initial orthopedic consultation. He diagnosed her to have cervical and lumbar spine strain and a right rotator cuff tear. (Pet.Ex. 2). On September 26, 2001, Claimant underwent arthroscopy to her right shoulder with rotator cuff repair. On September 28, 2001, Dr. Carlyle prescribed physical therapy for Claimant three times a week for four weeks, with instructions that Provider evaluate and treat Claimant.

IV. DISCUSSION

A. Treatments and services at issue

The treatments and services in dispute in this proceeding are listed below 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 Commission’s Medical Fee Guideline (MFG). For each CPT code, Carrier denied payment for lack of documentation. Carrier also denied payment of charges billed under CPT code 99213-MP because more than the MAR amount had been charged.

  • 97010 (Application of a modality to one or more areas; hot or cold packs. MAR ‘$11) Provider charged Carrier $44 for heat applications provided to Claimant on August 24, August 27, August 31, and October 29, 2001.
  • 97014 (electrical stimulation, unattended. MAR ‘$15) Provider billed Carrier $20 each for five electrical stimulation treatments on August 24, August 27, August 31, September 7, and October 29, 2001, for a total of $100.
  • 97110 (Therapeutic procedures[2] one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. One-to-one setting is required. MAR’$35 for each 15 minutes) Provider billed Carrier $210 for treatment rendered on August 24, 2001; $140 for treatment on August 27, 2001; $140 for treatment on August 31, 2001; and $105 for treatment on September 7, 2001.
  • 97250-59(Myofascial release/soft tissue mobilization, one or more regions. MAR ‘$43)Provider billed Carrier $45 per date for treatment on August 24, August 27, August 31, and September 7, 2001. Provider billed Carrier $43 for treatment on October 29, 2001.
  • 97261 (Manipulation performed by physician, each additional area. MAR ‘$8) Provider charged Carrier $8 for an additional manipulation on September 7, 2001.
  • 99080 (Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form. MAR ‘DOP[3]) Provider charged $15 for a Work Status Report prepared on August 22, 2001.
  • 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)Provider billed $50 each for office visits on August 27 and September 7, 2001.
  • 99213-MP[4] (Office visit: first manipulation. MAR’$48)Provider charged Carrier $50 apiece for office visits with first manipulations on August 24, August 31, 2001, and October 4, 2001.[5]
  • 99214(Office or other outpatient visit. Requires two of three components: detailed history; detailed examination; medical decision making of moderate complexity. MAR’$71) Provider charged Carrier $75 for an office visit on October 2, 2001.

B. Applicable Law

Because Claimant’s compensable injury is to her spine and shoulder, the Commission’s Spine Treatment Guideline (STG) found at 28 Tex. Admin. Code (TAC) §134.1001applies, as does the Upper Extremities Treatment Guideline (UETG) found at 28 TAC § 134.1002. Both the STG and the UETG require treatment of a work-related injury to be adequately documented. UETG (e)(2)(A)(i) and STG (e)(2)(A)(i). The STG further requires that documentation for physical medicine treatment be objective and illustrate compliance and substantive and continued improvement over time. STG (e)(3)(C).

C. Evidence

Provider offered the 63-page certified record of the MRD proceeding, which was admitted, and two additional documents, one of which was admitted in part and the other that was not admitted. Dr. Malekzadeh testified.Carrier offered no documents and called no witnesses.

D. ANALYSIS

  1. Documentation supports reimbursement for charges billed under CPT Code 97010 (Application of a modality to one or more areas; hot or cold packs), which has an MAR of $11. Application of heat is documented on August 24, August 27, August 31, and October 29, 2001 (Pet. Ex.1 at 52-54), so Carrier should reimburse Provider $44 for this treatment.
  2. Documentation supports partial reimbursement for charges billed under CPT Code 97014 (electrical stimulation, unattended), which has an MAR of $15. Electrical stimulation is documented for August 24, August 27, August 31, and September 7, 2001. Documentation does not support reimbursement for October 29, 2001. (Pet. Ex.1 at 52-54). The total recommended reimbursement for this CPT Code is $60.
  3. Documentation does not support reimbursement for treatment charged under CPT Code 97110 (Therapeutic procedures: one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. One-to-one setting is required), with an MAR of $35 for each 15 minutes. The evidence does not establish that this treatment was provided in a one-on-one setting.[6]
  4. Documentation supports reimbursement for charges billed under CPT Code97250-59(Myofascial release/soft tissue mobilization, one or more regions), with an MAR of $43.Documentation establishes the treatment was provided on August 24, August 27, August 31, September 7, and October 29, 2001. (Pet. Ex.1 at 52-54). Carrier should reimburse Provider $215.
  5. Documentation supports reimbursement for charges billed under CPT Code 97261(Manipulation performed by physician, each additional area), with an MAR of $8. Documentation indicates there was manipulation of both the cervical and lumbar spine on September 7, 2001(Pet. Ex.1 at 53), so reimbursement of $8 is warranted.
  6. Documentation supports reimbursement for charges billed under CPT Code99080 (Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form), with an MAR of DOP.[7] Provider charged $15 for completion of a Work Status Sheet on August 22, 2001 (Pet. Ex. 1 at 26), which the ALJ finds to be a reasonable charge. Reimbursement of $15 is warranted.
  7. Documentation does not support charges billed under CPT code99213 (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), with an MAR of $48. No reimbursement is warranted.
  8. Documentation supports reimbursement for charged billed under CPT code99213-MP[8] (Office visit: first manipulation), with an MAR of $48. Documentation supports cervical adjustments on August 24, August 31 and October 4, 2001[9] (Pet. Ex.1 at 52-53), so reimbursement of $144 is warranted.
  9. Documentation and testimony support reimbursement of charges billed under CPT Code 99214(Office or other outpatient visit. Requires two of three components: detailed history; detailed examination; medical decision making of moderate complexity), with an MAR of $71. Reimbursement of $71 for the office visit on October 2, 2001 (Pet. Ex. 1 at 42-43) is warranted.

V. CONCLUSION

Provider met its burden of proof in showing that reimbursement should be ordered for CPT codes 97010 in the amount of $44; 97014 in the amount of $60; 97250-59 in the amount of $215; 97261 in the amount of $8; 99080 in the amount of $15; 99213-MP in the amount of $144; and 99214 in the amount of $71. Provider did not establish that reimbursement is warranted for charges billed under CPT codes 97110 and 99213. Accordingly, the ALJ orders a total reimbursement of $557.

VI. FINDINGS OF FACT

  1. ____. (Claimant) sustained a compensable work-related injury on___________, while employed with ________in _________Texas. ________workers’ compensation insurance carrier was National Fire Insurance Company (Carrier).
  2. Brian K. Randall, D.C., (Provider) began treating Claimant at least by July 9, 2001, and diagnosed her compensable injury to be lumbar disk herniation, lumbar radiculopathy, torn supraspinatus in the right shoulder with impingement syndrome, cervical sprain and strain, and post-traumatic myofasciitis.
  3. Provider used electrical stimulation, heat treatments, therapeutic procedures, myofascial release, and manipulations to treat Claimant’s compensable injury.
  4. Provider sought reimbursement of $3,232 from Carrier for services rendered to Claimant, and billed under the following CPT codes:
  5. 97010 (Application of a modality to one or more areas; hot or cold packs. MAR ‘$11) Provider charged Carrier $44 for heat applications provided to Claimant on August 24, August 27, August 31, and October 29, 2001.
  6. 97014 (electrical stimulation, unattended. MAR ‘$15) Provider billed Carrier $20 each for five electrical stimulation treatments on August 24, August 27, August 31, September 7, and October 29, 2001, for a total of $100.
  7. 97110 (Therapeutic procedures: one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. One-to-one setting is required. MAR’$35 for each 15 minutes) Provider billed Carrier $210 for treatment rendered on August 24, 2001; $140 for treatment on August 27, 2001; $140 for treatment on August 31, 2001; and $105 for treatment on September 7, 2001.
  8. 97250-59(Myofascial release/soft tissue mobilization, one or more regions. MAR ‘$43)Provider billed Carrier $45 per date for treatment on August 24, August 27, August 31, and September 7, 2001. Provider billed Carrier $43 for treatment on October 29, 2001.
  9. 97261 (Manipulation performed by physician, each additional area. MAR ‘$8) Provider charged Carrier $8 for an additional manipulation on September 7, 2001.
  10. 99080 (Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form. MAR ‘DOP) Provider charged $15 for a Work Status Report prepared on August 22, 2001.
  11. 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)Provider billed $50 each for office visits on August 27 and September 7, 2001.
  12. 99213-MP (Office visit: first manipulation. MAR’$48)Provider charged Carrier $50 apiece for office visits with first manipulations on August 24, August 31, 2001, and October 4, 2001.
  13. 99214(Office or other outpatient visit. Requires two of three components: detailed history; detailed examination; medical decision making of moderate complexity. MAR’$71) Provider charged Carrier $75 for an office visit on October 2, 2001.
  14. Carrier denied reimbursement for the treatments and services in Finding of Fact No. 4 for lack of documentation, and also denied charges billed under CPT code 99213-MP because the charge was more than the MAR.
  15. Documentation supports reimbursement for services and treatments billed under CPT codes 97010, 97014, 97250-59, 97261, 99080, 99213-MP, and 99214, although the amount of reimbursement warranted is the MAR only, and not the amount billed, where the amount billed exceeds the MAR.
  16. Documentation does not support reimbursement for services billed under CPT codes 97110 and 99213.
  17. On April 9, 2002, Provider filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission’s Medical Review Division (MRD), asking for reimbursement of $3,232 for the above-described services.
  18. On November 18, 2002, the MRD denied reimbursement of the disputed $3,232, listing the MAR for all treatments at $1,263, and allowing reimbursement of $15 for a service provided under CPT code 99080.
  19. On November 25, 2002, Provider appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
  20. On December 30, 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.
  21. On February 20, 2003, SOAH Administrative Law Judge Sharon Cloninger convened the hearing in the William P. Clements Building, 300 West 15th Street, Fourth Floor, Austin, Texas. Provider appeared by telephone through its representative Marjan Malekzadeh, D.C. Carrier’s was represented by James Loughlin, attorney, who appeared at the hearing. The Commission was not represented at the hearing. The hearing concluded and the record closed that same day.

VII. 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. Provider 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. §§ 2001.051 and 2001.052 and 28 TAC § 148.4(b).
  5. As the party appealing the MRD decision, Provider had the burden of proving the case by a preponderance of the evidence, pursuant to 28 TAC §148.21(h) and (i).
  6. The Spine Treatment Guideline (STG) found at 28 TAC § 134.1001 and the Upper Extremities Treatment Guideline (UETG) found at 28 TAC ' 134.1002 apply 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 97110 and 99213, 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 for services and treatments billed under CPT codes 97010, 97014, 97250-59, 97261, 99080, 99213-MP, and 99214.
  9. Based on the above Findings of Fact and Conclusions of Law, Provider’s appeal should be granted in part and denied in part, and Carrier should reimburse Provider $557.

ORDER

IT IS ORDERED THAT National Fire Insurance Company is to reimburse Brian K. Randall, D.C., $557 for the disputed services and treatments.

Signed this 22nd day of April, 2003.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. While Provider billed $3,232.00 for the disputed services, the maximum allowable reimbursement (MAR) for those services under the Commission’s Medical Fee Guideline is $1,263.
  2. Therapeutic procedures are defined as therapeutic exercises used to develop strength, endurance, range of motion, and flexibility. MGR at 32.
  3. Documentation of procedure (DOP) in the MAR column indicates that the value of this service shall be determined by written documentation included in or attached to the bill. MGR, at 1.
  4. The MP modifier is added to the evaluation and management code when the first manipulation for the visit is performed. (MFG at 43).
  5. The October 4, 2001, date of service is listed on the Table of Disputed Services (Pet. Ex. 1 at 19) without the -MP modifier, which Dr. Malekzadeh testified should have been added. The item is not listed at all in the MRD decision.
  6. Provider stated in closing argument that these treatments were provided in a one-on-one setting, but the ALJ cannot consider statements made during closing argument to be evidence.
  7. Documentation of procedure (DOP) in the MAR column indicates that the value of this service shall be determined by written documentation included in or attached to the bill. MGR, at 1.
  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. The October 4, 2001, date of service is listed on the Table of Disputed Services (Pet. Ex. 1 at 19) without the -MP modifier, which Dr. Malekzadeh testified should have been added. The item is not listed at all in the MRD decision.
End of Document
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