Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-03-2110-m8
Date:
July 21, 2003
Status:
Summary Disposition

453-03-2110-m8

July 21, 2003

DECISION AND ORDER

GRANTING SUMMARY DISPOSITION

This case involves the decision by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) to order a refund by Madhavan Pisharodi, M.D. for alleged overpayments received by him and discovered in a Commission audit. The Commission has moved for summary disposition, pursuant to 1 Tex. Admin. Code § 155.57, contending that the evidence establishes as a matter of law that Dr. Pisharodi was overpaid in regard to services billed under CPT Code 63030 because that CPT Code is considered global to CPT Code 63047, for which Dr. Pisharodi also billed and received payment.[1]

After considering the parties’ arguments and evidence, the Administrative Law Judge (ALJ) grants the Commission’s motion to admit exhibits and finds that the evidence establishes, as a matter of law, that Dr. Pisharodi received overpayments in the amount of $9,484.37 for services billed under CPT Code 63030 which were global to other services billed under CPT Code 63047. Therefore, the ALJ finds that summary disposition is proper under 1 Tex. Admin. Code §155.57, and that Dr. Pisharodi should be ordered to refund the sum of $9,484.37 consistent with the MRD order of January 15, 2003.

I. Background

In 2002, MRD conducted an audit of Dr. Pisharodi’s billing of surgical procedures. During the audit period, 65medical services/procedures were reviewed. After reviewing the services/procedures, MRD concluded that Dr. Pisharodi had improperly billed for services rendered to numerous different patients. Specifically, in each instance, MRD concluded that Dr. Pisharodi billed certain services under CPT code 63030, when such services were global to the primary procedure performed and billed under CPT code 63047. Upon concluding its audit, MRD issued a refund order requiring Dr. Pisharodi to refund the amount of $9,484.37 to the insurance carriers that had made the overpayments. Dr. Pisharodi then requested a hearing on the MRD order, resulting in this case before the State Office of Administrative Hearings (SOAH).

II. Applicable Law

The Commission’s rules provide very specific procedures governing reimbursement for medical services provided in the Texas workers’ compensation system. When multiple procedures are performed on a patient, the Commission’s rules require that the medical provider identify the primary and secondary procedures performed. The primary procedure is defined as the major procedure reflecting the greatest value.[2] The primary procedure is normally reimbursed at its full reimbursement rate, but secondary procedures may be subject to limited reimbursement according to the schedule set forth in the Commission’s rules.[3] Some services are considered global to the primary procedure (i.e., they are considered to be included within the primary procedure) and are not to be reimbursed at all.[4] The Commission’s rules explain the rationale for this:

A. Global Fee Concept

The concept of a global fee for surgical procedures is a long established concept under which a single fee is billed and paid for all necessary services normally performed by the surgeon before, during, and after the surgical procedure. . . .[5]

Essentially, the medical community recognizes that there are some smaller procedures that are so integral to another major procedure that they are to be included within the billing for the major procedure. Whether a surgical procedure is global to another surgical procedure is determined by reference to the 1994 revised edition of the Global Service Data for Orthopedic Surgery.

In regard to the importance of proper coding, the introduction to Medical Fee Guideline states:

The accurate coding of services rendered is essential for proper reimbursement. . . Reimbursement for services is dependent on the accuracy of the coding and documentation. All participants shall be responsible for correctly applying the ground rules contained within the Medical Fee Guideline, and the rules contained within the CPT/HCPCS, the ICD-9-CM coding systems, and the global service surgery coding guidelines (e.g., Global Service Data for Orthopedic Surgery). All modifiers that are recommended by TWCC or by the AMA to further clarify services shall be used when required by the ground rules. Providers are encourage to bill their usual charges while following the ground rules as outlined in the Medical Fee Guideline regarding coding. Medical Review is mandated by law to monitor health care providers and to ensure the quality of care and cost effectiveness. The consistent submission of proper codes is a large part of this process. . . .[6]

As noted by the Commission, the general scheme for determining payment for surgery services under the Medical Fee Guideline involves first identifying the maximum allowable reimbursement (MAR) for all of the services provided. Then, the primary procedure is determined as the one with the highest MAR. Next, the 1994 revised edition of the Global Service Data for Orthopedic Surgery is referenced to determine which procedures are global to other procedures and, therefore, are not to be reimbursed. All remaining procedures are then paid at a reduced rate if secondary or subsequent or at the listed MAR if they are one of the “addition to procedures listed in the table contained in the Surgery Ground Rules.[7]

III. Discussion

A. Parties’ Arguments

The issue in this case is whether, in each of the instances identified by the Commission, Dr. Pisharodi improperly billed and received reimbursement for procedures that were global to other procedures also reimbursed. The Commission alleges that the evidence establishes the following instances of overbilling by Dr. Pisharodi:

  • On May 24, 2000, Dr. Pisharodi provided services to claimant and billed CPT Code 63047 in conjunction with CPT Code 63030. The explanations of benefits (EOBs) show that Dr. Pisharodi was paid $1,896.87 for CPT Code 63030 in addition to the amount he was reimbursed for CPT code 63047. According to the Commission, the procedure billed under CPT Code 63030 was global to the procedure billed under CPT Code 63047 and Dr. Pisharodi was not entitled to the additional payment of $1,896.87.
  • On June 8, 2000, Dr. Pisharodi provided services to claimant and billed CPT Code 63047 in conjunction with CPT Codes 63030 and 63030-50. The EOBs show that Dr. Pisharodi was paid $1,517.50 for each instance of CPT Code 63030 in addition to the amount he was reimbursed for CPT code 63047. According to the Commission, the procedures billed under CPT Code 63030 and 63030-50 were global to the procedure billed under CPT Code 63047 and Dr. Pisharodi was not entitled to the additional payment of $3,035.00.
  • On March 15, 2000, Dr. Pisharodi provided services to claimant and billed CPT Code 63047 in conjunction with CPT Code 63030. The EOBs show that Dr. Pisharodi was paid $1,517.50 for CPT Code 63030 in addition to the amount he was reimbursed for CPT code 63047. According to the Commission, the procedure billed under CPT Code 63030 was global to the procedure billed under CPT Code 63047 and Dr. Pisharodi was not entitled to the additional payment of $1,517.50.
  • On March 2, 2000, Dr. Pisharodi provided services to claimant, and billed CPT Code 63047 in conjunction with CPT Codes 63030 and 63030-50. The EOBs show that Dr. Pisharodi was paid $1,517.50 for each instance of CPT Code 63030 in addition to the amount he was reimbursed for CPT code 63047. According to the Commission, the procedures billed under CPT Code 63030 and 63030-50 were global to the procedure billed under CPT Code 63047 and Dr. Pisharodi was not entitled to the additional payment of $3,035.00.

In asserting that the procedures billed under CPT Code 63030 or 63030-50 are global to the procedures billed under CPT Code 63047, the Commission relies on the 1994 revised edition of the Global Service Data for Orthopaedic Surgery Guide, which states that code 63030 is global to code 63047 when performed together.[8] Further, the Commission points out that the MAR for code 63047is $3,540.00, while the MAR for code 63030 is $3,035.00.[9] Under the Commission’s rules, then, the procedure billed under CPT Code 63047 is the primary procedure because it is more expensive. Because Dr. Pisharodi performed the procedures at the same time in each of the four instances cited above, the Commission contends that he was required to bill the procedure under CPT Code 63047 as the primary procedure, and should not have billed any procedures under CPT Code 63030 because any procedures otherwise falling within that code are global to CPT Code 63047.

Dr. Pisharodi filed only a short response to the Commission’s motion for summary disposition. In his response, Dr. Pisharodi essentially presents three arguments. First, Dr. Pisharodi contends that he needs additional time to obtain clarification of the CPT Code billing procedures from the Global Orthopaedic Academy in order to dispute the Commission’s position in this case.[10] Next, he contends that the Commission’s rules prohibit it from ordering a refund more than one calendar year after the services were provided. Because the disputed services were provided in 2000, and the Commission’s refund order was not issued until January 2003, Dr. Pisharodi contends the deadline had passed and the Commission’s refund order is barred. Finally, Dr. Pisharodi asserts that a number of the insurance carriers to which he allegedly owes a refund have not properly paid him for other services; therefore, he argues that he should not be required to refund money to them when they still have unpaid amounts due and owing to him.

The Commission filed a response to Dr. Pisharodi’s arguments. In its response, the Commission argues that Dr. Pisharodi is not entitled to additional time to obtain information regarding CPT Code billing procedures. The Commission points out that Dr. Pisharodi, in discovery, has admitted that the 1994 revised edition of the Global Service Data for OrthopedicSurgery applies to this proceeding and that it provides that CPT Code 63030 is listed as included within the global service package for CPT Code 63047.[11] Therefore, the Commission asserts that he could not now dispute those admissions and additional time to obtain CPT Code billing procedures from some unknown entity is pointless.

Next, the Commission argues that Dr. Pisharodi is simply wrong in asserting that a one-year deadline applies. Dr. Pisharodi cites to Commission Rule 133.305 in support of his contention, but the Commission notes that there is no one-year deadline found anywhere in that rule. It concedes that there is a one-year deadline found in Commission Rule 133.307, but points out that the one-year deadline there does not apply to the Commission’s audit and refund proceedings but only to a carrier or provider’s request for medical dispute resolution regarding fee disputes.[12] The Commission contends that nowhere in the underlying statute or in the Commission’s rules is a one-year deadline established for Commission audit and refund procedures.

Finally, the Commission argues that other fee disputes that Dr. Pisharodi may have with insurance carriers, even those to whom he allegedly owes refunds in this proceeding, are not before SOAH and cannot be considered in this proceeding. The Commission notes that Dr. Pisharodi has not requested medical dispute resolution regarding them nor have they been referred to SOAH and consolidated with this proceeding. Accordingly, there is simply no jurisdiction to consider such matters; instead, SOAH’s jurisdiction extends solely to the dispute before it, namely the refund order issued by the Commission on which Dr. Pisharodi requested a hearing.

B. ALJ’s Analysis[13]

The ALJ concludes that the Commission’s arguments have merit. The legal authorities presented by the Commission clearly establish that CPT Code 63047 is a more expensive procedure than CPT Code 63030 and, therefore, is the primary procedure under the Commission’s rules. This was admitted by Dr. Pisharodi. The applicable Global Service Data for Orthopedic Surgery establishes that CPT Code 63030 is global to CPT Code 63047 when performed together. This also was admitted by Dr. Pisharodi. Here, the procedures were performed together on the patients in issue. As such, Dr. Pisharodi was not entitled to bill separately for the CPT Code 63030 procedures.

As for Dr. Pisharodi’s responsive arguments, the ALJ finds that they are without merit. The Commission’s refund order was issued in January 2003 and Dr. Pisharodi has been on notice of the Commission’s reasons for such order since that time. He has had ample time to obtain evidence to dispute the Commission’s position. Moreover, given Dr. Pisharodi’s discovery admissions, it is doubtful whether he would be able to offer controverting evidence even if he could obtain it. So, the ALJ does not find it improper to rule on the Commission’s motion without allowing additional time for Dr. Pisharodi to attempt to gather evidence. Also, the ALJ can find no basis whatsoever for Dr. Pisharodi’s contention that the Commission is barred by a one-year deadline from issuing its refund order. No such deadline exists, either in the Commission’s rules or in the underlying statutes that authorize the Commission to engage in audits and order refunds.

Finally, as to Dr. Pisharodi’s claim that he should not be required to issue refunds to insurance carriers that currently owe him money, the ALJ has no authority to consider matters that have not been exhausted through the Medical Dispute Resolution process and referred to SOAH. Currently, the sole issue in this proceeding (on which Dr. Pisharodi requested a hearing) is the Commission’s refund order. The ALJ is aware of no fee disputes involving Dr. Pisharodi and the insurance carriers in issue that have been referred to SOAH or that could be consolidated with this matter. Therefore, such matters are not before this ALJ and do not impact this proceeding. For the reasons set forth above, the ALJ finds that the Commission is entitled to summary disposition because the uncontroverted evidence proves that Dr. Pisharodi was overpaid $9,484.37 for services billed under CPT Code 63030. The ALJ further finds that Dr. Pisharodi should be ordered to refund the sum of $9,484.37 consistent with the MRD order of January 15, 2003.

IV. Findings of Fact

  1. On May 24, 2000, Madhavan Pisharodi, M.D. (Petitioner) provided services to claimant___.
  2. Petitioner billed CPT Code 63047 in conjunction with CPT Code 63030 for the services provided together to ___.
  3. Petitioner was paid $1,896.87 for CPT Code 63030 in addition to the amounts he was reimbursed for CPT Code 63047 in regard to the services provided to ___.
  4. On June 8, 2000, Petitioner provided services to claimant ___.
  5. Petitioner billed CPT Code 63047 in conjunction with CPT Code 63030 and 63030-50 for the services provided together to ___.
  6. Petitioner was paid $1,517.50 for each instance of CPT Code 63030 in addition to the amounts he was reimbursed for CPT Code 63047 in regard to the services provided to ___.
  7. On March 15, 2000, Petitioner provided services to claimant ___.
  8. Petitioner billed CPT Code 63047 in conjunction with CPT Code 63030 for the services provided together to ___.
  9. Petitioner was paid $1,517.50 for CPT Code 63030 in addition to the amounts he was reimbursed for CPT Code 63047 in regard to the services provided to ___.
  10. On March 2, 2000, Petitioner provided services to claimant ___.
  11. Petitioner billed CPT Code 63047 in conjunction with CPT Code 63030 and 63030-50 for the services provided together to ___.
  12. Petitioner was paid $1,517.50 for each instance of CPT Code 63030 in addition to the amounts he was reimbursed for CPT Code 63047 in regard to the services provided to ___.
  13. The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) conducted an audit of Petitioner’s billing of surgical procedures.
  14. During the audit period, MRD reviewed 65medical services/procedures.
  15. After completing the audit, MRD concluded that Petitioner had improperly billed for services rendered to numerous different patients and issued an order, on January 15, 2003, requiring Petitioner to refund the amount of $9,484.37 to the insurance carriers that had made the overpayments.
  16. On February 3, 2003, Petitioner requested a hearing on the refund order issued by MRD.
  17. Notice of the hearing was provided to all parties by the Commission’s Chief Clerk on February 12, 2003.
  18. The hearing was continued from its original setting on motion from Petitioner.
  19. On June 17, 2003, the Commission moved for the admission of evidence and for summary disposition.
  20. On June 20, 2003, Petitioner filed a response to the Commission’s motion for summary disposition.

V. Conclusions of Law

  1. The Commission has the authority to conduct audits and order refunds of overpayments pursuant to Tex. Labor Code §§ 413.015 and 413.016.
  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 §§ 402.073(b), 413.031(a)(3), and 413.031(k) and Tex. Gov’t Code ch. 2003.
  3. Petitioner timely requested a hearing pursuant to 28 Tex. Admin. Code §§102.3, 102.5, and 148.3.
  4. Adequate and timely notice of the hearing was provided to all parties pursuant to Tex. Gov’t Code §§2001.051 and 2001.052.
  5. Summary disposition is appropriate in this case, pursuant to 1 Tex. Admin. Code§155.57, because the pleadings, affidavits, materials obtained by discovery, admissions, matters officially noticed, stipulations, or evidence of record show there is no genuine issue as to any material fact and that the Commission is entitled to a decision in its favor as a matter of law.
  6. When multiple procedures are performed on a patient, the Commission’s rules require that the medical provider identify the primary and secondary procedures performed.
  7. The Commission’s rules define the primary procedure as the major procedure reflecting the greatest value.28 Tex. Admin. Code §134.201, Medical Fee Guideline, I.D.1 a.
  8. The term greatest value in Surgery Ground Rules, I.D.1.a. refers to the maximum allowable reimbursement (MAR) value.
  9. Pursuant to 28 Tex. Admin. Code §134.201, Medical Fee Guideline 1996, the MAR value for CPT Code 63047 is $3,540.00.
  10. Pursuant to 28 Tex. Admin. Code §134.201, Medical Fee Guideline 1996, the MAR value for CPT Code 63030 is $3,035.00.
  11. Under the Commission’s rules, the procedure billed under CPT Code 63047 is the primary procedure.
  12. Procedures that are considered global to the primary procedure (i.e., they are considered to be included within the primary procedure) are not to be reimbursed at all under the Commission’s rules. 28 Tex. Admin. Code §134.201, Medical Fee Guideline 1996, Surgery Ground Rules, I, Surgery Instructions.
  13. The 1994 Edition of the Global Service Data for Orthopaedic Surgery applies to the billing of CPT Codes pursuant to 28 Tex. Admin. Code §134.201, Medical Fee Guideline 1996.
  14. CPT Code 63030 is global to CPT Code 63047 when the two are performed together. See 1994 Edition of the Global Service Data for Orthopaedic Surgery.
  15. Petitioner was not entitled to bill separately for CPT Code 63030 when also billing for CPT Code 63047 for procedures performed together.
  16. Petitioner was overpaid $9,484.37 for services billed to CPT Code 63030 that were not eligible for reimbursement because they were global to services billed to CPT Code 63047.

ORDER

IT IS ORDERED that the Texas Workers’ Compensation Commission’s Motion to Admit Exhibits is GRANTED.

IT IS FURTHER ORDERED that Madhavan Pisharodi, M.D. shall refund the amount of $9,484.37 to the applicable insurance carriers consistent with the refund order of January 15, 2003, issued by the Medical Review Division of the Texas Workers’ Compensation Commission.

Signed this 21st day of July 2003.

.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. CPT refers to Current Procedural Terminology which is a reference to the method of coding medical procedures and services for uniform billing purposes. CPT coding methodology is standard in the healthcare industry and is used in calculating reimbursements in both Medicare and most workers’ compensation systems.
  2. See 28 Tex. Admin. Code §134.201, Medical Fee Guideline, I.D.1 a., attached as Appendix A to the Commission’s motion for summary disposition.
  3. Id.
  4. Medical Fee Guideline, Surgery Ground Rules, I, Surgery Instructions, attached as Appendix D to the Commission’s motion for summary disposition.
  5. Id.
  6. See Medical Fee Guideline, Appendix E to the Commission’s motion for summary disposition.
  7. See Medical Fee Guideline, Surgery Ground Rules.
  8. See Appendix C to the Commission’s motion for summary disposition.
  9. See Appendix B to the Commission’s motion for summary disposition.
  10. The record does not indicate what the Global Orthopaedic Academy is or what relevance it might have regarding this proceeding. The Commission also appears to not recognize an entity known as the Global Orthopaedic Academy. SeeReply to Petitioner’s Opposition to Commission’s Motion for Summary Disposition, at 2.
  11. See Commission Ex. 2.
  12. See 28 Tex. Admin. Code § 133.307(d)(1)-(3).
  13. The parties’ arguments are detailed above; for the sake of brevity, in this analysis section the ALJ refers to those authorities and arguments with which he agrees without fully restating them.
End of Document
Top