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At a Glance:
Title:
453-03-2299-m4
Date:
April 21, 2003
Status:
Medical Fees

453-03-2299-m4

April 21, 2003

DECISION AND ORDER

I. SUMMARY

Petitioner, William D. Strinden, M.D., sought reimbursement for filing form TWCC-69. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denied reimbursement of $15.00 for the form. Petitioner challenges that denial. Based on the evidence, the Administrative Law Judge (ALJ) concludes that Petitioner’s claim for reimbursement should be denied. The particular facts and reasoning in support of this decision are set forth below in the Findings of Fact, and the legal conclusions derived from those facts appear in the Conclusions of Law. The ALJ convened a hearing on these issues on April 16, 2003, and the record closed the same day.

II. EVIDENCE AND ARGUMENT

The record in this case consisted of Petitioner’s Ex. 1, copies of Commission rules, and additional information from a seminar on billing workers’ compensation claims.

Sarah Strinden, Dr. Strinden’s billing manager, argued that under the Commission’s rules, any required report is entitled to reimbursement, including the required TWCC-69. The State Office of Risk Management argued that the TWCC-69 is not reimbursed separately because it is part of CPT code 99455, which includes the completion of necessary reports.

III. FINDINGS OF FACT

  1. On_______, Claimant suffered a compensable injury.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by the State Office of Risk Management (Carrier).
  3. Following treatment for Claimant’s injury, William D. Strinden, M.D. performed an examination to determine Claimant’s level of impairment.
  4. Dr. Strinden was Claimant’s treating doctor and did all of the examination and assignment of Claimant’s Maximum Medical Improvement (MMI).
  5. Dr. Strinden was required to file a TWCC-69 form detailing the history of Claimant’s injury.
  6. Dr. Strinden billed Carrier $15.00 for the form TWCC-69 under CPT code 99080-69.
  7. Carrier denied reimbursement for the TWCC-69 form on the grounds that the report is part of the required procedures under CPT code 99455 and may not be billed separately.
  8. Petitioner requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD) on June 24, 2002.
  9. The MRD issued its findings and decision on November 25, 2002, concluding that the TWCC-69 form could not be billed for separately because it is part of the examination and assignment of maximum medical improvement.
  10. On March 5, 2003, a notice of hearing was issued.
  11. On April16, 2003, a hearing convened at the State Office of Administrative Hearings, 300 West 15th Street, Austin, Texas. Both parties appeared and participated in the hearing. The record closed the same day.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §413.031.
  2. 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 §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by the Commission conformed to the requirements of Tex. Gov’t Code §2001.052 in that it contained a statement of the time, place and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular section of the statutes and rules involved; and a short plain statement of the matters asserted.
  4. Petitioner has the burden of proving by a preponderance of the evidence that he should prevail in this matter. 28 Tex. Admin. Code §§ 148.21(h) and (i); 1 Tex. Admin. Code 155.41.
  5. As the treating physician, Petitioner was required to bill CPT code 99455-26, which included the assessment, evaluation, preparation and submission of reports pursuant to 28 Tex. Admin. Code §134.201 Section XXII.D.1.c.
  6. Petitioner may not recover an additional $15.00 for filing the TWCC-69, a required report.
  7. Petitioner failed to prove by a preponderance of the evidence that the TWCC-69 should be reimbursed separately from the examination.
  8. Petitioner is not entitled to reimbursement.

ORDER

The claim by Petitioner, William D. Strinden, for payment of $15.00 from the State Office of Risk Management is denied.

Signed this 21st day of April, 2003.

WENDY K. L. HARVEL
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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