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At a Glance:
Title:
453-03-2304-m4
Date:
August 1, 2003
Status:
Medical Fees

453-03-2304-m4

August 1, 2003

DECISION AND ORDER

I. INTRODUCTION

Neuro-FunctioNalysis (Provider) seeks reimbursement for nerve conduction velocity (NCV) studies performed on _____ at the request of her treating physician. Travelers Indemnity Company (Carrier) denied payment stating in its explanation of reimbursement that the charges in issue had already been considered in another submission. Provider appealed to the Medical Review Division (MRD). The MRD also denied Provider’s request for reimbursement based on inadequate documentation. Provider appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).

This decision finds Provider’s appeal to be meritorious. The documentation submitted supported services billed under CPT codes 95900, 95904, 95925, and 95935 for lumbar studies in addition to cervical services performed on the same date and billed under the same CPT codes.

Provider did not request reimbursement in a specific amount nor offer proof of what amount of reimbursement would be appropriate. Based on the documentation submitted and the Medical Fee Guidelines, the ALJ orders Carrier to reimburse Provider for services rendered in the amount of $1,214 .

II. PROCEDURAL HISTORY

The hearing was held on May 30, 2003, before the undersigned ALJ at the State Office of Administrative Hearings (SOAH) hearing facility, Fourth Floor, William P. Clements Building, 300 West Fifteenth Street, Austin, Texas. Van Heldorf, owner of Provider, appeared by telephone. Carrier appeared through its representative, Dan Flanagan. Because there were no contested issues of notice, jurisdiction, or venue, those matters are addressed in the findings of fact and conclusions of law without further discussion here.

III. BACKGROUND

A. Legal Standards

Section 408.021(a)(1-3) of the Texas Labor Code (Act) provides:

(a) 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. The employee is specifically entitled to health care that:

  1. cures or relieves the effects naturally resulting from the compensable injury;
  2. promotes recovery; or
  3. enhances the ability of the employee to return to or retain employment.

Under §401.011(19) of the Act, “health care” includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.

Provider has the burden of proof because it appealed the MRD decision.[1]

B. Evidence and Argument

Provider performed upper (cervical) and lower (lumbar) NCV studies on the injured worker, ____, on January 17, 2002, at the request of her treating physician. It submitted separate HCFA-1500 forms for each study to the Carrier. Both nerve conduction velocity studies were submitted containing the same CPT codes: 95900, 95904, 95935, and 95925.

Carrier paid $2029 of $5180 billed for the cervical study on or about March 5, 2002, according to the MAR rate for the services provided. It denied payment for the lumbar study, billed at $4080.

Provider pointed out that TWCC’s coding system requires that the same CPT codes be used on both of these HCFA-1500s and recognized that, on first glance, a reviewer might think they were duplicate claims. However, Provider argued that there was sufficient information submitted on and with the HCFA-1500s to show that one involved cervical studies and the other involved lumbar studies. Provider cites the following information that it submitted first to Carrier, then to TWCC, and now as evidence in this appeal:

Handwritten notes in block 21 of the HCFA-1500

One included the handwritten statement this is not a duplicate. Lumbar study. The other included “This is not a duplicate. Cervical study.”

Different diagnosis codes in block 21 of the HCFA-1500

Block #21 of each form contained codes from the ICD-9-CM coding system to describe diagnosis or nature of illness or injury. The HCFA-1500 related to lumbar studies contained the following diagnostic codes:

839.20 = lumbar vertebrae

737.30 = scoliosis and ayphoscoliosis, idiopathic

839.21 = thoracic vertebrae on the lumbar

By contrast, block #21 of the HCFA-1500 regarding the cervical studies contained the following diagnosis codes:

723.1 = cervical myalgia

839.05 = fifth cervical vertebrae

839.21 = scoliosis and ayphoscoliosis, idiopathic

Report of Robert S. Blair, M.D., dated January 17, 2002

Dr. Blair interpreted the NCV studies. His report included a Brief History section as follows:

This is a 35-year-old patient, who presents today with central neck, interscapular, central thoracic, low back and left leg pain.

The following studies will include dermatomal somatosensory evoked potentials of the upper and lower extremities, as well as nerve conduction studies of the upper and lower extremities.

The patient was referred today to rule out evidence consistent with cervical and lumbar radiculopathy, as well as entrapment neuropathy of the upper and lower extremities. (Emphasis added)

Dr. Blair interpreted the results of the studies, referring to testing of cervical and lumbar regions of the ___ body. He then gave his impressions and concluded [T]he remainder of the upper and lower extremity study is unremarkable. (Emphasis added)

After paying the MAR related to the cervical studies, Carrier rejected the request for reimbursement for the lumbar studies. Its Explanation of Reimbursement (EOB) forms related to the lumbar studies claim included the following remark codes:

DUPLD These services have already been considered for reimbursement

DUPQ APrevious submission for the same service/procedure is being processed

The expanded version of the EOB form related to the lumbar studies stated repeatedly:

DUPL - D - THESE SERVICES HAVE ALREADY BEEN CONSIDERED FOR REIMBURSEMENT

This was the only explanation Provider received as to why his request for payment for the lumbar studies was rejected. However, at the hearing, Carrier introduced an exhibit containing one page that it argued demonstrated the claim was contested because some of these tests were performed on body parts that were not part of the compensable injury. (Respondent’s Exhibit 1, page 1). At the top of this document is the notation draft. Carrier could not explain the significance of that notation.

Provider’s representative testified it had never received this document, that the document had been generated over two months after the services were provided, and that none of the EOBs included any reason other than duplicate charges. Provider argued that Carrier could not now claim the refusal was based on anything other than duplicate charges because TWCC rules require a sufficient explanation for providers to understand why the carrier refused payment. There was nothing in any of the EOBs that questioned compensability.

IV. ANALYSIS AND CONCLUSION

Provider proved by a preponderance of the evidence that he performed two NCV studies, one for the lumbar region and another for the cervical region. Carrier’s EOB indicated it denied reimbursement of the charges submitted regarding the lumbar region solely because these charges had been previously submitted. Carrier was wrong. These were not duplicate charges.

Carrier’s attempt to raise a question of compensability at the hearing has no merit. The document itself is not reliable because it is marked draft. The EOBs sent by Carrier to Provider did not provide an explanation that would allow Provider to understand that Carrier was raising a compensability issue as a reason for denying Provider’s charges. TWCC rules require such an explanation in the EOBs and without that, Carrier is precluded from raising a compensability issue in this proceeding. 28 Tex. Admin. Code §133.304(c)[2].

In addition, this case was referred to SOAH by TWCC as a fee dispute. Finally, the document indicates that the compensable body part was the lumbar and abdominal wall. The ALJ observes that Carrier paid the charges related to the cervical studies; it was the lumbar studies of the compensable body part according to this document that are the subject of this appeal. So, the document itself does not support Carrier’s argument.

No additional evidence or argument was submitted regarding the reimbursable amount of Provider’s charges under the Medical Fee Guideline. The MRD decision included the MARs for each CPT code but did not calculate a total for each taking into account the number of units provided. The ALJ has calculated the following amount due under the 1996 MFG. Provider’s HCFA-1500 for the lumbar studies included the following charges and number of units provided:

CPT Code

Amount Charged

Units

MAR

Reimbursable Amount

95900

$ 600

6

64

$ 384

95904

$1,000

8

64

512

95935

$ 900

6

53

318

95925

$1,520

4

175 but already paid for this date[3].

0

Total

$1,214

V. FINDINGS OF FACT

  1. The injured worker in this case ______ was referred to Neuro-FunctioNalysis (Provider) by her treating physician, Jesus Garcia, D.C., for upper and lower nerve conduction velocity (NCV) studies on January 17, 2002.
  2. The studies were intended to rule out evidence consistent with cervical and lumbar radiculopathy, as well as entrapment neuropathy of the upper and lower extremities.
  3. Travelers Indemnity Company (Carrier) was the workers’ compensation insurance carrier at the time of ___ injury.
  4. Neuro-FunctioNalysis Co. (Provider) performed the requested services
  5. Roger S. Blair, M.D., interpreted the results of the nerve conduction velocity studies performed on the upper and lower extremities of ___ in a report dated January 17, 2002.
  6. Studies performed included dermatomal somatosensory evoked potentials of the upper and lower extremities, as well as nerve conduction velocity studies of the upper and lower extremities.
  7. Provider submitted two HCFA-1500s that contained the same CPT codes for the upper (cervical) and lower (lumbar) NCV studies: CPT 95900, 95904, 95935, and 95925.
  8. The CPT codes for cervical and lumbar NCV studies are the same.
  9. The HCFA-1500s for the cervical and the lumbar studies performed on January 17, 2002, included different diagnostic codes and handwritten notes indicating that both a cervical and a lumbar study had been performed.
  10. Separate upper (cervical) and lower (lumbar) nerve conduction velocity studies were performed by Provider on January 17, 2002.
  11. Provider charged $5180 for the upper body cervical studies and was paid $2029 according to the 1996 Medical Fee Guideline.
  12. Provider charged $4080 for the lumbar studies.
  13. Provider is entitled to payment according to the Medical Fee Guideline for the lumbar studies.
  14. The Texas Workers’ Compensation Commission Medical Review Division (MRD) issued an order on November 12, 2002, finding Provider was not entitled to reimbursement because of inadequate documentation. Provider requested a State Office of Administrative Hearings (SOAH) hearing to contest the MRD decision. There were no issues concerning the timeliness of the appeal.
  15. A hearing on this matter was held on May 30, 2003.
  16. The parties received timely notice of the hearing, including notice of the time, place and nature of the hearing; the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  17. The parties were allowed to respond and present evidence and argument on each issue involved in the case.
  18. Provider is entitled to the reimbursement for lumbar nerve conduction velocity tests calculated according to the following table:

CPT Code

Amount Charged

Units

MAR

Reimbursable Amount

95900

$ 600

6

64

$ 384

95904

$1,000

8

64

512

95935

$ 900

6

53

318

95925

$1,520

4

175 but already paid for this date[4].

0

Total

$1,214

V. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction over this matter pursuant to Section § 413.031 to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. § 402.073(b) and 413.031(k).
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
  4. Provider has the burden of proof in the case. 28 Tex. Admin. Code §148.21(h).
  5. Provider proved it performed two separate nerve conduction velocity studies on January 17, 2002, and was entitled to reimbursement for the lumbar studies as well as the cervical studies.
  6. Provider is entitled to reimbursement of $1,214 for the services in question.

ORDER

IT IS THEREFORE ORDERED THAT Traveler’s Indemnity Co. pay Neuro-FunctioNalysis $1214 plus interest for the January 17, 2002, lumbar nerve conduction velocity studies.

Signed on August 1, 2003

Nancy N. Lynch
Administrative Law Judge

  1. 28 Tex. Admin. Code (TAC) § 148.21(h).
  2. The rule provides, in pertinent part:
  3. The explanation of benefits shall include the correct payment exception codes required by the Commission's instructions, and shall provide sufficient explanation to allow the sender to understand the reason(s) for the insurance carrier's action(s). A generic statement that simply states a conclusion such as "not sufficiently documented" or other similar phrases with no further description of the reason for the reduction or denial of payment does not satisfy the requirements of this section.

  4. The MFG p. 34, states that if a physical medicine code states “one or more areas” but has no time limit, then only one unit can be charged regardless of the number of body areas treated. This CPT code is for Somatosensory testing, one or more nerves. Carrier reimbursed this code for only one unit on the cervical studies. Provider did not offer any explanation why this limitation should not be applied. Therefore, the ALJ concluded that the limitation in the MFG, and the Carrier’s payment for the cervical studies on the same day, prevent Provider from recovering another MAR unit for these services.
  5. The MFG p. 34, states that if a physical medicine code states one or more areas but has no time limit, then only one unit can be charged regardless of the number of body areas treated. This CPT code is for Somatosensory testing, one or more nerves. Carrier reimbursed this code for only one unit on the cervical studies. Provider did not offer any explanation why this limitation should not be applied. Therefore, the ALJ concluded that the limitation in the MFG, and the Carrier’s payment for the cervical studies on the same day, prevent Provider from recovering another MAR unit for these services.
End of Document
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