DECISION AND ORDER
John A. Sazy, M.D. (Petitioner) seeks reimbursement in the amount of $142.00 from the State Office of Risk Management (SORM) for two office visits provided to injured worker S.R. (Claimant). The Medical Review Division (MRD) of the Texas Workers= Compensation Commission (Commission) conducted medical dispute resolution and issued an order denying reimbursement. Petitioner has requested a hearing on MRD's decision. After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Petitioner has not shown by preponderance of the evidence that the documentation for the two office visits supports the level of service billed. Therefore, the ALJ denies the request for reimbursement.
The sole issue in this case is whether the documentation supports reimbursement for services billed under CPT Code 99214. Petitioner saw Claimant for office visits on March 12, 2002, and June 25, 2002, in relation to her compensable injury. Petitioner billed the office visits under CPT Code 99214, which is the code for moderately complex office visits involving at least two of the following components: a detailed history, a detailed examination, and medical decision-making of moderate complexity. SORM denied payment, arguing that the documentation submitted by Petitioner to support the office visits was illegible in many parts and did not establish the required components for a moderately complex office visit billed under CPT Code 99214. After considering the evidence presented, the ALJ agrees with SORM. Petitioner's documentation is largely illegible. From reviewing the documentation, the ALJ is unable to conclude that at least two of the three required components were present. Petitioner's documentation contains no detailed history nor indication of a detailed examination (or, if it does contain such information, the ALJ is unable to decipher it due to the illegible writing). Further, there is no testimony to establish that medical decision-making of moderate complexity was involved. For these reasons, and as set forth in the findings of fact and conclusions of law below, Petitioner has not shown by a preponderance of the evidence that the treatments in issue were properly provided and documented according to the Commission's rules. Therefore, reimbursement is denied.
II. Findings of Fact
- Claimant suffered a compensable, work-related injury on.
- The State Office of Risk Management (SORM) is the provider of workers= compensation insurance covering Petitioner for her compensable injury.
- On March 12, 2002, and June 25, 2002, Claimant saw John A. Sazy, M.D. (Petitioner) for treatment of her injury.
- Petitioner billed SORM for the office visits, with each visit billed under CPT Code 99214.
- CPT Code 99214 reflects a billing of a medical examination of moderate complexity.
- The maximum allowable reimbursement for office visits billed under CPT Code 99214 is $71.00, and the total amount in dispute in this proceeding is $142.00 (the total for the two office visits).
- SORM denied reimbursement for the office visits on the basis that the documentation for the two office visits did not support the level of service billed.
- Petitioner requested medical dispute resolution by the Texas Workers= Compensation Commission's Medical Review Division (MRD).
- After conducting medical dispute resolution, MRD issued an order on June 4, 2003, declining to order reimbursement.
- On June 10, 2003, Petitioner requested a hearing and the case was referred to the State Office of Administrative Hearings (SOAH).
- Notice of the hearing was sent on July 11, 2003.
- The notice contained a statement of the time, place, and nature of the hearing, and the legal authority and jurisdiction under which the hearing was to be held; a reference to the sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
- On September 17, 2003, ALJ Craig R. Bennett convened a hearing in this case. Petitioner appeared and was represented by Leslie Scott. SORM appeared and was represented by its attorney, Stephen Vollbrecht. The hearing concluded and the record closed that same day.
- For each office visit, Petitioner failed to document a detailed history for Claimant, a detailed examination of Claimant, or medical decision-making of moderate complexity.
- Petitioner's documentation for each office visit is largely illegible.
III. Conclusions of Law
- SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers' Compensation Act (the Act), specifically Tex. Labor Code Ann. ' 413.031(k), and Tex. Gov=t Code Ann. ch. 2003.
- The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov=t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
- The request for a hearing was timely made pursuant to 28 Tex. Admin. Code ' 148.3.
- Adequate and timely notice of the hearing was provided according to Tex. Gov=t Code Ann.'' 2001.051 and 2001.052.
- Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code '148.21(h).
- Under 28 Tex. Admin. Code ' 133.1(a)(3)(D)-(E), a medical provider is required to submit legible documentation supporting and substantiating the care given for which the medical provider is seeking reimbursement.
- Petitioner failed to establish, by a preponderance of the evidence, that the documentation for the two office visits supports and substantiates the level of service billed on the two dates of service in issue.
- Petitioner's request for reimbursement should be denied.
IT IS ORDERED that the State Office of Risk Management is not required to reimburse Petitioner any amount for the services billed under CPT Code 99214 for the two office visits provided to Claimant on March 12, 2002, and June 25, 2002.
Signed this 18th day of September 2003.
CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS