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Title: 

453-04-1841-m5

Date: 

January 25, 2005

Type: 

Retrospective Medical Necessity

453-04-1841-m5

DECISION AND ORDER

I. DISCUSSION

The University of Texas System (Petitioner) requested a hearing to contest the November 14, 2003 Findings and Decision of the Texas Workers’ Compensation Commission (Commission) allowing reimbursement for (1) office visits with manipulations,[1] joint mobilization,[2] traction,[3] therapeutic procedures,[4] muscle testing,[5] myofacial release,[6] and work hardening[7] from March 19, 2001, through October 18, 2001.[8] Alta Healthsouth Clinic, L.P. (Respondent), requested $5,789.40 in reimbursement and the Commission awarded Respondent $3,437.40.

The hearing initially convened on March 8, 2004, before Administrative Law Judge (ALJ) Howard S. Seitzman. Kerry O’Brien represented Petitioner. Ben Higbee, D.C., represented Respondent.[9] There were no contested issues of notice or jurisdiction. The hearing recessed and the parties filed additional documentation. The hearing reconvened on December 6, 2004, and the record closed the same day.

As of December 6, 2004, Petitioner contested only five (5) dates of service: (1) June 13, 2001-CPT Code 97265;[10] (2) June 14, 2001-CPT Code 97265;[11] (3) June 18, 2001-CPT Code 99213-MP;[12] (4) June 19, 2001- CPT Codes 99213-MP[13] and 97265;[14] and (5) June 20, 2001-CPT Codes 99213-MP[15] and 97265[16] (Disputed Services). The amount in dispute for these five dates of service totals $316.00. Effectively, neither party disputes any of the other determinations made by the Commission in its November 14, 2003 Decision.

This decision DENIES the relief sought by Petitioner and orders payment to Respondent for the Disputed Services. This decision also orders reimbursement for those procedures and dates of service for which the Commission ordered reimbursement and Petitioner no longer contests the Commission’s order.

II. BACKGROUND

___ (Claimant) sustained a work-related injury on ___, when he fell off a golf cart and injured his low back, hand and wrist. Claimant was treated following the injury. Claimant underwent wrist surgery on May 15, 2001. Following removal of his cast in early June, he began therapy on June 13, 2001. Preauthorization was obtained for post-operative physical therapy and rehabilitation exercises with a frequency of three times per week for four weeks.

III. ANALYSIS

As discussed below, Petitioner raised two legal defenses at the hearing on the merits: (1) Respondent’s request for reconsideration did not comply with Commission rules[17] and (2) Respondent withdrew dates of service denied on medical necessity.

In its Explanation of Benefits (EOB) for CPT Code 97265 services provided on June 13-14, 2001, Petitioner denied reimbursement for joint mobilization as “N-not appropriately documented.” The Commission determined the office notes adequately documented provision of the service.

For CPT Code 99213-MP, the EOBs for June 18-20, 2001, state that Petitioner denied reimbursement for office visits with manipulation as “A-preauthorization required but not requested.” The Commission found that an office visit with manipulation does not require preauthorization and that the office notes supported delivery of the service.

For CPT Code 97265, the EOBs for June 19-20, 2001, show that Petitioner denied reimbursement for joint mobilization as “A-preauthorization required but not requested.” The Commission found that preauthorization was obtained for post-operative physical therapy and rehabilitation exercises and that the office notes supported delivery of the service.

Petitioner contends Respondent’s requests for reconsideration for June 13, 14, and 18 failed to comply with 28 Tex. Admin. Code (TAC) § 133.304(k) because they did not include a copy of the EOBs. Commission Rule 28 TAC § 133.304(l) states that a carrier shall treat a request for reconsideration as an incomplete medical bill under 28 TAC § 133.300 if the request does not comply with 28 TAC 133.304(k). Pursuant to 28 TAC § 133.300(c)(2)(A), the bill is not incomplete if the missing information is already known to the carrier. Petitioner generated the EOB with its initial denial and is required to maintain a copy of the EOB.[18] Because Petitioner had the missing information, the request for reconsideration was not incomplete under 28 TAC § 133.300. Moreover, the Form HCFA 1500 was submitted by Respondent in its request for reconsideration. The Form HCFA 1500 appropriately identified the dates of service, the procedures or services and the amounts in dispute. Respondent complied with 28 TAC § 133.304(k). Respondent is entitled to reimbursement for the procedures in dispute on these dates of service.

Petitioner contends Respondent withdrew its request for reimbursement for June 19-20. Petitioner contends it denied reimbursement for those dates of service as not medically necessary using a “U” denial code. However, the EOBs in the certified record from the Commission reflect, on those dates, only an “A” code denial for lack of preauthorization.[19] Because the dates of service were not denied as medically unnecessary, they were not dates of service withdrawn by Respondent. Therefore, Respondent is entitled to reimbursement for the procedures in dispute on these dates of service. Respondent is also entitled to reimbursement for the services Petitioner no longer contests.

IV. FINDINGS OF FACT

  1. ___ (Claimant) sustained a work-related injury on ___.
  2. Claimant underwent wrist surgery on May 15, 2001. Following removal of his cast in early June, he began therapy on June 13, 2001.
  3. Preauthorization was obtained for post-operative physical therapy and rehabilitation exercises with a frequency of three times per week for four weeks.
  4. Alta Healthsouth Clinic, L.P. (Respondent), requested $5,789.40 in reimbursement for office visits with manipulations, joint mobilization, traction, therapeutic procedures, muscle testing, myofacial release, and work hardening from March 19, 2001, through October 18, 2001.
  5. The University of Texas System (Petitioner) denied reimbursement.
  6. The Texas Workers’ Compensation Commission (Commission) awarded Respondent $3,437.40.
  7. Petitioner timely requested a hearing to contest the Commission’s decision.
  8. The Commission issued a notice of hearing on January 2, 2004.
  9. The hearing initially convened on March 8, 2004, before Administrative Law Judge (ALJ) Howard S. Seitzman. Kerry O’Brien represented Petitioner. Ben Higbee, D.C., represented Respondent. There were no contested issues of notice or jurisdiction. The hearing recessed and the parties filed additional documentation. The hearing reconvened on December 6, 2004, and the record closed the same day.
  10. As of December 6, 2004, Petitioner contested only five (5) dates of service: (1) June 13, 2001-CPT Code 97265; (2) June 14, 2001-CPT Code 97265; (3) June 18, 2001-CPT Code 99213-MP; (4) June 19, 2001- CPT Codes 99213-MP and 97265; and (5) June 20, 2001-CPT Codes 99213-MP and 97265 (Disputed Services).
  11. The amount in dispute for these five dates of service totals $316.00.
  12. Neither party disputes any of the other determinations made by the Commission in its November 14, 2003 Decision.
  13. Petitioner no longer disputes $3,124.40 of the $3,437.40 reimbursement ordered by the Commission in its November 14, 2003 Decision.
  14. Respondent did not withdraw its request for reimbursement for Disputed Services provided on June 19 and 20, 2001.
  15. Petitioner did not deny reimbursement for Disputed Services provided on June 19 and 20, 2001, as not medically necessary, a “U” denial code.
  16. Petitioner denied reimbursement for Disputed Services provided on June 19 and 20, 2001, for lack of preauthorization, an “A” code.
  17. Respondent’s requests for reconsideration for June 13, 14, and 18 complied with 28 Tex. Admin. Code (TAC) § 133.304(k).
  18. By Decision dated November 14, 2003, the Commission ordered Petitioner to reimburse Respondent for office visits with manipulations, joint mobilization, traction, therapeutic
  19. procedures, muscle testing, myofacial release, and work hardening from March 19, 2001, through October 18, 2001.

V. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 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. Lab. Code Ann. § 413.031(k) and Tex. Gov’t. Code Ann. ch. 2003.
  3. Petitioner timely requested a hearing in this matter pursuant to 28 Tex. Admin. Code (TAC) §§ 102.7 and 148.3.
  4. Notice of the hearing was proper and complied with the requirements of Tex. Gov’t. Code Ann. ch. 2001.
  5. Petitioner had the burden of proof in this matter, which was the preponderance of evidence standard. 28 TAC §§ 148.21(h) and (i); 1 TAC § 155.41(b).
  6. Petitioner failed to sustain its burden of proof.
  7. Based upon the Findings of Fact and Conclusions of Law, Respondent is entitled to reimbursement of $316.00 for the Disputed Services provided to Claimant.
  8. Based upon the Findings of Fact and Conclusions of Law, Respondent is entitled to $3,121.40 for those services ordered reimbursed in the Commission’s November 14, 2003 Decision and which Petitioner no longer contests.

ORDER

THEREFOREIT IS ORDERED that The University of Texas System (Petitioner) pay Alta Healthsouth Clinic, L.P. (Respondent), the $3,437.40 the Texas Workers’ Compensation Commission awarded Respondent, plus any and all applicable interest, for the services provided to Claimant ___.

Signed January 25, 2005.

HOWARD S. SEITZMAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. CPT Code 99213-MP.↑
  2. CPT Code 97265.↑
  3. CPT Code 97122.↑
  4. CPT Code 97110.↑
  5. CPT Code 97750-MT.↑
  6. CPT Code 97250.↑
  7. CPT Codes 97545-WH and 97546-WH.↑
  8. Because Respondent withdrew dates of service denied by Petitioner as medically unnecessary, the disagreement became a fee dispute.↑
  9. Cody Pettey represented Respondent at the December 6, 2004 hearing on the merits.↑
  10. $43.00.↑
  11. $43.00.↑
  12. $48.00.↑
  13. $48.00.↑
  14. $43.00.↑
  15. $48.00.↑
  16. $43.00.↑
  17. It is not clear that Petitioner raised this defense at the Commission. The Commission did not address the defense in its decision. To the extent Provider did not raise the defense at the Commission, it waived the defense. Assuming Petitioner did raise the defense, it was impliedly rejected by the Commission because the Commission ordered reimbursement. The ALJ addresses the issue assuming the defense was raised by Petitioner at the Commission.↑
  18. 28 TAC § 133.304(c).↑
  19. The ALJ reviewed the EOBs in the Commission’s certified record to verify the denial codes cited in the Commission’s Decision. The EOBs in the certified record reflect an audit date of February 13, 2002 (February EOBs) and a print date of March 11, 2002. At the hearing, Petitioner submitted EOBs with a March 14, 2002 audit date that show a “U” denial code (March EOBs). The two sets of EOBs differ significantly. Although”U” denial codes are reflected elsewhere in the February EOBs, the February EOBs for June 18-19, 2001, reflect only “A” denial codes. The March EOBs contain “U”, “S” and “N” denial codes but no “A” denial codes. Because of the significant disparity between the February EOBs and the March EOBs, the ALJ finds the EOB denial codes cited in the Commission’s Decision to be the controlling denial codes.↑