DECISION AND ORDER

Liberty Mutual Insurance Corporation (Liberty) requested a hearing to contest the May 27, 2004, Findings and Decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission), which authorized additional reimbursement for a lumbar facet injection provided to Claimant ___ on October 30, 2003. This decision denies the additional reimbursement sought by Metroplex Orthopedics, P.A., (Metroplex).

I. PROCEDURAL HISTORY, JURISDICTION, AND NOTICE

The hearing convened on January 12, 2005, before Administrative Law Judge Katherine L. Smith. Kevin Franta represented Liberty. Metroplex did not appear. The record closed the same day. Jurisdiction and notice were not contested issues.

II. BACKGROUND

Claimant, a 22-year old woman, sustained a work-related injury on ___, when a box fell on her, injuring her lower back. Claimant began experiencing lower back pain. She was seen at Concentra Medical Center on June 11, 2003, where physical therapy and other treatments were provided. Although Claimant initially received some relief, she plateaued and continued having pain in her lower back. She was subsequently referred to Metroplex where she was diagnosed with mechanical low back pain, a lumbar contusion, lumbar and thoracic myositis, and lumbar facet syndrome. On October 30, 2003, Mike Shah, M.D., of Metroplex performed a lumbar facet injection on Claimant. The procedure was performed in a special room at the office. Claimant was then transferred to another room for recovery and observation, where she remained for eighteen minutes. Metroplex billed a total of $1,301.45 for the procedure. Liberty paid Metroplex $323.78.

III. ANALYSIS

Of the $1,301.45, only two charges are at issue: HCPCS Code J2000, for a Lidocaine injection, billed at $18.60, and HCPCS Code 99499-RR, for evaluation and management in the recovery room, billed at $200.00. The MRD had found that both of the charges were not global to the primary procedure and awarded reimbursement in the amounts of $4.99 for the injection and $200.00 for the recovery room.

Liberty had the burden of proof in this proceeding. Liberty presented the testimony of its expert witness, Lisa Hannusch, a healthcare consultant who was involved in the drafting and

implementation of the new Commission Rules based on the Medicare Fee Guidelines. Ms. Hannusch testified that the services provided under the two codes at issue are considered to be global to the primary procedure. She testified more specifically that the RR modifier, for recovery room, is not recognized by Medicare and that healthcare providers are required to code properly. She also testified that a recovery room, nursing care, and supplies are part of the overhead of a doctor’s office to be covered in the overall charge. Ms. Hannush also stated that the $323.78 that Liberty paid Metroplex is a fair and reasonable reimbursement amount pursuant to the Commission’s requirements.

IV. FINDINGS OF FACT

1. Claimant ___ sustained a work-related injury on ___, when a box fell on her, injuring her lower back.
2. Claimant was referred to Concentra Medical Center on June 11, 2003, where she underwent physical therapy and other treatments that gave her temporary relief.
3. On September 1, 2003, the new rules of the Texas Workers’ Compensation Commission (Commission) implementing the Medicare Fee Guidelines went into effect.
4. Because of persistent pain, Claimant underwent a facet injection at Metroplex Orthopedics, P.A. (Metroplex), on October 30, 2003.
5. Mike Shah, M.D., performed the facet injection in a specially designated room. Claimant was then transferred to another designated room for recovery, where she remained for eighteen minutes.
6. Metroplex billed a total of $1,301.45 for the procedure. Liberty Mutual Insurance Corporation (Liberty) paid Metroplex $323.78.
7. Metroplex requested medical dispute resolution at the Commission.
8. On May 27, 2004, the Commission’s Medical Review Division found that Metroplex was due an additional $204.99, based on its finding that the procedures billed under HCPCS Code J2000 and HCPCS Code 99499-RR were not considered global to the primary procedure.
9. Liberty appealed the decision by requesting a hearing at the State Office of Administrative Hearings (SOAH) on June 8, 2004.
10. The Commission sent notice of the hearing to the parties on December 6, 2004. The hearing notice informed the parties of the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing was to be held; the statutes and rules involved; and the matters asserted.
11. A hearing convened on January 12, 2005, before Administrative Law Judge Katherine L. Smith, at the SOAH hearing rooms, William P. Clements Building, 300 W. 15^th Street (4^th Floor), Austin, Texas.
12. HCPCS Code 99499 with the RR modifier is not recognized by Medicare.
13. A recovery room, nursing care, and supplies are part of the overhead of a doctor’s office to be covered in the overall charge.
14. The $323.78 that Liberty paid Metroplex is a fair and reasonable reimbursement amount.

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. Liberty 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. Liberty had the burden of proof in this matter by a preponderance of the evidence. 28 TAC §§ 148.21(h) and (i); 1 TAC § 155.41(b).
6. Texas Workers’ Compensation system participants shall apply the Medicare program reimbursement methodologies, models and values or weights including its coding, billing, and reporting payment policies in effect on the date a service is provided. 28 TAC § 134.202(b).
7. Liberty demonstrated that Metroplex was paid a fair and reasonable rate for the service provided pursuant to Tex. Labor Code Ann.§ 413.011.
8. Based upon the Findings of Fact and Conclusions of Law, Metroplex is not entitled to additional reimbursement.

ORDER

IT IS ORDERED that Metroplex Orthopedics, P.A., is not entitled to additional reimbursement from Liberty Mutual Insurance Corporation for the service provided to Claimant.

Signed March 14, 2005.

KATHERINE L. SMITH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS