DECISION AND ORDER

Zurich American Insurance Company (Carrier) requested a hearing to contest a Medical Fee Dispute Resolution (MDR) decision issued by the Texas Department of Insurance, Division of Workers’ Compensation (Division) regarding medical services provided to an injured worker (Claimant). In its order, the Division determined that Carrier owed an additional $8,881.38 to Summit Rehabilitation Centers (Provider). Carrier challenged this decision, and the matter was referred to the State Office of Administrative Hearings for a contested case hearing.

On May 4, 2011, a contested case hearing was convened before Administrative Law Judge (ALJ) Craig R. Bennett. Carrier appeared through its attorney, Steven M. Tipton. Provider did not appear at the hearing, and the latest filings in the case (as well as representations by Carrier at the hearing) indicate that Provider has subsequently closed and is no longer an ongoing business enterprise. After considering the evidence and arguments presented, the ALJ finds that Carrier has established that it is not liable for any additional amounts. Therefore, Carrier is relieved from the liability ordered by the Division through the MDR, and is not required to reimburse Provider any amounts above those already provided.

In support of this decision, the ALJ makes the following findings of fact and conclusions of law.

I. FINDINGS OF FACT

1. Summit Rehabilitation Centers (Provider) is a medical provider which provided medical services to an injured worker (Claimant) arising from a ___ compensable, work-related injury.
2. Zurich American Insurance Company (Carrier) provided workers’ compensation insurance coverage for Claimant’s work-related injury.
3. Provider submitted medical bills for services provided to Claimant for various dates of service between November 4, 2004, and April 12, 2005. Carrier reviewed the bills submitted and reduced or denied some dates of service.
4. When Provider was dissatisfied with the amount of Carrier reimbursement, it filed a request for Medical Dispute Resolution (MDR) with the Texas Department of Insurance, Division of Workers’ Compensation (Division), seeking additional reimbursement of $9,101.04.
5. Provider alleged underpayment of some bills, denial of payment of some bills and no response—i.e., no EOBs—from Carrier for some bills in dispute.
6. The Division, through MDR, determined that Carrier owed Provider the additional sum of $8,881.38.
7. In response to the MDR Findings and Decision, Carrier timely requested a hearing before the State Office of Administrative Hearings (SOAH).
8. The Division referred the matter to SOAH.
9. All parties received adequate notice of not less than 10 days of the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing was to be held; the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
10. Upon proper notice to the parties, this case was first convened for hearing on the merits on July 29, 2009. Provider did not appear. At that time, Carrier agreed to a continuance in order to grant attorney Daniel Morris time to resolve a lien issue between Provider and creditor banks. Following numerous unsuccessful attempts to resolve the lien issues, this case was again noticed for hearing on the merits.
11. On May 4, 2011, ALJ Craig Bennett convened the hearing in this matter at the Austin offices of SOAH. Carrier was represented by its attorney, Steven M. Tipton. Provider did not appear. The hearing concluded and the record closed that same day.
12. Carrier did not timely receive initial complete bills and requests for reconsideration in accordance with Division rules then in effect for the following CPT Codes and corresponding Dates of Service:

CPT CodeDates of Service

95852 11/8/04, 11/22/04, 2/10/05

96004 11/8/04, 11/22/04, 12/7/04, 2/10/05

97018 11/8/04, 11/16/04, 11/22/04, 11/23/04,

11/24/04, 2/10/05, 2/11/05, 2/14/05,

2/15/05, 2/18/05

97110 11/8/04, 11/11/04, 11/15/041, 1/16/04,

11/17/04, 11/18/04, 11/22/04, 11/23/04,

11/24/04, 11/29/04, 11/30/04, 2/10/05,

2/11/05, 2/14/05, 2/15/05, 2/18/05

97140 11/8/04, 11/22/04, 11/23/04, 11/24/04, 2/10/05,

2/11/05, 2/14/05, 2/15/05, 2/18/05

99213 11/8/04, 11/11/04, 11/15/04, 11/15/04, 11/16/04,

11/17/04, 11/18/04, 11/22/04, 11/23/04, 11/24/04,

11/29/04, 11/30/04, 12/7/04, 2/2/05, 2/10/05,

2/11/05, 2/14/05, 2/15/05, 2/18/05, 4/12/05

G0283 11/15/04, 11/16/04, 11/17/04, 11/18/04, 11/22/04,

11/23/04, 11/24/04, 11/29/04, 11/30/04, 2/10/05,

2/11/05, 2/14/05, 2/15/05, 2/18/05

95832 12/7/04

97454-WH 12/13/04, 12/14/04, 12/15/04, 12/16/04, 12/17/04, 12/20/04, 12/21/04, 12/29/04

97456-WH 12/13/04, 12/14/04, 12/15/04, 12/16/04, 12/17/04,

12/20/04, 12/21/04, 12/29/04, 1/3/05

99080-73 12/16/04, 2/15/05

1. Provider’s failure to submit to Carrier the bills reflected in Finding of Fact No. 12 denied Carrier the timely opportunity to audit payment, deny payment and/or reduce payment in accordance with applicable preauthorization requirements, fee guidelines, treatment guidelines, Center for Medicare & Medicaid Services (CMS) policies and Division policies.
2. Provider billed for services of 11/4/04 and 1/18/05 for CPT code pair 96004 and 97750-FC. Carrier denied reimbursement based upon “G-unbundling” and “Z8, A procedure has been billed on the same date, and on the same site, as a more extensive procedure. Since the extensive procedure has an increased level of complexity, a charge for the less extensive procedure is not appropriate.”
3. Under applicable Correct Coding Initiative (CCI) Edits, CPT Code 97750 in column two is a component of CPT Code 96004, listed in column one, whereby only the column one code is paid in the absence of an allowable CCI modifier and if clinically appropriate. The only appropriate CCI modifiers for the services in issue were “-59” and “-91.”
4. Provider used only the “–FC” modifier for CPT 97750 to identify the type of physical performance evaluation/measurement actually performed as a functional capacity evaluation. “–FC” is a Division-specific modifier under the applicable medical fee guideline which allows audit for that procedure which is limited in its numbers and extent by that Division guideline [specifically, 28 Tex. Admin. Code § 134,202(4)]. The modifier “-FC” is not a CCI modifier. Provider did not also use the only available CCI modifiers of “-59” or “-91” to request additional payment of the column two CPT Code 97750 in addition to the column one CPT Code 96004.
5. Provider billed for services of January 6, 2005, to include CPT Code 96004. Carrier denied reimbursement based upon “OT, A procedure has been billed which is out of the scope of practice for this provider.” The use of this procedure by this healthcare practitioner for the date of service claimed is not supported by the medical records or evidence.

II. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order. Tex. Lab. Code § 413.031 and Tex. Gov’t. Code ch. 2003.
2. 1. Notice of the hearing was proper and timely. Tex. Gov’t. Code §§ 2001.051 and 2001.052.
3. 1. Carrier had the burden of proving by the preponderance of the evidence that Provider was not entitled to the reimbursement ordered by the Division for the disputed services. 1 Tex. Admin. Code § 155.427; 28 Tex. Admin. Code § 148.14(a).
4. 1. At all time pertinent to this matter, Provider was required to submit a complete medical bill to Carrier not later than the first day of the eleventh month after the date of service under 28 Tex. Admin. Code § 134.801(c) and in accordance with 28 Tex. Admin. Code §§ 133.1 and 133.304.
5. 1. Carrier has shown by a preponderance of the evidence that Provider did not timely submit bills and submitted improperly-coded bills, and is not entitled to the additional reimbursement claimed before the Division in MRD Tracking No. M4-06-1137-01.
6. 1. Based on the above findings of fact and conclusions of law, Carrier is not liable to Provider for the reimbursement amount of $8,881.38 as ordered by the Division, and is not liable to Provider for any other reimbursement for the services at issue in this matter.

ORDER

THEREFORE, IT IS ORDERED THAT Zurich American Insurance Company is relieved from the liability ordered by the Texas Department of Insurance, Division of Workers’ Compensation, regarding medical services provided by Summit Rehabilitation Centers, and is not required to reimburse any amounts above those already provided for the services rendered and at issue in this case.

Signed May 11, 2011.