TX MUTUAL WINS ONE MORE

In another Texas Mutual case, SOAH ruled that chiropractor, David Olson, D.C., misrepresented group physical medicine as individual treatment. The case began when Olson billed Texas Mutual for one-on-one sessions because an injured worker was frequently the only patient in his physical medicine facility at the end of the day. Chiropractors may charge for each 15 minutes of treatment during one-on-one sessions; group physical medicine sessions, however, entail flat fees that are less expensive. According to expert testimony from another chiropractor, one-on-one physical medicine would be appropriate for severely injured patients, such as stroke patients, those with significant gait problems, or those with profound neurological deficits. The chiropractor also testified that Dr. Olson’s physical medicine session was no different than what is available at a health club for far less expense or in a home setting if the patient had the right equipment. For Texas workers’ compensation cases, health care providers bill for their services using Current Procedural Terminology (CPT) codes from the Texas Workers’ Compensation Commission Medical Fee Guideline. The guideline also includes ground rules that govern the use of the CPT codes. SOAH agreed with Texas Mutual that Dr. Olson did not perform one-on-one physical medicine and that CPT code 97110 (one-on-one physical medicine) is not a “default code” just because the claimant is the only patient in the clinic at the end of the day. SOAH also agreed that Texas Mutual had correctly reimbursed Olson.

Topics Texas Workers' Compensation