99-0070 - Alaska



ALASKA WORKERS' COMPENSATION BOARD

P.O. Box 25512 Juneau, Alaska 99802-5512

CHARLENE THOMPSON, )

)

Employee, )

)

and )

)

DALE E. SPRINGHILL, D.C. )

Physician, )

Applicants, ) FINAL

) DECISION AND ORDER

v. )

) AWCB CASE No. 9810671

SISTERS OF PROVIDENCE, )

(Self-Insured), ) AWCB Decision No.99-0070

) Filed in Anchorage, Alaska

Employer, ) On April 1, 1999.

Defendant. )

___________________________________)

We heard the applicants' claim for benefits on March 11, 1999, at Anchorage, Alaska. The employee appeared; Dr. Springhill also appeared and represented the employee. Attorney Connie Livsey represented the employer. We closed the record at the hearing's conclusion.

ISSUES

1. Whether the employer must pay for medical charges.

2. Whether the employer / medical review utilized the proper fee schedule codes.

3. Whether the employer frivolously or unfairly controverted the employee's claim.

SUMMARY OF THE EVIDENCE AND PROCEEDINGS

The employee presently works as the employer's director of medical records, and has since September 25, 1989. The employer filed a report of occupational injury on June 15, 1998 (dated June 11, 1998). The report lists the date of injury as June 1, 1998, and describes the employee's mechanism of injury as follows: "I started having upper back pain on the right side in mid-May. This has continued and progressed to affecting my neck and right shoulder, with pain going down my right arm. The muscles have gone into spasms." This information was taken from the employee's undated "Employee Incident Report." In the "Body Part Affected:" section of the Incident Report, the employee listed the numbers corresponding only to the front and back of her right shoulder, and her entire right arm.

The employee first sought treatment with her treating physician, Dr. Springhill, on June 5, 1998. Dr. Springhill described the following mechanism of injury in his June 12, 1998 report: "Repetitive motion has created upper back and neck pain since May 1998. This has progressed to include radiating shoulder and arm pains." In the "Describe Complaints" section of our Physician's Report form (Form 07-6102) Dr. Springhill listed: "Neck, arm, back pains with associated muscle spasms." (Id). In the "X-rays?" section, Dr. Springhill checked "yes" and stated: "Mild cervical lumbar degenerative changes. Multiple levels of spinal biomechanical dysrelationships present." (Id). Dr. Springhill has treated the employee since 1992.

In her July 2, 1998 letter to Dr. Springhill, Madeline Rush, the employer's adjuster, wrote in pertinent part:

In our telephone conversation (today), I requested that the lumbar treatment charges be removed from your billing for this claim as the lumbar condition is unrelated to her workers' compensation injury. You refused our request to separate the unrelated charges. As such, a controversion is being filed denying payment in full until we are able to receive a copy of your complete chart and review for appropriate payments due for treatment rendered under this claim. It is of note that Ms. Thompson has been a patient under your care since approximately 1985. Without your assistance in clarifying these matters, we are unable to proceed with adjustment of this claim until we have had an opportunity to review Ms. Thompson's complete chart.

On July 6, 1998, the employer filed a controversion notice dated July 2, 1998, denying certain treatments by Dr. Springhill. The employer listed the following reasons: "1) Treatment to lumbar spine is unrelated to 6/1/98 injury. 2) Medical records from Dr. Springhill have been requested to evaluate and sort out compensable medical treatment provided under this claim." In his letter to Ms. Rush dated July 9, 1998, Dr. Springhill explained the relationship cervical complaints with her lumbar condition. Numerous other correspondences have exchanged between all three parties.[1]

In his July 8, 1998 billing statement, Dr. Springhill detailed the medical services he provided for the employee between June 5, 1998, and July 8, 1998, totalling $1,235.00. This bill includes 10 billings for "CMT[2] 3-4 Regions," each for $55.00; the bill also includes a billing from June 8, 1998 for an X-ray for "Lumbar - (ap & lat) in the amount of $100.00. In addition, Dr. Springhill twice billed $70.00 for performing a "Myofacial Release." At the time he submitted his July 8, 1998 bill, Dr. Springhill did not include specific Physician's Current Procedural Terminology (CPT) codes on his statements.[3]

At the employer's request, Corvel Corporation reviewed Dr. Springhill's July 8, 1998 bill for compliance with the official Alaska Workers' Compensation Fee Schedule. After its review, Corvel recommended the employer pay $1,074.76. On July 28, 1998, the employer issued and hand delivered a check for $1,104.76.[4] Corvell reduced each $55.00 billing by $0.92 under the CPT code 98940: "Chiropractic Manip TX; Spinal 1-2 regions." Corvel recommended the employer not pay the $100.00 billing for the lumbar X-ray. Corvel recommended the employer reduce each of Dr. Springhill's $70.00 bills by $10.52 each.

Under the Alaska Fee Schedule, CPT code 98940 allows a total maximum fee of $54.08. Under the Alaska Fee Schedule, CPT code 98941, "Chiropractic Manip TX; Spinal 3-4 regions" allows a total maximum fee of $69.53. Under the Alaska Fee Schedule, CPT code 97250, "Myofasc Releas/soft Tiss Mobiliz 1/More regions" allows a total maximum fee of $59.48.

The employee's application and prehearing conference summary both state the employee seeks payment of medical costs of $133.00. The employee argues (based on Dr. Springhill's hearing testimony and arguments, and his correspondence and reports) that spinal bio-mechanics are interrelated. The employee argues the lumbar X-ray charges must be paid. The employee argues that the employer's change of the CPT codes from 98941 to 98940 was improper. The employee asserts that the employer's non-payment and controversion of the employee's lumbar treatment was frivolous and unfair, and requests we find the same and notify the Division of Insurance.

The employer argues it acted appropriately based on the employee's statements and her report of injury (or Incident Report) that only her cervical area and right shoulder/arm were allegedly injured. It argues it is only required to pay for necessary and reasonable medical expenses related to a work injury. The employer asserts no injury has occurred. It asserts that since Dr. Springhill did not submit CPT codes, no CPT codes could have been changed.

FINDINGS OF FACT AND CONCLUSIONS OF LAW

I. Lumbar X-ray.

In Amaya v. Our Lady of Compassion Care, AWCB Decision No. 98-0046 (March 11, 1996), a different panel concluded:

We find that when the employee sought treatment in January and May of 1996 she reasonably believed her work injury was causing her complaints. Her doctors appear to agree her complaints may be work related. The diagnostic tests the employer takes issue with were performed to rule out possible causes for the employee's complaints. Had these tests shown the employee's complaints stemmed from a non-work-related source (a stroke for example), and that her work or work injury did not aggravate or accelerate the condition, then the liability for treatment for the non-work-related condition would not lie with the employer (although we believe the diagnostic test itself would be an employer's responsibility).

In summary, we find the diagnostic tests, done in this case to rule out possible causes of the employee's complex complaints, are reasonable and necessary. These tests did not rule out the employee's work as a cause. The employer shall pay for these tests, or reimburse the employee if she has already paid.

As in Amaya, we find Dr. Springhill's June 8, 1998 lumbar X-ray was done for diagnostic purposes. Further, we find Dr. Springhill specifically noted lumbar complaints, related by the employee, in his June 12, 1998 report. We find the lumbar X-ray reasonably related to the employee's diagnosis and subsequent treatment. We conclude the employer shall pay Dr. Springhill's bill of $100.00 for the employee's lumbar X-ray.

II. Fee Schedule Issues.

We find the employer's agent, Corvel, input the improper CMT code when it reviewed Dr. Springhill's bill. We find the maximum Dr. Springhill could charge for a CMT 3-4 regions, was $69.53; Dr. Springhill only billed $55.00. We find the employer paid at $54.08 for each of the 10 CMT billings. We conclude the employer shall Reimburse Dr. Springhill $9.20 (10 X $0.92) for the CMT billings.

We find the employer correctly reduced Dr. Springhill's bill for myofacial releases according to the Alaska Fee Schedule. We conclude the employer reduced his bill properly.

III. Frivolous and Unfair Controversion.

AS 23.30.155(o) provides in pertinent part: "The board shall promptly notify the division of insurance if the board determines that the employer's insurer has frivolously or unfairly controverted compensation due under this chapter." We find the employee specifically complained of upper back and right shoulder / arm pain in her report of injury / incident report. We find the employee has had many years experience dealing with medical records. We find as a result of her experience, the employee recognized the importance of accuracy in medical reporting. We find she identified very specific areas of pain complaints. We find she did not initially complain of lumbar pain. We find she has treated with Dr. Springhill since at least 1992.

Based on the fact the employee was so specific, we find the employer's controversion of the employee's lumbar complaints to be reasonable. We deny and dismiss the employee's request to find the employer controverted frivolously and unfairly.[5]

We note, however, this is a very close case. This is not a situation where an employee reports an injury to his right hand and submits medical bills for his left big toe. We can easily see how a lumbar condition could be related to a cervical injury. Nonetheless, we found enough of a distinction, based on the employee's specificity, that the employer did not frivolously or unfairly controvert in this case.

IV. Interest and Penalty.

We find the employer's agent, Corvel, clearly utilized the improper CPT code for the Dr. Springhill's "CMT 3-4 regions" billings. We find this resulted in an improper deduction in Dr. Springhill's payment of $9.20. We find this should have been paid by the employer. Under AS 23.30.155(e), we find the employee is due a penalty of $2.30 (9.20 X .25). We conclude the employer shall pay the employee a penalty of $2.30. We find the employer had justification to controvert the medical expenses for lumbar treatment, and conclude that no other penalties are due.

We find Dr. Springhill has been deprived of the time value of money not timely paid ($109.20). Accordingly, we conclude the employer shall also pay interest, at the statutory rate under AS 45.45.010, on $109.20 from the date it should have been paid to Dr. Springhill. Land and Marine Rental Co. v. Rawls, 686 P.2d 1187 (Alaska 1984); Moretz v. O'Neill Investigations, 783 P.2d 764 (Alaska 1989).

We feel a commentary regarding the handling of future medical fee disputes is in order. From a review of the extensive correspondence in the file, we recognize the parties appear to have come to an impasse in this case. We note that Dr. Springhill's advocacy on the employee's behalf exceeds that usually offered by other doctors, and we applaud him accordingly. However, we are troubled by the prospect dealing with other cases of this sort. Specifically faced with declining State revenues and reduced budgetary allowances, the Board would be hard pressed, and our administrative resources overwhelmed, trying to resolve every minor dispute over medical payments. We urge parties to first attempt a reconciliation of any Alaska Workers' Compensation Fee Schedule dispute they may have before asking for the Board's intervention.

ORDER

1. The employer shall pay Dr. Springhill $109.20 for medical services. In the event the employee has already paid Dr. Springhill, the employer shall reimburse the employee. The employer shall also pay interest, in accordance with this decision and order, on $109.20.

2. The employer shall pay the employee a penalty of $2.30.

3. The employee's request to refer the matter to the division of insurance is denied and dismissed.

Dated at Anchorage, Alaska this _________________ day of

_________________, 1999.

ALASKA WORKERS' COMPENSATION BOARD

___________________________________

Darryl L. Jacquot,

Designated Chairman

___________________________________

Harriet Lawlor, Member

___________________________________

Philip Ulmer, Member

If compensation is payable under terms of this decision, it is due on the date of issue and penalty of 25 percent will accrue if not paid within 14 days of the due date unless an interlocutory order staying payment is obtained in Superior Court.

APPEAL PROCEDURES

This compensation order is a final decision. It becomes effective when filed in the office of the Board unless proceedings to appeal it are instituted.

Proceedings to appeal must be instituted in Superior Court within 30 days of the filing of this decision and be brought by a party in interest against the Board and all other parties to the proceedings before the Board, as provided in the Rules of Appellate Procedure of the State of Alaska.

RECONSIDERATION

A party may ask the Board to reconsider this decision by filing a petition for reconsideration under AS 44.62.540 and in accordance with 8 AAC 45.050. The petition requesting reconsideration must be filed with the Board within 15 days after delivery or mailing of this decision.

MODIFICATION

Within one year after the rejection of a claim or within one year after the last payment of benefits under AS 23.30.180, 23.30.185, 23.30.190, 23.30.200 or 23.30.215 a party may ask the Board to modify this decision under AS 23.30.130 by filing a petition in accordance with 8 AAC 45.150 and 8 AAC 45.050.

CERTIFICATION

I hereby certify that the foregoing is a full, true and correct copy of the Final Decision and Order in the matter of Charlene Thompson, employee / applicant; v. Sisters of Providence (Self-Insured), employer / defendants; Case No. 9810671; dated and filed in the office of the Alaska Workers' Compensation Board in Anchorage, Alaska, this ___________ day of ________________, 1999.

_________________________________

Sierra D. McKeever, Clerk

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[1]Controversions were filed on August 27, 1998, and August 28, 1998, denying all benefits, and treatment for the lumbar condition. At the request of the employer, the employee was evaluated by James Dinneen, M.D., Orthopedist, and Richard Peterson, D.C., Chiropractor, on August 21, 1998. In their opinion, the employee did not suffer an injury at work, and would not recommend any treatment.

[2]Dr. Springhill testified CMT means chiropractic manipulative therapy.

[3]Dr. Springhill testified he now includes CPT codes in his billing statements.

[4]Corvel recommend the employer not pay Dr. Springhill's July 8, 1998 $30.00 billing for "Handling Services." The employer included this $30.00 as it was for copying the employee's file, which it requested.

[5]Even if we found a frivolous or unfair controversion, we could not refer to the division of insurance because the employer is self insured.

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