Witkin v. Bureau of Workers' Compensation Fee Review Hearing offfice
Witkin v. Bureau of Workers' Compensation Fee Review Hearing offfice
Opinion of the Court
OPINION BY
Evelyn Witkin, M.D. (Provider) petitions for review of the June 4, 2012 decision of a hearing officer of the Bureau of Workers’ Compensation Fee Review Hearing Office (Bureau) dismissing and denying Fee Review Application No. 281976 on the basis of collateral estoppel.
By way of background, section 306(f.l)(l)(i) of the Workers’ Compensation Act (Act)
Downcoding occurs when an insurer changes a CPT code submitted by a provider to a CPT code for a procedure of a
The relevant facts can be summarized as follows. On June 11, 2010, Provider performed TMR treatment on a workers’ compensation patient. (Reproduced Record (R.R.) at 17a.) On June 22, 2010, Provider submitted invoices for payment to the State Workers’ Insurance Fund (SWIF), for which she billed $3,298.00 per TMR treatment under CPT code 76498. (R.R. at 8a.) On August 16, 2010, SWIF downcoded the procedure to CPT code 97032 and paid Provider $26.24 per TMR treatment. (R.R. at 8a, 13a.) Provider filed two fee review applications to the Bureau, disputing the amount that she was paid. On October 6, 2010, the Medical Fee Review Section of the Bureau held that SWIF properly reimbursed Provider for the TMR treatment she performed on the patient, and Provider appealed the decision. The Bureau assigned the two applications to-a hearing officer in a consolidated appeal.
The hearing officer conducted a de novo review to determine whether Provider used the proper CPT code when billing for the TMR treatment. Without holding a hearing, the hearing officer issued a decision on June 4, 2012, setting forth the following relevant findings of fact:
2. An administrative determination was rendered that CPT code 97032 is the proper billable CPT code for TMR treatment.
3. The issue in fee review application (sic) # 225757 and # 281976 is identical to the issue of coding for TMR treatment. The issue has been fully litigated and adjudicated by hearing officers following a full and fair process of hearing. The proper CPT coding for TMR treatment has been consistently analyzed and confirmed to be 97032.
4. Upon de novo (sic) review, this [hearing officer] determines that no basis exists in fact or law which entitles [Provider] to a second chance to litigate*101 the CPT code for TMR treatment when a final decision has been rendered on the merits of the issue.
(R.R. at 4a, Findings of Fact Nos. 2-4.) The hearing officer dismissed and denied the fee review applications, holding that the issue in the fee review applications was identical to an issue that had already been fully adjudicated.
Provider appealed the hearing officer’s decision regarding Fee Review Application No. 281976 to this Court
Provider argues that the hearing officer failed to make an actual finding of collateral estoppel
Thus, we agree that the hearing officer improperly concluded that Provider’s fee review application was barred by collateral estoppel where the hearing officer did not conduct a hearing or address whether SWIF strictly complied with section 127.207 of the Regulations. A prior determination of the proper CPT code for TMR treatment is immaterial until the issue of whether SWIF strictly complied with the Regulations is decided. Moreover, a prior determination of the proper CPT code for TMR treatment is not dis-positive of this case. The hearing officer’s reliance on prior hearing officer determinations that the proper CPT coding for TMR treatment is 97032 to determine that Provider is collaterally estopped from re-litigating the issue is misplaced. These prior determinations are not binding on this Court or, in fact, the administrative agency. Liberty Mutual, 37 A.3d at 1270 n. 13. A hearing must be held to determine whether SWIF strictly complied with
Accordingly, we reverse and remand to the Bureau to conduct a full hearing on the merits.
ORDER
AND NOW, this 17th day of April, 2013, the June 4, 2012 order of the Bureau of Workers’ Compensation Fee Review Hearing Office is reversed and this matter is remanded to the Bureau of Workers’ Compensation for a hearing in accordance with 34 Pa.Code §127.259.
Jurisdiction relinquished.
. The hearing officer's decision dismissed and denied two of Provider’s fee review applications, Nos. 225757 and 281976, but Provider only appealed the dismissal and denial of Fee Review Application No. 281976 to this Court.
. Act of June 2, 1915, P.L. 736, as amended, 77P.S. § 53 l(l)(i).
. HCFA refers to the Health Care Financing Administration. The HCFA is now known as the Centers for Medicare and Medicare Services, or CMS.
.CPT codes are developed, maintained, and copyrighted by the American Medical Association to help ensure uniformity among medical professionals and the health insurance industry. CPT codes consist of a group of numbers assigned to every task and service a medical practitioner may provide to a patient, including medical, surgical, and diagnostic services.
. Section 127.209 of the Regulations provides that insurers must supply a written explanation of benefits to the provider, describing the calculation of payment of medical bills submitted by the provider. If payment is based on changes to a provider's codes, the explanation must state the reasons for changing the original codes. 34 Pa.Code § 127.209.
. Our scope of review in fee review application appeals is limited to determining whether the hearing officer’s findings are supported by substantial evidence and whether the hearing officer erred or violated constitutional rights. Section 704 of the Administrative Agency Law, 2 Pa.C.S. § 704; Roman Catholic Diocese of Allentown v. Bureau of Workers’ Compensation Fee Review Hearing Office (Lehigh Valley Health Network), 33 A.3d 691 (Pa. Cmwlth. 2011).
. Collateral estoppel bars re-litigation of an issue of fact or law that has been previously decided. Collateral estoppel applies if; (1) the issue decided in the prior case is identical to one presented in the later case; (2) there was a final judgment on the merits; (3) the party against whom the plea is asserted was a party or in privity with a party in the prior case; (4) the party or person privy to the party against whom the doctrine is asserted had a full and fair opportunity to litigate the issue in the prior proceeding; and (5) the determination in the prior proceeding was essential to the judgment. City of Pittsburgh v. Zoning Board of Adjustment of City of Pittsburgh, 522 Pa. 44, 559 A.2d 896 (1989).
Case-law data current through December 31, 2025. Source: CourtListener bulk data.