THOMAS M. FADDEN, Employee, v. CARVER COUNTY, SELF-INSURED/MINNESOTA COUNTIES INTERGOVERNMENTAL TRUST, Employer/Appellant, and RIDGEVIEW MED. CTR., Intervenor.
WORKERS’ COMPENSATION COURT OF APPEALS
MARCH 9, 2011
MEDICAL TREATMENT & EXPENSE - FEE SCHEDULE; STATUTES CONSTRUED - MINN. STAT. § 176.136; RULES CONSTRUED - MINN. R. 5221.4030, SUBP. 2b.I.(11). A hospital may charge a facility fee for the use of its emergency room for outpatient treatment. The compensation judge properly found the relative value fee schedule does not apply to the hospital’s charge for the use of its emergency room for treatment provided to the employee, and the hospital is entitled to be paid 85% of its usual and customary charge for the use of its emergency room.
Determined by: Johnson, C.J., Stofferahn, J., and Wilson, J.
Compensation Judge: Jennifer Patterson
Attorneys: Randall S. Lane, Heacox, Hartman, Koshmrl, Cosgriff & Johnson, St. Paul, MN, for the Appellant. Todd J. Thun, Thun Law Office, Minneapolis, MN, for the Intervenor.
THOMAS L. JOHNSON, Judge
The self-insured employer appeals the compensation judge’s decision that the relative value fee schedule does not apply to the facility fee charged by Ridgeview Medical Center for use of its emergency room for outpatient treatment provided to the employees. We affirm.
Bryan Stranberg was exposed to meningitis on January 29, 2009, while in the course and scope of his employment with the Carver County Sheriff. On that date, the employer was self-insured through the Minnesota Counties Intergovernmental Trust (MCIT). The self-insured employer admitted liability for a personal injury.
Mr. Stranberg was seen in the emergency room at Ridgeview Medical Center (RMC) on January 30, 2009. Thereafter, MCIT received a bill from RMC in the amount of $322.00 for a facility fee for the use of the emergency room. MCIT applied the relative value fee schedule established by Minn. Stat. § 176.136, subd. 1a, and paid RMC $71.05.
Thomas M. Fadden sustained a personal injury to his right knee on November 6, 2008, arising out of his employment with Carver County. On that date, the employer was self-insured through the MCIT. The self-insured employer admitted liability for the employee’s personal injury.
Following his injury, Mr. Fadden was treated in the emergency room at RMC by Dr. Matthew Herold of Emergency Physicians & Consultants. Dr. Herold ordered an x-ray and a CT scan of the employee’s right knee, both of which were performed at RMC. The x-ray and the CT scan were reviewed by radiologists employed by Consulting Radiologists, Ltd. Dr. Herold prescribed a knee immobilizer for the employee that was provided by RMC. Thereafter, MCIT received a bill from RMC for a facility fee for use of its emergency room and charges for the x-ray, CT scan, and a knee immobilizer. MCIT was also billed by Emergency Physicians & Consultants for the treatment provided by Dr. Herold and by Consulting Radiologists for reviewing the scans. With the exception of the knee immobilizer, MCIT applied the relative value fee schedule established by Minn. Stat. § 176.136, subd. 1a, to each of the charges. The facility fee of RMC was $631.00 of which MCIT paid $200.24.
RMC filed two medical requests seeking payment of 85 percent of its usual and customary charge for its facility fee for use of the emergency room to treat Mr. Fadden and Mr. Stranberg. MCIT filed responses denying further liability for the charges. The cases were consolidated by the Office of Administrative Hearings. At the hearing, the parties stipulated that RMC is a hospital with more than 100 licensed hospital beds; that the medical treatment provided to each of the employees was reasonable, necessary, and causally related to the personal injuries; that a hospital is allowed to charge for the use of its emergency room during a patient’s outpatient treatment at the hospital’s emergency room; and that the charges presented by RMC represented its usual and customary charge for the use of its emergency room facilities in connection with the medical treatment provided to each of the employees.
Following a hearing, the compensation judge found that the Minnesota relative value fee schedule does not contain a provision that applies to a facility fee for outpatient evaluation and treatment in an emergency room. The compensation judge concluded that the fee schedule did not apply to the charge by RMC for the use of its emergency room by the two injured employees. Accordingly, the compensation ordered MCIT to pay 85% of RMC’s usual and customary charge for the use of its emergency room. MCIT appeals.
Minn. Stat. § 176.135 obligates an employer to furnish such treatment as may reasonably be required to cure and relieve the employee from the effects of a personal injury. Minn. Stat. § 176.136, subd. 1, provides that the commissioner “shall by rule establish procedures for determining whether or not the charge for a health service is excessive.” Pursuant to this authority, the commissioner developed and promulgated a relative value fee schedule.
Minn. Stat. § 176.136, subd. 1a, entitled “Relative value fee schedule,” states that the “liability of an employer for services included in the medical fee schedule is limited to the maximum fee allowed by the schedule in effect on the date of the medical service, or the provider’s actual fee, whichever is lower.” Subdivision 1b(b) of the statute provides that the liability of an employer for treatment, articles, and supplies that are not limited by the relative value schedule, “shall be limited to 85 percent of the provider’s usual and customary charge, or 85 percent of the prevailing charges for similar treatment, articles, and supplies furnished to an injured person when paid for by the injured person, whichever is lower.”
Charges to all payors for use of a hospital’s facilities, medical supplies provided by the hospital, and testing performed by the hospital are billed on a Uniform Billing Form referred to as a UB-92. It is understood in the insurance industry that the UB-92 billing form reflects hospital charges and does not reflect the charges of a medical professional. The UB-92 billing form used by hospitals includes a revenue code to identify the hospital department providing the service such as the emergency room, the x-ray department, or the operating room. A National Uniform Billing Committee prescribes a four-digit revenue code that identifies the hospital department. The code for an emergency room is 0450.
Minn. Stat. § 176.135, subd. 7, requires health care providers submit to a workers’ compensation insurer an itemized statement of charges on a billing form prescribed by the commissioner. Minn. R. 5221.0700, subp. 2b, provides that hospitals licensed under Minn. Stat. § 144.50 must submit itemized charges on the uniform billing claim form, UB-92. RMC has developed and uses a single UB-92 billing form that can be sent to Medicare, Medicaid, private health insurance companies, and workers’ compensation insurers. Some of the information on RMC’s UB-92 billing form is present because Medicare and/or private health insurance companies require it and not because workers’ compensation insurers require the information. Medicare requires that the revenue code identifying the hospital department providing the service be accompanied by a Current Procedural Terminology (CPT) code defining the service provided. Medicare will not pay an emergency room charge with revenue code 0450 unless a CPT code appears on the same billing line. (See Pet. Ex. A; Finding 7.)
The issue in these consolidated cases is whether the relative value fee schedule applies to the facility fee charge of RMC. The appellant contends that since RMC submitted a UB-92 bill utilizing a CPT code contained within the relative value fee schedule, the bill must be paid pursuant to the fee schedule. The appellant has stipulated that RMC is allowed to charge for the use of its emergency room during a patient’s outpatient treatment at the hospital’s emergency department. However, MCIT contends that it properly paid the bills from RMC by applying the relative value fee schedule. RMC argues that the presence or absence of a CPT code on it’s billing statement is not dispositive with respect to whether the facility fee is included in the relative value fee schedule. RMC asserts the services described in the relative value fee schedule relate to professional medical services, not hospital facility fees. Accordingly, RMC contends the compensation judge correctly ordered MCIT to pay RMC 85% of its usual and customary charge for the use of its emergency room.
Chapter 5221 of the Minnesota Rules governs fees for medical services in workers’ compensation cases. The parties agree that Minn. R. 5221.4030 is the rule applicable to the emergency room services provided to the employees in these consolidated cases. This rule contains a list of medical/surgical procedure codes. Subpart 2b.I.(11) is entitled “Emergency department services” and contains five CPT codes (codes 99281 to 99285) defining five levels of service from the most basic to the most complex. The amount of the charge increases as the complexity of the services provided increases. The CPT codes utilized by RMC on its bills for the facility fee charge for the use of its emergency room were 99282 for Mr. Stranberg and 99284 for Mr. Fadden. These same codes were utilized by the emergency room physicians when billing for the treatment provided by them in the emergency room to the employees. These five codes are contained within a larger subsection (code numbers 99201 through 99449) that “relate[s] to evaluation and management services.” Minn. R. 5221.1030, subp. 2b.I.
Petitioner’s Exhibit C is a copy of two pages of the CPT manual explaining CPT codes 99281 through 99285. The manual states: “The following codes are used to report evaluation or management services provided in the emergency department.” Each of the five codes is defined as an emergency department visit for “the evaluation and management of a patient” requiring three key components: a problem-focused history, a problem-focused examination, and five different levels of complexity of medical decision making ranging from straight forward medical decision making to medical decision making of high complexity.
There is no dispute that some hospital charges are included within the relative value fee schedule while others are not. For example, it is undisputed that RMC’s charge for the x-ray and CT scan provided to Mr. Fadden are each identified by specific CPT codes and are, therefore, subject to the relative value fee schedule. The parties agree, however, the knee immobilizer prescribed for Mr. Fadden is not identified by a specific CPT code within the relative value fee schedule and was, therefore, payable at 85% of RMC’s usual and customary charge.
Kelly Soderholm, the manager of revenue development for RMC, testified at the hearing. Her position encompasses responsibility for payments to RMC from various payers, including workers’ compensation insurance companies. Ms. Soderholm testified that RMC’s facility fee is a charge for the use of the emergency room, which includes overhead, staff, equipment, and nursing services associated with the emergency room. Ms. Soderholm testified most nursing services are not separately codeable or billable. The parties stipulated that RMC is allowed to charge for the use of its emergency room for outpatient treatment. The CPT code used by RMC for its facility fee charge in the Fadden case, 99284, is exactly the same CPT code used by Dr. Herold on his bill for the treatment provided to Mr. Fadden in the emergency room. As Ms. Soderholm explained, RMC included the CPT code on its bill for the emergency room charge only because Medicare and other private insurers require the code be included on the bill.
The excerpt of the federal register in evidence as Exhibit F states that Medicare requires that the revenue code of the hospital department providing the service be accompanied by the CPT code defining what service was provided. Medicare will not pay an emergency room charge with a revenue code 0450 unless a CPT code appears on the same billing line. Accordingly, RMC provided a CPT code on each bill in these cases. The CPT codes for an emergency department visit are defined as evaluation and management services provided to a patient and are based upon three components: obtaining a history, performing an examination, and making a medical decision of some level of complexity. These three components are clearly functions performed by a medical professional. The CPT codes applicable to emergency room services do not, however, make any reference to a facility fee for the use of the emergency room. The same CPT code cannot describe or apply to both a facility fee and a physician’s professional services. We can only conclude, therefore, that the CPT codes 99281 through 99285 relate solely to charges of a medical professional providing services in an emergency room setting. The decision of the compensation judge is affirmed.
 See Stranberg v. Carver County Sheriff, No. WC10-5178 (Mar. 9, 2011). This case and Stranberg were consolidated for hearing before a compensation judge at the Office of Administrative Hearings and on appeal before this court.
 RMC contracted with Emergency Physicians & Consultants to provide physician services in its emergency room.
 RMC has not asserted a prevailing charge for its facility fee in either case.
 Charges by medical professionals, such as Emergency Physicians & Consultants and Consulting Radiologists, are billed on a HCFA 1500 form.
 A CPT code is a numeric code included in the Physician’s Current Procedural Terminology Systems manual used to identify a specific medical service, article, or supply. CPT codes are incorporated in the rules governing charges by providers for medical services and supplies for compensable injuries under Minn. Stat. § 176.135. See Minn. R. 5221.0405, subp. D.
 See footnote 5.
 An x-ray exam of a knee is CPT code 73560 and a CT scan of the leg is CPT code 73700.