24 visit limitation of §4604.5 (California) (California) (Ca

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24 visit limitation of §4604.5 (California) (California) (Ca

Postby steelmanlaw on Fri Aug 14, 2009 7:26 pm

Anyone aware of a PTP getting special dispensation to circumvent the 24 visit rule, because he/she is PTP? (Other than of course the statutory exceptions for employer authorzed PT and/or postsurgical exceptions.)
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Re: 24 visit limitation of §4604.5 (California) (California) (Ca

Postby jonbrissman on Fri Aug 14, 2009 9:07 pm

No. See Jose Facundo-Guerrero v. WCAB (2008) 73 CCC 785.

But -- the statute applies only to dates of injury on and after 01/01/2004. Also, the limitation is to 24 chiropractic visits AND 24 physical therapy visits AND 24 occupational therapy visits, so as many as 72 visits could be involved in the therapies were not concurrent. Further, a claims administrator may authorize additional visits after a surgery. Lastly, there is nothing to prevent a claims administrator from approving a PTP's request for additional treatment above the 24-visit cap on a non-surgical patient (hey, it can't hurt to ask, right?).

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Re: 24 visit limitation of §4604.5 (California) (California) (Ca

Postby jakelast@aol.com on Mon Aug 17, 2009 12:20 pm

Somewhere out there is a panel WCAB decision that holds a DC can continue to act as a treating physician post 24 visits and continue to monitor Tx (without being the direct provider). In this respect the 24 visit cap would appear to conflict with the statutory provision that allow an employee to select their own physician and allow a DC to serve as a PTP. While the level of authority is low, I have generally recommended to my clients that such a position makes sense in light of the employee's right to select their PTP.

It is also my opinion that the PT/OT and Chiro visits can overlap is the Chiro is providing Physical &/or Occ Therapy threatments in their office. No authority for this issue one way or another. However the claims administrator has control over whether the PTP provides physical therapy Tx in their own office as it must be specifically pre-authorized under lc 139.31.
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Re: 24 visit limitation of §4604.5 (California) (California) (Ca

Postby jonbrissman on Mon Aug 17, 2009 1:54 pm

Jake: The case to which you referred is the same case that I cited, Jose Facundo-Guerrera v. Nurserymen's Exchange, SFO 0489218. The appeal that was reported as 73 CCC 785 (2008) considered a different issue in the case, i.e., the constitutionality of L.C. Sect. 4064.5 (the Court of Appeal upheld the statute).

WCJ Susan Hamilton issued an Order Rescinding Decision and Reissuing Findings and Order on 09/05/2007 that ruled, inter alia, that 1) Dr. Marijan Pevec, D.C. had treated in excess of 24 visits, 2) applicant was not entitled to any additional chiro visits; 3) Dr. Pevec, a member of defendant's MPN, was the duly-selected PTP; 4) Dr. Pevec remained responsible for managing applicant's care; and 5) applicant is entitled to additional visits with Dr. Pevec for the purpose of enabling the PTP to manage his care and render opinions on all medical issues necessary to determine his eligibility for compensation.

Procedural history: The reissued F&O was in response to applicant's counsel's petition for reconsideration which raised two points: 1) Can a DC who has exhausted the 24-visit cap remain the PTP?, and 2) Is Sect. 4604.5 constitutional? WCJ Hamilton vacated her initial decision and substituted the one referenced above, which settled the first question. Subsequently, applicant's counsel petitioned for reconsideration solely on the constitutionality-of-the-statute question, and the WCAB (which is without authority to consider constitutionality issues) denied reconsideration. Applicant's counsel then petitioned the Court of Appeal for a writ of review, which was granted. The decision reported at 73 CCC 785 resulted.

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Re: 24 visit limitation of §4604.5 (California) (California) (Ca

Postby jakelast@aol.com on Tue Aug 18, 2009 3:16 pm

That certainly sounds like the case I remember reading.

I think Judge Hamilton's approach is a sound one and balances the employee's right to select his/her own physician with the statutory limitation on Chiropractic TX.
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Re: 24 visit limitation of §4604.5 (California) (California) (Ca

Postby steelmanlaw on Fri Aug 21, 2009 1:26 pm

Thanks, Gents.

So, the consensus is that while A is entitled to select his/her PTP (or selection of PTP within MPN access, when applicable), the PTP is limited to 24 chiro and 24 PT and 24 OT visits. That's what I expected and though Facundo-Guerrera does not address this specific issue, it does generally establish a constitutional basis for the visit limitation.

Of course, the devil is in the details, i.e., whether the PTP Chiro can characterize some visits as PT and some chiro, and whether the latter limited strictly to spinal and/or joint adjustments. I would expect Jon to have an answer to that, though it might understandably be proprietary.
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Re: 24 visit limitation of §4604.5 (California) (California) (Ca

Postby jonbrissman on Fri Aug 21, 2009 3:09 pm

Steelmanlaw: No secrets, nothing proprietary. The CPT codes identify what is being done. 98940 through 98943 identify chiropratic manipulative therapy; CPTs 97945 and 97946 are work conditioning or work hardening, and 97660 is work tolerance (occupational therapy); most other CPT codes in the 97000 series are physical therapy. The acupuncture codes (97801 et al) are in the the physical medicine section and arguably could be considered a type of physical therapy.

In any case, if there is a question, get the billing and go to the OMFS to look up the description of a service.

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Re: 24 visit limitation of §4604.5 (California) (California) (Ca

Postby steelmanlaw on Mon Aug 24, 2009 11:57 am

thanks Jon; you are a scholar and a gentleman. You could write a book on this area.
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