DECISION AND ORDER

Texas Mutual Insurance Company (Carrier) appealed the findings and decision of the Texas Workers’ Compensation Commission’s (Commission’s) designee, an independent review organization that found that the office visits and physical medicine treatment that Central Dallas Rehab (Provider) provided to ___, a workers’ compensation claimant (Claimant), were medically necessary health care. This decision finds that the treatments provided to Claimant were not medically necessary, except for muscle testing provided on March 7, 2003.

I. NOTICE, JURISDICTION, AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction or notice. Those issues are set out in the Findings of Fact and Conclusions of Law.

The hearing in this matter convened on September 15, 2004, before State Office of Administrative Hearings (SOAH) Admistrative Law Judge (ALJ) Katherine L. Smith. Scott Placek, an attorney, represented the Carrier. Scott Hilliard, an attorney, represented the Provider. The record closed the same day.

II. DISCUSSION

A.Background

Claimant sustained a compensable injury on ___, when he fell off a step ladder and injured his left knee and lower back. The results of an MRI of the left knee administered on February 19, 2003, revealed a lateral meniscal tear on February 24, 2004. Claimant underwent surgery to repair the meniscal tear on April 3, 2003.^[1] Provider began treating Claimant on January 28, 2003. The treatments in dispute were provided from March 7 to March 31, 2003, and were billed under the following CPT^[2] codes: 99213 (office visits); 97110 (one-on-one physical therapy); 97530 (therapeutic activities); 97122 (manual traction); 99750MT (muscle testing); 97250 (myofascial release); and 97265 (joint mobilization). The Carrier denied reimbursement.

A.Analysis

Carrier presented the testimony of its expert, Charles Pearce, M.D., an orthopedic surgeon, who testified that the treatments were excessive and that the medical documentation did not justify the excessive treatment provided. Provider contends that the treatment was necessary to potentially avoid surgery and to ensure that the Claimant was in good physical condition before the surgery.

When a healthcare provider bills for one of the three highest level office visits, which includes CPT code 99213, and for physical medicine treatment, the Commission’s rules require the healthcare provider to submit the following progress or SOAP^[3] notes substantiating the care given and the need for further treatment and services and indicating progress, improvement, the date of the next treatment and services, complications, and expected release date.^[4] With this directive in mind, the ALJ finds the testimony of Dr. Pearce challenging the adequacy of the documentation and the necessity of the disputed treatments to be persuasive.

In general, the Provider’s SOAP notes are identical from day to day indicating that they were cut and pasted, with little or no discussion about what was needed for further treatment and no indication of progress, improvement, and complications. For example, the notes up through March 3, 2003, still indicated that the results of the MRI were impending, even though they were available on February 24, 2003.

Moreover, the record reflects substantial “over-coding.” Regarding the office visits provided on March 7, 10, 11, 17,18,19,26,27,28 and 31, which were coded as CPT code 99213, that coding is not appropriate unless two of the following occurs: an expanded problem-focused history, and expanded focused examination, and medical decision making of low complexity. The medical notes document neither an expanded problem-focused history, nor an expanded examination. They are virtually the same for each visit.

The ALJ also notes that even though Provider billed for providing one-on-one physical therapy on March 3,10,11,17,18 and 19, using CPT code 97110, the treatment notes documenting that therapy are sparse and do not indicate what physical therapy treatments were provided to Claimant, the purpose of each activity performed, the equipment used, the number of repetitions, their duration, and what Claimant’s response was to the treatments. Dr. Pearce testified that one-on-one physical therapy was not necessary by March 7, 2003, unless safety issues were documented and Claimant was having difficulty performing the activities, which was not the case. Even Dr. Plate, the treating chiropractor, admitted that the notes did not document that one-on-one therapy was provided.^[5] Although the medical notes of March 26,27,28, and 31, show increased documentation, they do not justify the billing of eight, 15 minutes-units of one-on-one physical therapy activities. At this point in the treatment, according to Dr. Pearce, Claimant should have been performing home exercises to maintain his range of motion, strength, and conditioning.

In addition, the treatment notes do not document why joint mobilization, manual traction, myofascial release, and other passive treatments, were being provided at this time. According to Dr. Pearce, passive treatments provided more than one month after the injury are not appropriate unless the medical notes explain why they are necessary at such a late stage, particularly when there is no documentation of scar formation and spasms. Dr. Pearce also testified that joint mobilization of the left knee was contraindicated when the meniscal tear was discover on February 24, 2003.

Because Dr. Plate adequately stated the need for the muscle testing on March 7, 2003, and Carrier did not dispute the need, the ALJ finds that the muscle testing was medically necessary. As far as the muscle testing that was performed on March 26, 2003, the record contains no indication why the testing was being performed at that time, particularly when surgery was being recommended on March 24, 2003.

Concluding that the great majority of continuing chiropractic care provided between March 7 and March 31, 2003, was inadequately documented and excessive, the ALJ finds that the Carrier has met its burden of proof that the treatments provided to Claimant were not medically necessary and denies reimbursement of the disputed claims, except for the muscle testing performed on March 7, 2003.

III. FINDINGS OF FACT

1. ___ (Claimant) sustained a compensable injury on ___, when he fell off a step ladder and injured his left knee and lower back.
2. At the time of the compensable injury, Claimant’s employer had workers’ compensation insurance coverage with Texas Mutual Insurance Company (Carrier).
3. Central Dallas Rehab (Provider) began treating Claimant on January 28, 2003.
4. An MRI of the left knee revealed a lateral meniscal tear. Claimant underwent surgery to repair the meniscal tear on April 10, 2003.
5. The treatments in dispute were provided from March 7 to March 31, 2003, and were billed under the following current procedural code (CPT) codes: 99213 (office visits); 97110 (one-on-one physical therapy);97530 (therapeutic activities); 97122 (manual traction); 99750MT (muscle testing); 97250 (myofascial release); and 97265 (joint mobilization).
6. Texas Mutual Insurance Company (Carrier) denied reimbursement for the treatments.
7. Provider appealed to the Texas Workers’ Compensation Commission (Commission), which referred the dispute to its designee, an Independent Review Organization (IRO).
8. On March 18, 2004, the Commission’s Medical Review Division (MRD) issued a decision based on the IRO’s review. Which found that the treatments were medically necessary.
9. Carrier timely appealed the MRD’s decision on April 7, 2004.
10. On May 19, 2004, the Commission issued the notice of hearing, which stated the date, time, and location of the hearing and cited to the statutes and rules involved, along with a short, plain statement of the factual matters involved.
11. Use of CPT code 99213 requires that two of the three occur during an office visit: an expanded problem-focused history, and expanded focused examination, and medical decision making of low complexity.
12. The medical records documenting the office visits provided Claimant on March 7, 10, 11, 17,18,19,26,27,28 and 31, document neither an expanded problem-focused history, nor an expanded focused examination.
13. Although Provider billed for providing one-on-one physical therapy on March 3,10,11,17,18 and 19, using CPT code 97110, the treatment notes documenting that therapy do not indicate which physical treatments were provided, the number of repetitions, what Claimant’s response was to the treatments, and the duration of the treatments.
14. Although Provider billed for providing one-on-one physical therapy and activities on March 26,27,28, and 31, using CPT codes 97110 and 97350, The treatment notes documenting that treatment do not justified the billing of eight, 15 minutes-units of one-on-one physical therapy and activities.
15. By the end of March and after surgery was recommended on March 24, 2003, Claimant should have been performing home exercises to maintain his range of motion, strength, and conditioning prior to surgery on April 3, 2004.
16. The treatment notes do not document why joint mobilization, manual traction, and myofascial release, passive treatments, were being provided more than one month after the injury.
17. The treatment notes do not document scar formation requiring myofascial release.
18. The treatment notes do not ducument spasms justifying the need for manual traction.
19. The treatment notes fail to justify the need for muscle testing on March 26, 2003, after surgery was recommended on March 24, 2003.
20. The treatments provided to Claimant between March 7 and 31, 2003, except for the muscle testing of March 7, 2003, were not shown to be reasonably required by the nature of Claimant’s injury.

IV. CONCLUSIONS OF LAW

1. The Texas Workers’ Commission has jurisdiction over this matter pursuant to the Texas Workers’ Compensation Act (Act), TEX. LAB. CODE ANN. § 413.031
2. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to §413.031(k) of the Act and Tex. Gov’t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
4. Carrier had the burden of proof in this proceeding. 28 TAC §§ 148.21 (h) and (i); 1 TAC §155.41.
5. When a healthcare provider bills for an office visit using CPT code 99213 and for physical medicine treatment, the healthcare provider must submit progress or SOAP notes substantiating the care given and the need for further treatment and services, and indicating progress, improvement, the dated of the next treatment and services, complications, and expected released date. 28 TEX ADMIN. CODE § 133.1
6. Based upon findings of fact no. 11-12, the treatments provided to Claimant that include office visits, physical therapy, joint mobilization, manual traction, and myofascial release from March 7 to 31, 2003, and the muscle testing of March 7, 2003, were not medically necessary health care under TEX. LAB. CODE ANN. §§ 401.011 and 408.021 (a).
7. Based upon findings of fact no. 19, the muscle testing of March 7, 2003, was medically necessary health care under TEX. LAB. CODE ANN. §§ 401.011 and 408.021 (a).
8. Based upon the foregoing findings of fact and conclusions of law, Provider’s request for reimbursement should be denied, except for the muscle testing provided on March 7, 2003.

ORDER

IT IS, THEREFORE, ORDERED that Texas Mutual Insurance Company shall reimburse Provider &86 for the muscle testing provided to Claimant on March 7, 2003. The remainder of Central Dallas Rehab’s request for reimbursement is denied.

Signed November 12, 2004.

KATHERINE L. SMITH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The IRO decision incorrectly stated that the surgery occurred on April 10, 2003. See Petitioner’s Ex. 1 at 142-43 for operative report.↑
2. Current procedural terminology↑
3. Subjective/Objective assessment plan/procedure.↑
4. 28 TEX. ADMIN. CODE § 133.1↑
5. Respondent’s Ex 4 at 224-29.↑