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At a Glance:
Title:
453-01-2759-m5
Date:
August 22, 2002
Status:
Retrospective Medical Necessity

453-01-2759-m5

August 22, 2002

DECISION AND ORDER

I. Introduction

Marsha Miller, D.C. (Provider) has appealed a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) that denied her request for reimbursement of $1,689[1] from Texas Education Equity Cooperative (Carrier) for certain services (Disputed Services) that she furnished to J.O. (Claimant). The only disputed issues are:

  • Whether the services provided through May 25, 2000, treated the compensable injury;
  • Whether the Provider adequately documented the services provided through May 25, 2000;
  • Whether the services provided after May 25, 2000, were reasonably medically necessary to treat the compensable injury; and
  • Whether the Provider adequately stated the disputed issues prior to the hearing.

As set out below, the Administrative Law Judge (ALJ) finds that the Disputed Services through May 25, 2000, totaling $1,420.90, were provided to treat the Claimant’s compensable shoulder injury and adequately documented. Moreover, the Provider’s request for that reimbursement should not be denied based on the alleged deficiency of her statement of disputed issues. However, the ALJ finds that Disputed Services provided after May 25, 2000, in the total amount of $268.10,[2] were not reasonably medically necessary to treat the Claimant’s compensable injury. Accordingly, the ALJ orders the Carrier to reimburse the Provider a total of $1,420.90.

II. Background

The Parties agree that the Claimant’s only compensable injury was to her right shoulder.[3] The Provider agrees that she is only entitled to be reimburse the maximum fee set for each service under the TWCC’s medical fee guideline.[4] The Provider furnished the Disputed Services from February 8, 2000, until August 10, 2000. Only some of the services furnished during that time are in dispute. The Parties resolved their disputes concerning other services provided during that time frame.[5]

Because the Provider’s objections to the Disputed Services are global, rather than based on the character of each service, the specifics of each service are unimportant. Mostly, the Disputed Services were provided to reduce swelling and pain.[6] Others included passive exercises to improve the Claimant’s shoulder; Provider examinations of the Claimant to determine the Claimant’s initial condition, nerve conduction, and progress; brief office visits with the Provider; and different types of allowable workers-compensation claim-handling services, including review of the reports of other doctors.[7]

A. Disputed Services Provided Through May 25, 2000 Compensability

While the Claimant’s only compensable injury was to her right shoulder, each health insurance claim form (HCFA-1500)[8] that the Provider, seeking reimbursement, sent to the Carrier listed four diagnoses: sprain of shoulder and upper arm, suspect of injury to the brachial plexus,[9] symptoms involving head and neck, and paresthesia.[10] The Provider agreed during her testimony,[11] that the head and neck and paresthesia diagnoses had nothing to do with the compensable shoulder injury.

The inclusion without a further explanation of those unrelated diagnoses on the HCFA-1500s led the Carrier to deny reimbursement for all of the Disputed Services. It contends that the Provider failed to show through documentation that the Disputed Service provided through May 25, 2000, totaling $1,420.90, were provided to treat only the compensable injuries.

It is certainly understandable that the HCFA-1500s would have confused the Carrier if it had no other information. They are forms containing only basic data and codes.[12] However, the Provider testified that she also sent her subjective-objective-assessment-plan (SOAP) notes to the Carrier twice: with every HCFA-1500 as each service was provided and again as a complete package when the Provider asked for MRD dispute resolution.[13] The complete package of SOAP notes is in the record,[14] though the originals sent with each HCFA-1500 are not. Though in a somewhat generic format, the SOAP notes adequately explained, as the Provider stipulated at the hearing,[15] why each service was necessary to treat and how it treated the compensable shoulder injury. They do not, however, discuss whether or not the service was also needed to treat the diagnosed non-compensable conditions or, if so, how the service cost was allocated between those compensable and non-compensable injuries.

At the hearing, however, the Provider explained that she knew that the other conditions from which the Claimant suffered were not compensable and that she did not treat them because the Claimant could not afford to pay for that treatment. Instead, she treated only the compensable shoulder injury. She also explained that the non-compensable injuries would have required different treatments. The Claimant suffered from symptoms involving head and neck, (i.e. headaches), and paresthesia. The Provider would have performed other diagnostic tests before treating them, but did not since the Claimant could not pay for such tests. She points out that her SOAP notes only describe treatment to the compensable injury. She also explained that regardless of compensability, under worker’s compensation laws, she was obligated, as a doctor, to list all of her diagnoses on the HCFA-1500.[16] There in no contrary expert medical opinion evidence indicating that the Disputed Services provided through May 25, 2000, failed to treat the compensable injuries, treated only the non-compensable injuries, or treated both the compensable and non-compensable injuries. The ALJ concludes that the Disputed Services were provided through May 25, 2000, to treat the compensable injury.

B.Adequacy of Documentation

Despite their compensability the Carrier still hyper-technically contends that reimbursement for the Disputed Services provided through May25, 2000, should be denied. The Carrier contends that the Provider’s statement of disputed issues[17] failed to meet the requirements of former rule 28 TAC § 133.305(e)(2). For this alleged failure, the Carrier asks that the Provider be sanctioned by having her request for reimbursement denied. The ALJ finds that the requested sanction under a repealed rule, even if the statement of disputed issues was inadequate, to be unreasonable and disproportionate. Hence, the request for such a sanction is denied.

Also, the Carrier argues that the Provider failed to properly document the Disputed Services provided through May 25, 2000, and that lack of documentation also made her subsequent request for dispute resolution incomplete, requiring its denial. Since more than one year has passed since those services were provided, the Carrier argues that the Provider’s incomplete dispute resolution request must be denied. The ALJ disagrees.

It is true that TWCC’s Medical Fee Guideline,[18] Section III - Documentation of Procedure, states that documentation of procedure (DOP) is used when the services provided . . . are unusual . . . The required documentation may vary based on the complexity of the procedure. The DOP shall include pertinent information about the procedure including:

(2) Nature, extent, and need (diagnosis and rationale) for the service or procedure;

(3) Time required to perform the service or procedure; [and]

(6) Other information as necessary.

While no information concerning the time required to perform the service was included, the documentation that the Provider furnished was not wholly inadequate. The Carrier’s SOAP notes, which the evidence shows were twice sent to the Provider, showed that the services were provided to treat the compensable shoulder injury. What was not included, and would have legitimately, initially confused the Carrier, was any discussion to clarify that the Disputed Services were not provided to treat the other non-compensable diagnosed injuries. At worse there were marginal failures to document, which the Carrier could have resolved with a phone call.

In fact, 28 TAC § 133.300 (c)(2)(B) requires a Carrier to contact a Provider, by phone or otherwise, to obtain information necessary to make a bill complete. There is no evidence that the Carrier did this. It merely sent explanations of benefits (EOBs) indicating the Disputed Service were non-compensable[19] without even indicating it thought the Provider’s documentation was incomplete, much less how. The Carrier cites former TWCC rule 28 TAC §133.305(e)(2),[20] which required the denial of a request for reimbursement until it was filed in the form required by the Commission rules. Since that rule has been repealed, it does not apply. The ALJ does not find that the documentation was so inadequate that reimbursement should be denied on that basis. Instead, he finds that the Carrier should reimburse the Provider for the Disputed Services provided to the Claimant through May 25, 2002, which the Parties agree totals $1,420.90[21] under the Medical Fee Guideline.

C. Post May 25, 2000 Disputed Services

As to the post-May 25, 2000 Disputed Services the Carrier argues that the Claimant had reached maximum medical improvement by May 25, 2000, making any further treatment medically unnecessary and unreimbursable. The ALJ agrees.

On May 25, 2000, a Carrier-requested doctor found that the Claimant had reached maximum medical improvement (MMI), with a three-percent whole-person impairment, making any further treatment, beyond applying ice to her shoulder at home and a home exercise program, medically unnecessary.[22] His report was thorough and well reasoned.

The Provider prepared a response on that same date, but it did not challenge the peer-review doctor’s conclusion or otherwise indicate why further services to treat the Claimant’s compensable injury were necessary.[23] Nor did she explain at hearing why services after May 25, 2000, were needed for that purpose. In a report on or about August 10, 2000, a Provider-requested doctor concluded that the Claimant had not reached MMI.[24] He recommended more aggressive treatment by the Provider, but did not explain why.

As the party appealing the MRD’s decision, the Provider has the burden of proof in this matter.[25] The evidence does not show that it is more likely than not that the Claimant would have benefitted from further treatment after May 25, 2000. Instead, it shows that the opposite was more likely. The ALJ finds that the Provider’s Disputed Services after May 25, 2000, in the total amount of $268.10,[26] were not reasonably medically necessary to treat the Claimant’s compensable injury.

III. Summary

The ALJ concludes that the Disputed Services that the Provider furnished to the Claimant through May 25, 2000, totaling $1,420.90, were provided to treat the Claimant’s compensable shoulder injury and adequately documented. Moreover, the Provider’s request for that reimbursement should not be denied based on the alleged deficiency of its statement of disputed issues. The ALJ also finds that the Provider’s Disputed Services after May 25, 2000, in the total amount of $268.10,[27] were not reasonably medically necessary to treat the Claimant’s compensable injury. Accordingly, the ALJ orders the Carrier to reimburse the Provider $1,420.90.

IV. Findings of Fact

  1. The Claimant sustained a work-related injury to her right shoulder on_____________, while her employer was ______________and the Carrier was its workers’ compensation insurance carrier.
  2. The Provider is the Claimant’s treating doctor.
  3. The Provider furnished the Claimant several services between February 8, 2000, and August 10, 2000 (Disputed Services).
  4. Most of the Disputed Services were provided to reduce swelling and pain in the Claimant’s shoulder. Current Procedural Terminology (CPT) codes 97010, 97014, and 99070.
  5. Other Disputed Services included passive exercises to improve the Claimant’s shoulder; Provider examinations of the Claimant to determine the Claimant’s initial condition, nerve conduction, and progress; brief office visits with the Provider; report reviews; and other types of allowable services regarding the handling of the Claimant’s workers-compensation claim. CPT codes E0745, 95851, 99214, 95851, 95904, 99362, 99199, 99455-RP, 99358, 99080, 99335, and 97540.
  6. The Provider sought reimbursement for the Disputed Services from the Carrier within one year of providing them.
  7. The Carrier denied the requested reimbursement, questioning:
    1. Whether the Disputed Services provided through May 25, 2000, treated the compensable injury;
    2. Whether the Provider adequately documented the Disputed Services provided through May 25, 2000; and
    3. Whether the Disputed Services provided after May 25, 2000, were reasonably medically necessary to treat the compensable injury.
  8. On December 14, 2000, the Provider filed a request for medical dispute resolution with the TWCC.
  9. MRD reviewed the dispute and denied the Provider’s request for reimbursement, though it did order reimbursement for other services that are no longer in dispute.
  10. The Provider appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
  11. The hearing was continued several times.
  12. On July 29, 2002, notice of an August 7, 2002, hearing in this case was mailed to the Carrier and the Provider.
  13. On August 7, 2002, William G. Newchurch, a SOAH Administrative Law Judge (ALJ) held a hearing on the Carrier’s appeal at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas, Austin, Texas. The Provider appeared on her own behalf, by phone, and the Carrier, represented by attorney J. Keith Mayo, attended that hearing in person. The hearing concluded and the record closed on that same day.
  14. Each health insurance claim form (HCFA-1500) for the Disputed Services that the Provider, seeking reimbursement, sent to the Carrier listed four diagnoses: sprain of shoulder and upper arm, suspect of injury to the brachial plexus, symptoms involving head and neck, and paresthesia.
  15. The head and neck and paresthesia diagnoses had nothing to do with the compensable shoulder injury.
  16. The Provider sent her subjective-objective-assessment-plan (SOAP) notes regarding each Disputed Service to the Carrier twice: with each HCFA-1500 as each service was provided and again as a complete package when the Provider asked for dispute resolution.
  17. In generic format, the SOAP notes adequately explained why each service was necessary to treat and how it treated the compensable shoulder injury.
  18. The SOAP notes only describe treatment to the compensable injury.
  19. The SOAP notes showed that the Disputed Services were provided to treat the compensable shoulder injury.
  20. Services different from the Disputed Services would have been required to treat the Claimant’s diagnosed non-compensable conditions.
  21. The Provider only treated the compensable shoulder injury and did not treat the other diagnosed non-compensable conditions from which the Claimant suffered.
  22. The Carrier’s explanations of benefits (EOBs) denying the Provider’s request for reimbursement only indicated that the Disputed Service were non-compensable, not that the Carrier thought the Provider’s request-for-reimbursement documentation was incomplete, much less how.
  23. By May 25, 2000, the Claimant had reached maximum medical improvement (MMI), with a three-percent whole-person impairment, making any further treatment of the compensable injury, beyond applying ice to her shoulder at home and a home exercise program, medically unnecessary.

V. Conclusions of Law

  1. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. §§ 402.073(b) and 413.031(d) (West 2002) and Tex. Gov’t Code Ann. ch. 2003. (West 2001).
  2. Adequate and timely notice of the hearing was provided in accordance with Tex Gov’t. Code Ann. §§2001.051 and 2001.052 (West 2001).
  3. As the party appealing the MRD’s decision, the Provider has the burden of proof in this case pursuant to 28 Tex. Admin. Code (TAC) §148.21(h) (2002).
  4. TWCC’s Medical Fee Guideline, Section III - Documentation of Procedure, Paragraph (4), adopted by reference at 28 Tex. Admin. Code §134.201, states that documentation of procedure (DOP) is used when the services provided . . . are unusual . . . The required documentation may vary based on the complexity of the procedure. The DOP shall include pertinent information about the procedure including:

(2) Nature, extent, and need (diagnosis and rationale) for the service or procedure;

(3) Time required to perform the service or procedure; [and]

(6) Other information as necessary.

  1. Based on the above Findings of Fact, the Provider’s DOP was adequate.
  2. 28 TAC § 133.300 (c)(2)(B) requires a Carrier to contact a Provider, by phone or otherwise, to obtain information necessary to make a bill complete.
  3. The above Findings of Fact do not show that the Carrier attempted to comply with 28 TAC § 133.300 (c)(2)(B) to make the Provider’s bills for the Disputed Services complete.
  4. Under Tex. Labor Code § 408.021 (a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.
  5. Based on the above Findings of Fact, the Disputed Services that the Provider furnished to the Claimant through May 25, 2000 were provided to treat the compensable injury.
  6. Based on the above Findings of Fact, the Disputed Services that the Provider furnished to the Claimant after May 25, 2000 were not reasonably medically necessary to treat the Claimant’s compensable injury.
  7. A Provider is only entitled to be reimbursed the maximum fee set under TWCC’s Medical Fee Guideline for a service. 28 TAC § 134.202(d).
  8. Based on the above Findings of Fact, Conclusions of Law, and the Medical Fee Guideline the Provider is entitled to be reimbursed $1,420.90 for the Disputed Services that she provided to the Claimant through May 25, 2000, to treat the compensable injury.

ORDER

The Carrier shall reimburse the Provider $1,420.90 for the Disputed Services provided to the Claimant through May 25, 2000.

Signed August 22, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WILLIAM G. NEWCHURCH
Administrative Law Judge

  1. As amended at the hearing. Tape 2, side 1.
  2. Provider Ex. 1, pp. 15 and 16.
  3. Provider Ex. 1, p. 24; Tape 1, side 1.
  4. Provider Ex. 1, p. 27; Tape 2, side 2.
  5. Provider Ex. 1, pp. 12-13; Tape 2, side 1.
  6. Current Procedural Terminology (CPT) codes 97010, 97014, and 99070. Provider Ex. 1, pp. 12 et seq.
  7. CPT codes E0745, 95851, 99214, 95851, 95904, 99362, 99199, 99455-RP, 99358, 99080, 99335, and 97540. Provider Ex. 1, pp. 12 et seq.
  8. See Provider Ex. 1, p. 36 for example.
  9. A network of nerves lying mostly in the armpit and supplying nerves to the chest, shoulder, and arm. MERRIAM-WEBSTER’S COLLEGIATE DICTIONARY, http://www.m‑w.com/cgi‑bin/dictionary.
  10. A sensation of pricking, tingling, or creeping on the skin that has no objective cause. MERRIAM-WEBSTER's COLLEGIATE DICTIONARY, http://www.m‑w.com/cgi‑bin/dictionary.
  11. Tape 1, side 2.
  12. See for example Provider Ex. 1, p. 167.
  13. Tape 1, side 1.
  14. Provider Ex. 1, pp. 107 et seq.
  15. Tape 2, side 1.
  16. Tape 2, side 1.
  17. Provider Ex. 1, p. 18.
  18. Adopted by reference at 28 Tex. Admin. Code §134.201.
  19. Provider Ex. 1, pp. 240 et seq.
  20. The Carrier cites to the version of 28 TAC §133.305 that was in effect at the time the request for reimbursement were filed. Section 133.305 was later repealed and a very different version was adopted in it place. 26 Tex. Reg. 10934, eff. Jan. 2, 2002.
  21. Provider Ex. 1, pp. 15 and 16.
  22. Provider Ex. 1, pp. 159 et seq.
  23. Provider Ex. 1, pp. 164 et seq.
  24. Provider Ex. 1, p. 172 et seq.
  25. 28 Tex. Admin. Code '148.21(h).
  26. Provider Ex. 1, pp. 15 and 16.
  27. Provider Ex. 1, pp. 15 and 16.
End of Document
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