DECISION AND ORDER

The Petitioner, Curtis Adams, D.C., appealed the decision of the Texas Workers’ Compensation Commission Medical Review Division (MRD) denying reimbursement of $1,632.00 for spinal manipulations. The Administrative Law Judge (ALJ) finds that the Petitioner did not meet his burden of proof because he did not document the treatment’s effectiveness in accordance with the Spine Treatment Guideline.

I. PROCEDURAL HISTORY, JURISDICTION, AND NOTICE

Notice and jurisdiction were not contested and are discussed only in the Findings of Fact and Conclusions of Law.

The hearing was held on March 19, 2002, at the William P. Clements Building, 300 West Fifteenth, Austin, Texas. Attorney David Swanson represented the Carrier, and the Petitioner’s office manager, Rick Muniz, represented the Petitioner. The record closed at the conclusion of the hearing.

II. DISCUSSION

The worker had disc bulges at L3-4 and L4-5. The MRD found the Petitioner’s documentation inadequate because the progress notes had no measurable objective data indicating the treatment’s effectiveness.

Testifying for the Carrier, Chiropractor Bill Defoyd also noted the inadequate documentation of substantial and continued improvement, as required by the Spine Treatment Guideline (STG), 28 Tex. Admin. Code (TAC) §’134.1001. (See the Appendix for pertinent excerpts from this rule.)

In Dr. Defoyd’s opinion, the Petitioner’s notes do not comply with the STG because they have no objective findings or assessments. Further, the Petitioner administered about twice as many manipulations as what retrospective reviews usually show, Dr. Defoyd testified.

The Petitioner’s treatment notes from January 6 to April 5, 2000, the dates covered by this appeal, describe decreased range of motion, hypertonic musculature, and swelling in the thoraco-lumbar and the lumbo-sacral spine areas. As for the worker’s progression, the notes almost uniformly state that the complaints are slightly improved and the patient is improving. At times, the notes indicate a flare-up or muscle spasms (Ex. 1, pp. 424-450).

At the hearing, the Petitioner asserted that the thirty-four manipulations in question helped to alleviate pain and to support the worker’s progress. For all the manipulations, the Petitioner billed $48.00 under CPT code 99213-MP, intermediate office visit with manipulation. The worker also participated in physical therapy from January 6, 2000, through February 4, 2000, and in work conditioning from February 8, 2000, to March 7, 2000.

The worker had a five percent whole person impairment, according to an independent medical evaluation performed on February 7, 2000 (Ex. 1, p. 116-121). His permanent impairment evaluation, made June 14, 2000, showed a six percent whole person impairment (Ex. 1, p. 188-190).

III. ANALYSIS

In the extensive record in this case, the worker’s progress was documented, but not by the Petitioner. For example, the physical therapist documented progress through functional capacity evaluations on December 15, 1999, March 13, 2000, and April 4, 2000 (Ex. 1, pp. 543-546). However, the Petitioner’s work was not supported with objectively measured and demonstrated functional gains.

The Petitioner did not link the manipulations to recovery progress by appropriate re-evaluation of the treatment. Also, he included none of the documentation listed in 28 TAC §134.1001 (e)(3)(C). For example, there are no diagrams of pain locations, notes about decreased pharmacological use, or descriptions of increased sitting or standing tolerance.

In the ALJ’s opinion, the STG requires documentation for the specific type of service provided. Although it may be difficult to distinguish improvement gained from concurrent physical medicine treatments, the STG requires documentation that shows objective and continued improvement from the manipulations. The Petitioner’s notes in this case do not meet those standards; thus, the Petitioner did not meet his burden of proof, and his appeal should be denied.

IV. FINDINGS OF FACT

1. (1)The Petitioner, Curtis Adams, D.C., appealed the decision of the Texas Workers’ Compensation Commission Medical Review Division denying reimbursement of $1,632.00 for spinal manipulations.
2. (2)
3. (1)The worker whom the Petitioner treated was injured on________, and at the time, the worker’s employer had workers’ compensation coverage with the Carrier.
4. (1)The worker began treatment with the Petitioner on August 17, 1999.
5. (1)This appeal involves thirty-four dates treatment dates from January 6, 2000, through April 5, 2000.
6. (1)For all the manipulations, the Petitioner billed $48.00 under CPT code 99213-MP, identified as an intermediate office visit with manipulation.
7. (1)The worker also participated in physical therapy from January 6, 2000, through February 4, 2000, and in work conditioning from February 8, 2000, to March 7, 2000.
8. (1)The Petitioner’s treatment records almost uniformly describe decreased range of motion, hypertonic musculature, and swelling in the thoraco-lumbar spine and the lumbo-sacral spine.
9. (1)As for the worker’s progression, the notes refer to slight improvement without listing any objective data.
10. (1)Apart from repetitive summary data, the Petitioner’s records did not include the types of documentation listed in 28 Tex. Admin. Code (TAC) §134.1001 (e)(3)(C).
11. (1)The Petitioner did not link the manipulations to recovery progress by appropriate re-evaluation of the treatment. 28 TAC §134.1001(e)(2)(A).
12. (1)The Spine Treatment Guideline requires documentation for the specific type of service provided. 28 TAC§134.1001(e)(2)(A).
13. (1)Although it may be difficult to distinguish improvement gained from concurrent physical medicine treatments, the STG requires documentation of objective and continued improvement from the manipulations.
14. (1)Notice of the hearing on the Petitioner’s appeal was sent to all parties on June 29, 2001.
15. (1)The hearing convened as scheduled on March 19, 2002.

V. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401, et seq.
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Act §413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
4. The Petitioner had the burden of proof in this matter. 28 TAC §148.21(h).
5. The Petitioner’s notes did not document objective or quantified substantive and continued improvement as treatment continued. 28 TAC §134.1001(e)(3)(E).
6. The Petitioner did not meet his burden of proving the spinal manipulations were reasonable and necessary. The Act §408.021.
7. The Petitioner’s request for additional reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that the request of Curtis Adams, D.C., for reimbursement of $1,632.00, is denied.

Signed this 17^th day of May 2002.

SARAH G. RAMOS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

APPENDIX

The Spine Treatment Guideline, 28 TEX. ADMIN. CODE §134.1001, in Subsection (e)(2)(A) provides:

Not withstanding any other provision of this section, treatment of a work related injury must be:

(1)adequately documented;

. . .

1. (6)objectively measured and demonstrate functional gains; and
2. (7)(1) consistent in demonstrating ongoing progress in the recovery process by appropriate re-evaluation of the treatment.

Subsection (e)(2)(E) provides:

Manipulation should be performed for the minimum appropriate duration. Minimum appropriate duration can be defined as that duration of time from the initiation of treatment which will result in continued improvement, and where additional treatment will not further benefit the injured employee. . . . Substantive and continued improvement over time from the treatment should be objectively documented. For examples of objective documentation refer to paragraph (3)(E) of this subsection. Additional treatment or further evaluation may be necessary if repeated efforts to withdraw from treatment results in documented significant deterioration of clinical status and the doctor has taken steps to determine that the patient is not physician/system dependent (i.e. behavioral consultation).

Section (e)(3)(C) describes treatment documentation. The treatment:

should be objective and illustrate compliance and substantive and continued improvement over time. Examples of this documentation may include but are not limited to:

(i) patient diaries documenting home program;

(ii) description of patient’s capabilities and clinical progress made;

(iii) notes describing quantified changes in pain behavior using tools such as pain drawings;

(iv) notes describing the patient’s demonstrated independent performance of provider instructed exercise;

(v) notes describing patient’s exercise such as “patient is walking 45 minutes”;

(vi) notes indicating increased ability in activities of daily living;

(vii) notes indicating increase in walking distance;

(viii) notes indicating increase in sitting time tolerance;

(ix) notes indicating increase in standing time tolerance;

(x) neck disability index results;

(xi) back disability index results; or

(xii) notes indicating reduction or decrease in pharmacological usage.

Finally, section (e)(3)(E) states:

Documentation for manipulation should show objective/quantified substantive and continued measures of improvement over time. The examples listed in paragraph (3)(C) of this subsection may be used to appropriately document progress.