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At a Glance:
Title:
453-02-2929-m5
Date:
October 18, 2002

453-02-2929-m5

October 18, 2002

DECISION AND ORDER

This proceeding concerns an appeal by Continental Casualty Company (Carrier) from the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (Commission). The MRD determined that Central Dallas Rehab (Central) was entitled to reimbursement for office visits, manipulation treatments, and an X-ray provided to Claimant____. This decision concludes that Central is not entitled to reimbursement for the X-ray and office visits that included manipulation treatments because the services provided were not sufficiently documented, but that Central is entitled to reimbursement for two office visits provided to evaluate Claimant’s medical condition.

I. NOTICE AND JURISDICTION

There were no contested issues of notice or jurisdiction. Therefore, those issues are addressed in the Findings and Conclusions without further discussion here.

II. PROCEDURAL HISTORY

The hearing on the merits was held on August 19, 2002, in Austin, Texas at the State Office of Administrative Hearings (SOAH), William P. Clements Office Building, 300 W. 15th Street, Austin, Texas, with Administrative Law Judge (ALJ) Katherine Smith presiding. Carrier appeared through its attorney, James Loughlin. Central appeared through its attorney, Scott C. Hilliard. The record closed the day of the hearing.

III. BACKGROUND

Claimant sustained a work-related injury to his right knee on________. Claimant was seen by Dean Allen, D.C. at Central on September 21, 2000, at which time an X-ray was taken of the right knee. Claimant received chiropractic manipulations at Central during ten office visits from September 25 to November 27, 2000. Central billed a total of $666.00 for the services provided. Carrier denied reimbursement using the codes V and U for unnecessary treatment and T for not being pursuant to the treatment guidelines. Central’s request for Medical Dispute Resolution of the denial was received by the Commission on September 21, 2001. The MRD issued its decision on April 2, 2002, ordering reimbursement in the amount of $666.00. The Carrier appealed the decision on April 11, 2002, and the Commission issued its Notice of Hearing on May 10, 2002.

IV. DISCUSSION

A. Carrier’s Position and Evidence

Carrier is not contesting reimbursement for the initial office visit of July 21, 2000, and the billing for a report, which totals $121.00 of the $660.00 dispute. Carrier is contesting reimbursement for the X-ray taken during that office visit (because of lack of documentation) and the ten subsequent office visits during which manipulations were provided. Carrier asserts that chiropractic manipulations were not medically necessary treatment for Claimant’s knee injury. Relying on Central’s medical and billing records, Carrier notes that the primary diagnosis was a knee sprain/strain. Ex. 1 at 54, 45. Referring to page 42 of the Commission’s Lower Extremities Treatment Guideline (LETG),[1] Carrier notes that the list of appropriate treatments does not include manipulations. The only diagnoses in the LETG where manipulation is an appropriate treatment are neuropathy and arthritis. LETG at 54, 63. Carrier points out that although the LETG recognizes that some injured workers may be “found to be outside the guidelines’ parameters,” “cases exceeding the guidelines’ level of treatment shall be subject to more careful scrutiny and review and shall require documentation of the special circumstances justifying that treatment.” Ground Rule (e)(1). Carrier argues that Central’s medical records contain insufficient documentation justifying manipulation treatments outside the LETG. Carrier also points out that even though Claimant had arthroscopic surgery on his knee on November 9, 2000, Dr. Dean did not mention surgery in the medical notes written at that time.

B. Central’s Position and Evidence.

In response, Central notes that the X-ray taken on July 21, 2000, was necessary to obtain a proper diagnosis. Central asserts further that in addition to the manipulations, Claimant’s condition was being evaluated weekly while awaiting preauthorization for additional physical therapy. Central argues that the necessity for the treatments provided was addressed in Dr. Allen’s letters. Ex. 1 at 77, 82, 83, and 92. Central argues further that the office visits of November 21 and 27, 2000, were absolutely necessary to evaluate Claimant’s surgery.

C. ALJ’s Analysis

The issue in this case is whether the X-ray, office visits, and chiropractic manipulations were shown to be medically necessary in accordance with the provisions of the LETG. Although the Ground Rules of the LETG are not meant to be rigid, treatment provided outside its parameters must be sufficiently documented. Ground Rule (e)(1).

Ground Rule (e)(2)(A) provides further that “treatment of a work-related injury must be:”

  1. (1)adequately documented;
  2. (2)evaluated for effectiveness and modified based on clinical changes;
  3. (3)provided in the least intensive setting;
  4. (4)cost effective;
  5. (5)consistent with this guideline which may include providing a documented clinical rationale for deviation from this guideline;
  6. (6)objectively measured and demonstrate functional gains; and
  7. (7)consistent in demonstrating ongoing progress in the recovery process by appropriate re-evaluation of the treatment.

Ground Rule (e)(3)(B) concerns more specifically the type of documentation that is required:

Documentation shall be provided by the health care provider to determine the level of care to be provided and the necessity for that care. The elements of the documentation may include:

(i)a description, including the events surrounding that injury and the extent and severity of that injury;

(ii)a description of any pre-existing condition(s), complicating conditions and/ or any non-related conditions;

(iii)a treatment plan, including proposed methods of treatment, expected outcomes, and probable duration of treatment;

(iv)updates to the treatment plan as needed, including the clinical progress of the injured worker, and any revisions needed to the treatment plan based on the injured worker’s response to treatment;

(v)education/information provided to the injured worker regarding his or her injury and treatment plan, and the injured worker’s compliance with this treatment plan; and

(vi)documentation substantiating the need for deviation from the guideline, if necessary.

Although it is reasonable for an X-ray to have been taken at an initial office visit, the medical record lacks any indication why it was necessary and what the findings were. As for the manipulations, as noted by the Carrier, the LETG does not include manipulations as a listed treatment for a knee sprain/strain, and Central’s treatment notes provide no justification for why manipulations were being provided outside of the LETG. Ground Rule (e)(3)(B) requires that there be not only documentation for treatment provided outside the guideline, but that a treatment plan be laid out and updated. The only explanation for the office visits is provided in a May 16, 2002, letter in which Dr. Dean wrote, “While we were waiting for pre-authorization [of additional physical therapy] I scheduled [Claimant] to come in one time per week so I could provide pain relief and monitor him while he was resting from work.” Ex. 1 at 92.[2]

Even though Central suggests that other viable reasons existed for the weekly office visits, the medical notes contain no such explanation, however. Other than the manipulations, the medical records do not indicate what other treatments were being provided to relieve Claimant’s pain. Why Claimant needed weekly medical evaluations at a time when he was not working also is not clear.

The ALJ notes that Dr. Dean provided more specific information in the May 16, 2002, letter with regard to the office visits of November 15 and 27, 2000. Dr. Dean noted that he met with Claimant following the surgery and that Claimant’s pain had lessened, but that the swelling and instability were still present.[3] Dr. Dean also wrote that he gave Claimant a focused examination on November 27, 2000, to determine Claimant’s current status and capabilities for subsequent treatment planning. Id. The ALJ is willing to accept Central’s after-the-fact explanation of what occurred during those two office visits, but it is troubling that the medical notes made at the time of the treatment are virtually identical to those written before the surgery and do not mention the recent surgery or the purposes stated in the letter.

Based on the evidence presented, the ALJ concludes that the Carrier proved by a preponderance of the evidence that medical necessity for the office visits of September 25; October 2, 9, 16, 23, and 30; and November 6 and 21, 2000, which included manipulations, and the X‑ray of September 21, 2000, had not been shown according to the requirements of the LETG. Reimbursement is, therefore, not required.

The ALJ further concludes that the evidence shows that the office visits of November 15 and 27, 2000, were medically necessary, warranting reimbursement in the amount of $96.00. Although Central billed for the November 27, 2000, visit using CPT code 99214,[4] which is reimbursed at $71.00, the explanation for the visit does not meet the criterion of presenting a problem of moderate to high severity required by CPT 99214. Therefore the ALJ is recommending reimbursement of $48.00 for the November 27, 2000, visit pursuant to CPT code 99213, which is what Central billed for the November 15, 2000, visit.

V. FINDINGS OF FACT

  1. Claimant sustained an injury to his right knee in a work-related accident on _________.
  2. At the time of the injury, Claimant’s employer had its workers’ compensation insurance through Continental Casualty Company (the Carrier).
  3. Claimant was seen by Dean Allen, D.C. at Central Dallas Rehab (Central) on September 21, 2000, at which time an X-ray was taken of Claimant’s right knee.
  4. Claimant received chiropractic manipulations at Central during ten office visits from September 25 to November 27, 2000.
  5. Central billed a total of $666.00 for the services provided. Carrier denied reimbursement using the codes V and U for unnecessary treatment and T for not being pursuant to the treatment guidelines.
  6. Central’s request for Medical Dispute Resolution of the denial was received by the Texas Workers’ Compensation Commission (the Commission) on September 21, 2001.
  7. The Commission’s Medical Review Division (MRD) issued its decision on April 2, 2002, ordering reimbursement in the amount of $666.00.
  8. The Carrier timely appealed the MRD decision on April 11, 2002.
  9. The Commission issued a Notice of Hearing on May 10, 2002. The notice informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved in the matter.
  10. Dr. Dean diagnosed Claimant with a knee sprain/strain.
  11. The Commission’s Lower Extremities Treatment Guideline (LETG) does not include manipulations as a listed treatment for a knee sprain/strain.
  12. Central’s treatment notes provide no documentation substantiating the need for chiropractic manipulations as a treatment for Claimant’s knee sprain/strain and provide no treatment plan outlining the need for the chiropractic manipulations.
  13. Central’s treatment notes provide no explanation for the weekly office visits beyond providing manipulations.
  14. No documentation was provided indicating the need for and the results of the X-ray taken of Claimant’s knee on September 21, 2000.
  15. Claimant underwent arthroscopic surgery to the knee on November 9, 2000.
  16. In a letter dated May 16, 2002, Dr. Dean explained the need for the office visit of November 15, 2000, to evaluate Claimant’s knee after the surgery.
  17. In the letter dated May 16, 2002, Dr. Dean explained the need for the office visit of November 27, 2000, to determine the next course of treatment for Claimant.
  18. Although Central billed for the November 27, 2000, visit using CPT code 99214, which is reimbursed at $71.00, the explanation for the visit does not meet the criterion of presenting a problem of moderate to high severity as required by CPT 99214.
  19. Pursuant to CPT code 99213, the Maximum Allowable Reimbursement for the office visits of November 15 and 27, 2000, is $48.00 for each visit.

VI. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented, pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. §413.031.
  2. 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. Lab. Code Ann. §§ 402.073 and 413.031(k) and Tex. Gov't Code Ann. ch. 2003.
  3. The Carrier requested a hearing, as specified in 28 Tex. Admin. Code (TAC) § 148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov't Code Ann. ch. 2001 and 28 TAC § 148.4(b).
  5. The Carrier had the burden of proving by a preponderance of the evidence, pursuant to 28 TAC § 148.21(h) and (i), that the services provided were not medically necessary and should not be reimbursed
  6. An employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the compensable injury as and when needed. The employee is specifically entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Tex. Lab. Code Ann. § 408.021(a).
  7. Ground Rule (e)(3)(B) of the Lower Extremities Treatment Guideline (LETG), 28 TAC § 134.1003, states that “Documentation shall be provided by the health care provider to determine the level of care to be provided and the necessity for that care. The elements of the documentation may include: . . . (iii) a treatment plan. . . ; (iv) updates to the treatment plan. . . ; (vi) documentation substantiating the need for deviation from the guideline. . . .”
  8. The Carrier proved that no documentation or treatment plan substantiated the need for the X-ray taken on September 21, 2000, and the office visits, which included manipulation treatments, of September 25; October 2, 9, 16, 23, and 30; and November 6 and 21, 2000, to relieve Claimant’s condition, as is required by LETG Ground Rule (e)(3)(B)(iii), (iv), and (vi).
  9. Based on Findings of Fact Nos. 10 - 14 and Conclusions of Law Nos. 7 and 8, the Carrier met its burden of showing that the X-ray and office visits including manipulation treatments for which reimbursement is sought did not meet the requirements set out in the LETG.
  10. Therefore, the X-ray and the office visits of September 25, October 2, 9, 16, 23, and 30,
  11. November 6 and 21, 2000, were not medically necessary, as required by Tex. Lab. Code
  12. Ann. § 408.021, and the Carrier is not liable for their reimbursement.
  13. Based on Findings of Fact Nos. 15 - 17 and Conclusion of Law No. 6, Central provided sufficient justification of the medical necessity of the office visits of November 15 and 27, 2000, as required by Tex. Lab. Code Ann. § 408.021.
  14. Based on Findings of Fact Nos. 18 and 19 and Conclusion of Law No. 11, Central is entitled to reimbursement of $96.00 for medically necessary services.
  15. ORDER

It is hereby ordered that Continental Casualty Company is not required to reimburse Central Dallas Rehab for the X-ray taken on September 21, 2000, and for the office visits of September 25; October 2, 9, 16, 23, and 30; and November 6 and 21, 2000, but is required to reimburse $96.00 for the office visits of November 15 and 27, 2000.

Signed this 18th day of October 2002.

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

  1. The LETG is adopted in 28 Tex. Admin. Code (TAC) §134.1003.
  2. Central suggests that there are other letters justifying the office visits, but those letters were written by Cassandra Jackson, who references the SOAP notes and appears to be an office worker who would not be qualified to attest to the necessity of the medical treatment. Ex. 1 at 10-11, 77-80, 81-82, 83-84, 85-86, 87-88, and 89-90.
  3. Presumably the date of this office visit was November 15, 2000, although it is not stated in the letter.
  4. CPT is Current Procedural Terminology, which is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. The CPT code at issue comes from the 1996 Medical Fee Guideline, which was adopted in 28 TAC§ 134.201.
End of Document
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