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At a Glance:
Title:
453-02-3129-m5
Date:
October 24, 2002
Status:
Retrospective Medical Necessity

453-02-3129-m5

October 24, 2002

DECISION AND ORDER

This case is a dispute over whether reimbursement is appropriate for certain procedures rendered to____. (Claimant) at the facility of Champion Rehabilitation (Provider) on November 19, 2001, and November 21, 2001. Provider billed American Zurich Insurance Company (Carrier) for certain physical therapy procedures administered to Claimant which Carrier denied. The amount in controversy is $696.00.

The hearing convened on August 29, 2002, before Steven M. Rivas, Administrative Law Judge (ALJ). Provider appeared and was represented by Iris Forest. Carrier appeared and was represented by Steven Tipton, attorney. The record closed the same day.

In this Order, the ALJ concludes Provider is entitled to a reimbursement of $348.00 for the treatment rendered to Claimant on November 21, 2001, at its facility.

I.DISCUSSION

Background Facts

On_______, Claimant____., sustained a compensable injury. The circumstances of Claimant’s injury are not in dispute. At some point, Claimant was prescribed to undergo physical therapy at the facilities of Provider as part of his on-going treatment following his injury.

On November 1, 2001, Carrier forwarded a letter to Gregory Davidovich, M.D., indicating it had given preauthorization for four sessions of thoracic physical therapy to be completed between November 1, 2001, and November 30, 2001, at the Provider’s facility.[1] Provider billed Carrier for physical therapy procedures performed on Claimant on November 13, 2001, and November 16, 2001, which Carrier paid.

Provider additionally billed Carrier $348.00 per day for therapy procedures performed on Claimant on November 19, 2001, and November 21, 2001, which Carrier denied. The procedures administered on both days and performed at Provider’s facility were billed as CPT codes 97113, 97110, and 97530.

Provider sought reimbursement for the procedures administered to Claimant at its facility on November 19, 2001, and November 21, 2001, and filed a request for Medical Dispute Resolution (MDR) with the Medical Review Division (MRD). On April 11, 2002, the MRD issued its Findings and Decision which denied Provider any reimbursement. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH) seeking reimbursement in the amount of $696.00.

B. Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (the “Act”) and provides the relevant statutory requirements regarding compensable treatment for workers’ compensation claims. In particular, Tex. Lab. Code Ann §408.021 provides in pertinent part: (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. The employee is specifically entitled to health care that: (1) cures or relieves the effects naturally resulting from the compensable injury; (2) promotes recovery; or (3) enhances the ability of the employee to return to or retain employment.

* * *

Under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.600(b)(1)(B), the insurance carrier is liable for all reasonable and necessary medical costs relating to the health care required to treat a compensable injury where preauthorization was approved prior to providing the health care.

* * *

Under theCommission’s rule at 28 Tex. Admin. Code §133.301(a), the insurance carrier shall not retrospectively review the medical necessity of a medical bill for treatment(s) and/or services for which the health care provider has obtained preauthorization under Chapter 134 of this title.

* * *

Under the Commission’s Medical Fee Guideline, Medicine Ground Rules (I)(A)(11)(a), CPT code 97110 is defined as therapeutic exercises used to develop strength and endurance, range of motion and flexibility. Under the same rules at (I)(A)(9)(b), this type of procedure is considered a physical medicine activity where supervision by the doctor or health care provider is required.

* * *

Under the Commission’s Medical Fee Guideline, Medicine Ground Rules (I)(A)(11)(b), CPT code 97530 is defined as direct (one on one) patient contact by the provider with the use of dynamic activities to improve functional performance.

* * *

Under the Commission’s Medical Fee Guideline, CPT code 97113 is defined as aquatic therapy with therapeutic exercises.

* * *

The Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001(e)(2)(A)(i-vi), provides that treatment of a work-related injury must be adequately documented, evaluated for effectiveness, provided appropriately, cost effective, and objectively measured.

* * *

Under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001(e)(2)(D), physical medicine treatment is required to meet the definitions/criteria set forth in the current Medical Fee Guideline. Documentation of the injured employee’s compliance and substantive and continued improvement should be included in reports already being submitted. This documentation does not justify the continuation of therapy.

* * *

The Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001(e)(3)(C)(i-xii), provides examples of documentation may include patient diaries, progress notes, and notes on other patient activities like walking, standing, and sitting.

Evidence and Analysis

The issue in this matter is whether Provider should be reimbursed for three separate procedures administered to Claimant on two dates of service.

Preauthorization

Carrier conceded it gave preauthorization for Claimant’s physical therapy procedures that were performed at Provider’s facility on the dates in question but argued it can deny reimbursement for procedures that are not medically necessary or properly documented. The MRD Findings and Decision agreed with Carrier in denying reimbursement.

Medical Necessity

Carrier denied reimbursement based on peer reviews drafted by Drs. James Hood and Mike O’Kelley. Both doctors indicated no further physical therapy was necessary to treat Claimant for his injuries. The peer review by Dr. Hood was dated November 1, 2001, the same date Carrier issued its preauthorization letter for treatment at Provider’s facility.[2] The Carrier most likely received this review following its issuance of preauthorization. If the Carrier had any recourse, such as withdrawing or amending its original preauthorization, no steps were taken by the Carrier. The issue of withdrawing preauthorization was not addressed by either party at the hearing; therefore, it is not discussed in this Order. The peer review by Dr. O’Kelley relied on the November 1, 2001, review of Dr. Hood, and was thus issued subsequent Carrier’s to issuance of preauthorization.[3]

The letter sent to Provider by Carrier dated November 1, 2001, complies with the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.600 in that it authorized the type of service to be performed (physical therapy), the number of appointments (4 sessions), and the time period to complete the authorized services (November 1, 2001, through November 30, 2001). Additionally, under § 134.600, the insurance carrier is liable for the costs of health care required to treat a compensable injury where preauthorization was approved prior to providing the health care.

Provider asserted under the Commission’s rule at 28 Tex. Admin. Code §133.301(a), the Carrier can not “retrospectively” deny reimbursement of medical services based on medical necessity when Provider obtained preauthorization under Chapter 134 of this title. Since the preauthorization was obtained under Chapter 134, Carrier is unable to deny reimbursement based on medical necessity after it issued preauthorization.

Proper Documentation

Carrier additionally argued it could deny reimbursement because Provider did not properly document the treatment rendered to Claimant on November 19, 2001, and November 21, 2001. Carrier argued the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001 requires that treatment of a work related injury must be adequately documented. Carrier argued that Provider did not adequately and properly document the treatment rendered to Claimant. Specifically, Carrier pointed out Provider had no documentation in compliance of the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001, which indicates documentation of treatment may include patient diaries, progress notes, and notes on other patient activities like walking, standing, and sitting. Because Provider had not properly documented the treatment rendered to Claimant, Carrier denied reimbursement.

At the hearing, Provider asserted it properly documented the treatment rendered to Claimant at its facility and pointed to Progress Notes on pages 9 and 10 of the certified record. The notes indicate Claimant was seen on November 13, 16, 19, and 21, 2001. From the notes it appears Claimant underwent therapy exercises on November 19 and 21. The notes also include Claimant’s performance and response to the therapeutic exercises on November 19, 2001. However, for Claimant’s visit on November 21, 2001, there are no remarks about the treatment, if any, rendered to Claimant. The notes of November 21, 2001, indicate Claimant still had pain in the thoracic region but do not note whether Claimant underwent any treatment for that pain. The notes only mention a functional capacity evaluation to be performed on a later date.

Proper documentation exists for Claimant’s visit on November 19, 2001, because there are notes outlining the treatment rendered to Claimant and an evaluation of Claimant’s condition following that treatment in compliance with 28 Tex. Admin. Code § 134.1001(e)(2)(A). For example, the notes indicate Claimant had no difficulty during the session this day.

The documentation for Claimant’s visit on November 21, 2001, actually indicates no treatment was rendered that day. In fact, part of the notes for November 21, 2001, read, “continued therapy was denied at this time.”[4] Notations are made regarding a function capacity evaluation to be performed on November 29, 2001, but there are no notes that reference or evaluate Claimant’s condition following treatment.

Conclusion

Carrier cannot deny reimbursement based on medical necessity after it issued preauthorization for four sessions of thoracic physical therapy to be performed on Claimant pursuant to the Commission’s rule at 28 Tex. Admin. Code §133.301(a).

Carrier is entitled to deny reimbursement for the office visit that did not properly document the treatment rendered to Claimant under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001.

Provider is entitled to reimbursement of $348.00 for the treatment rendered to Claimant on November 21, 2001, at Provider’s facility.

III. FINDINGS OF FACT

  1. Claimant,____., suffered a compensable injury on________.
  2. American Zurich Insurance Company (Carrier) insured Claimant on the date of the injury.
  3. At some point following the injury, Claimant was prescribed thoracic physical therapy to be performed at Champion Rehabilitation (Provider).
  4. On November 1, 2001, Carrier issued a letter preauthorizing four sessions of thoracic physical therapy to be performed at Provider’s facility between November 1, 2001, and November 30, 2001.
  5. Claimant visited Provider on November 13, 16, 19, and 21, 2001, for thoracic physical therapy. Provider billed Carrier for the treatment rendered to Claimant on these dates and Carrier paid for the treatment rendered on November 13 and 16 only.
  6. Provider billed Carrier a total of $696.00 for treatment it performed at Provider’s facility on November 19 and 21, under CPT codes 97530, 97110, and 97113, which Carrier denied. Each date of service was billed at $348.00.
  7. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement for the treatment rendered to Claimant.
  8. On April 11, 2002, the Commission’s Medical Review Decision (MRD) found Provider was not entitled to reimbursement based on no medical necessity and improper documentation.
  9. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH) seeking reimbursement.
  10. Notice of the hearing was sent May 31, 2002.
  11. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  12. The hearing convened on August 29, 2002, before Steven M. Rivas, Administrative Law Judge (ALJ). Provider appeared and was represented by Iris Forest. Carrier appeared and was represented by Steven Tipton, attorney. The record closed the same day.
  13. Provider received preauthorization for the treatment rendered to Claimant at its facility on November 19, 2001, and November 21, 2001.
  14. Provider is entitled to reimbursement of $348.00 for the services rendered to Claimant at Provider’s facility on November 19, 2001.

IV. 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 Tex. Lab. Code Ann. § 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 Provider, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code § 148.21(h).
  5. Under theCommission’s rule at 28 Tex. Admin. Code §133.301(a), the insurance carrier shall not retrospectively review the medical necessity of a medical bill for treatment(s) and/or services for which the health care provider has obtained preauthorization under Chapter 134 of this title.
  6. Under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001(e)(2)(A)(i-vi), treatment of a work related injury must be adequately documented, evaluated for effectiveness, provided appropriately, cost effective, and objectively measured.
  7. Carrier is unable to deny reimbursement based on medical necessity under the Commission’s rule at 28 Tex. Admin. Code §133.301(a).
  8. Carrier may deny reimbursement if proper documentation does not exist for treatment rendered to Claimant under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001.
  9. Proper documentation exists for Claimant’s visit on November 19, 2001 under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001(e)(2)(A).
  10. Proper documentation does not exist for Claimant’s visit on November 21, 2001, under the Commission’s Spine Treatment Guideline found in 28 Tex. Admin. Code § 134.1001(e)(2)(A).
  11. Pursuant to the foregoing Findings of Fact and Conclusions of Law, Provider is entitled to $348.00 reimbursement for the treatment rendered to Claimant at Provider’s facility on November 19, 2001.
  12. Pursuant to the foregoing Findings of Fact and Conclusions of Law, Provider is not entitled reimbursement for the treatment rendered to Claimant at Provider’s facility on November 21, 2001.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Champion Rehabilitation, is entitled to receive reimbursement of $348.00, from the Carrier, American Zurich Insurance Company, for the treatment rendered to Claimant on November 19, 2001, at Provider’s facility.

Signed this 24TH day of October, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

  1. Letter from Carrier to Dr. Gregory Davidovich dated November 1, 2001. The letter was offered by Provider at the hearing and admitted without objection by Carrier.
  2. Peer review by James F. Hood, M.D., dated November 1, 2001. Pages 14 - 17 of the certified record.
  3. Peer review by Mike O’Kelley, D.C., contains no date but indicates he reviewed Dr. Hood’s peer review of November 1, 2001. Pages 18 - 20 of the certified record.
  4. Progress Notes of Claimant. Page 10 of the Certified Record.
End of Document
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