DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Cy-Fair Chiropractic seeks reimbursement of an additional $ 24,618 from Sentry Insurance Company (Carrier), for medical services rendered to Claimant___. from October 15, 1999, through October 13, 2000. The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) denied reimbursement for all charges except $213, because the documentation to support many of the services billed was insufficient or lacking. Petitioner appealed the denial. This decision agrees with MRD’s earlier determination.

Administrative Law Judge (ALJ) Ruth Casarez convened the hearing on November 5, 2002. A. Kent Rice, D.C., owner of Cy-Fair Chiropractic, and Topaz Lantz appeared by telephone for Petitioner. Attorney Janice Menzies represented Carrier. The hearing concluded, and the record was held open until November 12, 2002, for the parties to submit written closing arguments.

II. EVIDENCE AND BASIS FOR DECISION

The issue in this case is whether Petitioner complied with the Commission’s documentation requirements and should be reimbursed for the physical therapy, work hardening, and other services it provided to the Claimant.

The documentary evidence consisted of the 423-page certified record of the MRD proceeding. Dr. Rice testified on behalf of Petitioner. Having reviewed the documentation supplied by Petitioner, the ALJ finds that the remainder of its claim should be denied. The particular facts, reasoning, and legal analysis in support of this decision are set out below in the Findings of Fact and Conclusions of Law.

III. FINDINGS OF FACT

1. On__________, Claimant, a ____ for __________ in Houston, Texas, suffered a compensable injury when she tried to close the door to her delivery truck. She stepped on the bumper to grab the door handle and slipped.
2. When Claimant slipped, she hung onto the strap on the door and injured her right shoulder. She also injured her right knee when she hit it against the bumper.
3. Claimant’s injuries resulted in lumbar, shoulder, cervico-thoracic, and knee sprains.
4. _________ had workers’ compensation coverage with the Sedgwick Insurance Company at that time; it was succeeded by Sentry Insurance Company (Carrier).
5. Claimant’s symptoms consisted of back pain that radiated to her right leg, pain in her neck and right shoulder, and pain in her right knee.
6. On October 15, 1999, Claimant was examined by Christopher D. Boss, D.C., of Cy-Fair Chiropractic (Petitioner). Claimant was diagnosed with the sprains listed in Finding No. 3
7. Kent Rice, a chiropractor and owner of Petitioner, began treating Claimant. He and Dr. Boss developed a plan of conservative treatment for Claimant, consisting of chiropractic manipulations, traction, diathermy, myofascial release, and electrical muscle stimulation.
8. The following CPT Codes are assigned to the treatments indicated: manipulations-99213-MP; traction-97012; diathermy-97024; myofascial release-97250; electrical stimulation (unattended)-97014; and therapeutic activities-97530.
9. On November 4, December 6, 1999, and January 7, 2000, Dr. Boss re-examined Claimant and found muscle spasms and weakness, and decreased range of motion in the injured areas; on each date, he recommended conservative treatment be continued for another two weeks.
10. From October 15, 1999, through January 21, 2000, Petitioner rendered eight weeks or more of physical or occupational therapy to Claimant.
11. Commission rule 134.600 (h)(10) required preauthorization for physical treatment beyond eight weeks. Petitioner in this case did not obtain preauthorization for additional physical therapy, as required.
12. Petitioner sought pre authorizations to continue additional physical therapy for Claimant, but Carrier denied the requests on January 31, 2000, and March 17, 2000.
13. On January 20, 2000, and sometime in February 2000, Petitioner sought reconsideration from Carrier for continued outpatient physiotherapy.
14. No evidence was presented that Carrier gave favorable reconsideration to Petitioner’s requests.
15. Despite the denial of preauthorization and Carrier’s failure to reconsider and approve the treatment, Petitioner continued to administer physical therapy, including chiropractic manipulations during office visits to Claimant through October 12, 2000.
16. Petitioner did not submit daily progress notes to substantiate the medical necessity for continued physical therapy during office visits from October 15, 1999, to October 12, 2000.
17. Petitioner submitted some daily progress notes for some of Claimant’s office visits (CPT code 99213-MP) dated July 8, 14, 18, 21, and 31, 2000; August 2, 10, and 12, 2000; September 1, 4, 11, 25, and 29, 2000; and October 2, 4, 5, 9, and 12, 2000.^[1]
18. Petitioner enrolled Claimant in a work hardening program (CPT Code 97546-WH) on March 20, 2000, through April 28, 2000. Petitioner supplied no functional capacity evaluation report to justify the medical necessity for the program.
19. Medical Fee Guideline (MFG) Ground Rule II.E.8. requires that a provider document daily treatment and patient response to treatment for claimants in a work hardening program.
20. The only documenttion submitted by Petitioner of Claimant’s participation in the work hardening program was a AWeekly Patient Progress Work Hardening Report for dates March 20, through March 24, 2000.
21. Petitioner supplied no additional documentation to substantiate the medical necessity for the physical therapy and work hardening services provided, nor to show that Claimant made substantive and continued improvement over the course of the treatment.
22. Petitioner submitted the charges for the physical therapy, work hardening, and other services provided Claimant between October 15, 1999 through October 13, 2000, amounting to $24,831, to the Carrier.
23. The Carrier denied payment for the majority of the charges, indicating the treatments were not medically necessary.
24. Petitioner requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD) on December 19, 2000, seeking reimbursement for the medical treatments and services rendered to Claimant.
25. In filing his MRD request, Petitioner did not file a list of the charges in dispute in a table as required in Commission rule 133.305(e)(1)(G).
26. Petitioner did not submit for the dates of services in dispute the required medical records, e.g., descriptions of services rendered; Claimant’s response to the treatments; all requests for reconsideration sent to the Carrier; all responses from Carrier as well as copies of audit summaries sent by the Carrier, when it filed the request for dispute resolution, as required in Commission rule 133.305(e).
27. Despite the fact that Petitioner failed to comply with rule 133.305(e), on July 8, 2002, the MRD issued a decision granting reimbursement of $213 to Petitioner for some documented charges. However, itfound that much of the documentation supplied by Petitioner did not substantiate the medical necessity for many of the services that were billed.
28. On August 2, 2002, Petitioner timely appealed the MRD’s decision.
29. On August 30, 2002, the Commission sent a notice of hearing to the parties. The notice contained a statement of the time and place of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular section of the statutes and rules involved; and a short plain statement of the matters asserted.
30. The hearing referenced in Finding 29 was convened on November 5, 2002. A. Kent Rice, D.C., appeared on behalf of Petitioner; attorney Janice Menzies appeared for the Carrier. The hearing closed on November 12, 2002, with the filing of written closing arguments.

IV. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (the 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 § 413.031(d) of the Act; Tex. Gov’t Code Ann. ch. 2003 and 28 Tex.Admin. Code (TAC) chs. 148 and 149.
3. Petitioner timely appealed the MRD’s decision, pursuant to 28 TAC §148.3.
4. Pursuant to 28 TAC §133.305(e)(1) and Findings of Fact Nos. 25 and 26, Petitioner’s request for dispute resolution was not in proper form.
5. The notice of hearing sent by the Commission complied with the requirements of Tex. Gov’t Code § 2001.052 and 28 TAC §148.4(b).
6. Petitioner had the burden of proof to show by a preponderance of the evidence that it should prevail in this matter, pursuant to § 413.031 of the Act and 28 TAC §148.21(h) and (i).
7. Section 408.021 of the Act and 28 TAC § 134.1, provide that a health care provider is to bill carriers only for treatments and services rendered that are medically necessary to treat the compensable injury, and in accordance with Commission rules and guidelines.
8. The Medical Fee Guideline (MFG), effective April 1, 1996, applies in this case. The introduction to the MFG requires use of Current Procedural Terminology (CPT) codes and states that accurate coding of services is essential for proper reimbursement and that “reimbursement for services is dependent on the accuracy of the coding and documentation.”
9. CPT Code 99213(MP) requires that notes for an established patient office visit should include at least two of the following three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision making of low complexity. The modifier -MP shall be added to the Evaluation and Management (E/M) code when the first manipulation for the visit is performed.
10. Work hardening shall be billed as CPT Code 97545-WH for the first two hours of each session and Code 97546-WH for each additional hour.
11. MFG Medicine Ground Rule II(E), which relates to work hardening provides as follows:

* * * * * *

(1)Program [work hardening] supervision is provided by a licensed physical or occupational therapist or by a doctor. The program supervisor shall:

a. Provide direct on-site supervision of work hardening activities;

b. Participate in the initial and final evaluation of the patient;

c. Write the treatment plan for the patient and write changes to the plan based on documented changes in the patient’s condition;

d. Direct the interdisciplinary team when providing treatment and services; and

e. Review the patient’s program on a systematic basis.

(1)Daily treatment and patient response to treatment shall be documented and reviewed to ensure continued progress.

* * * * * *

(10)Exit/discharge summary shall delineate the injured worker’s:

a. Present functional status and potential; and

b. Functional status related to the targeted job, alternative occupations, or current job availability.

1. Petitioner’s documentation failed to comply with the requirement of MFG Medicine Ground Rule II.E. related to work hardening programs.
2. Petitioner failed to show through adequate documentation that the physical therapy, work hardening, and other services rendered were medically necessary and resulted in continued improvement in Claimant’s condition.
3. Petitioner failed to prove by a preponderance of the evidence that it was entitled to reimbursement for the remaining charges in its claim.
4. Based on the foregoing Findings of Fact and Conclusions of Law, Petitioner’s request for reimbursement beyond the amount granted by the MRD should be denied.

ORDER

It is hereby ordered that the appeal of Cy-Fair Chiropractic is denied. Carrier Sentry Insurance Company is ordered to pay Petitioner $213 as previously ordered by the MRD.

Signed this 23rd day of December 2002.

RUTH CASAREZ
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The daily notes (C. R. pp. 282-316) consist of multiple copies of virtually the same text with different dates, (the same misprints even appear on numerous “different” records). The progress notes are barely sufficient to comply with the Medical Fee Guideline CPT Code 99213 requirement that office notes involving such treatment reflect at least two of three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision making of low complexity.↑