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At a Glance:
Title:
453-03-0093-m5
Date:
January 6, 2003
Status:
Retrospective Medical Necessity

453-03-0093-m5

January 6, 2003

DECISION AND ORDER

Spencer Sloane, D.C. sought reimbursement for work hardening services provided to Claimant___. Underwriters Insurance Company (the Carrier) denied payment. The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) denied reimbursement. Dr. Sloane appealed the MRD’s order. This decision concludes that Dr. Sloane is not entitled to reimbursement because he failed to establish that the services provided met the requirements of a work hardening program.

I.PROCEDURAL HISTORY

Administrative Law Judge Katherine L. Smith (ALJ) convened the hearing on November 6, 2002, at the William P. Clements Building, 300 West 15th Street, Austin, Texas. Dr. Sloane was represented by Douglas Pruett, an attorney. The Carrier was represented by Steven Tipton, an attorney. The Commission did not appear. The parties did not contest notice or jurisdiction. The ALJ admits into evidence Exhibit 5, which are billing records submitted by the Carrier on November 8, 2002, showing that the mental health care provider had been paid separately for the five individual counseling sessions. The record closed on November 8, 2002.

II.BACKGROUND

Claimant sustained a work-related injury on__________. She underwent approximately six weeks of work hardening treatment with Dr. Sloane. Dr. Sloane requested preauthorization of two additional weeks. The Carrier preauthorized ten visits. At issue are a work hardening session that occurred on December 11, 2000, during the initial six weeks; eight work hardening sessions conducted between January 5 and 17, 2001, that were preauthorized; and a functional capacity evaluation (FCE) performed on December 26, 2000. Dr. Sloane billed $3481.60 for the work hardening sessions and $200.00 for the FCE. The Carrier denied payment for the services using either denial code N--not appropriately documented, or T--not sufficiently documented to support medical necessity outside the parameters of the treatment guidelines. The MRD ruled that contrary to the Spine Treatment Guideline (STG),[1] Dr. Sloane failed to submit documentation (1) establishing that the work hardening program was tailored to meet the physical demands required by Claimant’s job or to a job that she would most likely enter; (2) indicating that the treatment was interdisciplinary, including the participation of a licensed physical therapist or mental health provider; and (3) establishing the amount of time Claimant participated in each activity.[2]

III. DISCUSSION

A. Dr. Sloane’s position

Dr. Sloane complains that the Carrier failed to provide sufficient notice of its denial when it used the generic codes T and N. Dr. Sloan asserts that carriers must also include an explanation of the missing documentation to allow the provider to correct the error. Dr. Sloane asserts that he submitted a complete bill in accordance with 28 Tex. Admin. Code §133.1(a)(3)(E)(i). Dr. Sloane asserts further that even if the Carrier properly disputed the bill using code N, he has since provided enough information with the submission of Exhibit 4 to satisfy the objection raised. Dr. Sloane argues further that use of code T was inappropriate because medical necessity had already been established with the Carrier’s preauthorization of the work hardening treatment.

Dr. Sloane also complains that the MRD improperly raised additional documentation issues not raised by the carrier. In response to the MRD’s findings, Dr. Sloane points to Exhibit 4 as evidence that Claimant received behavioral counseling, which is an element of a work-hardening interdisciplinary program. Dr. Sloane also disputes that he insufficiently documented Claimant’s job requirements. As page 14 of Exhibit 4 shows, Claimant’s job as an inspector required light duty. Dr. Sloane argues that she was even unable to perform that job, however, and that STG Ground Rule (e)(2)(L) allows a claimant to get back to a reasonable level of physical functioning. Dr. Sloane also complains that documenting the amount of time a claimant spends in each activity is just a recommendation of the STG, not a requirement. All that is required is documentation showing substantive improvement. STG Ground Rule (e)(3)(D).

B. Carrier’s position

Although the Carrier admits that the work hardening program had been preauthorized and, therefore, was considered to be medically necessary, Carrier argues that payment is not guaranteed unless the medical documentation shows that work hardening was actually performed, which is why use of denial code T was appropriate. Carrier asserts that it gave Dr. Sloane sufficient notice that his documentation was inadequate when it included the note “must be interdisciplinary” on the explanation of benefit in addition to using denial codes N and T. Ex. 1 at 56, 60, 78, 83. Carrier argues further that even with the admission of Exhibit 4, which established that behavioral counseling had been provided, there was no documentation showing that any vocational assistance had been provided.

C. ALJ’s Analysis

Work hardening is an individualized, highly structured, goal-oriented treatment program designed to maximize the ability of the person receiving the treatment to return to work. Work hardening programs are interdisciplinary and intended to address the functional, physical, behavioral, and vocational needs of the injured worker. The Commission has adopted rules governing work hardening programs. The rules, found in the STG and Medical Fee Guideline (MFG), relate to, among other things, when work hardening is appropriate, how such programs are to be administered and billed, and what documentation is required of work hardening providers.[3]

Although Dr. Sloane submitted evidence in this proceeding indicating that he provided behavioral counseling, the evidence fails to show that the program met Claimant’s vocational needs. According to MFG Medicine Ground Rule II. E., work hardening is appropriate for a person whose level of functioning due to an injury interferes with his or her ability to perform specific tasks in the work place. When determining whether an injured worker is an appropriate candidate for work hardening, a health care provider should identify specific tasks required in the work place and then test the worker’s ability to perform those tasks. The record lacks a description of Claimant’s job duties and the extent to which the injury prevented her from doing her job. Dr. Sloane did not obtain a job description from Claimant’s employer. He only obtained a description of the occupation of inspector from the Ergos job description program of the U.S. Department of Labor, which provides little or no information about her job duties.

Also troubling is the lack of information regarding a job for which Claimant was being prepared. Although Dr. Sloane contends that the STG only requires that an injured worker be restored to a reasonable level of physical functioning pursuant to STG Ground Rule (e)(2)(L), the STG also requires that documentation show substantive and continued improvement over time correlating to a job that Claimant would likely enter upon completion of the program. STG Ground Rule (e)(3)(D). In this case there was no such documentation. And contrary to MFG Medicine Ground Rules II. E. 6 and 7, which require that a treatment plan be prepared and modified when needed, the SOAP[4] notes fail to show a comprehensive treatment plan with stated goals describing (a) Claimant’s condition at the start of the program; (b) the job simulation activities that she would perform during the program; and (c) the improvement that was projected at the end of the program that would allow her return to work. The only evidence of a goal was a brief statement that Claimant was unable to perform light level job requirements. Ex. 1 at 159.

The MFG Medicine Ground Rules also provide that daily treatment and response to treatment be documented and reviewed to ensure continued progress. Ground Rule II. E. 8. Although Dr. Sloane’s work hardening notes document daily treatment, the notes demonstrate little, if any, progress during the program or Claimant’s response to the treatment. As specified by the STG, documentation for work hardening “should show objective substantive and continued improvement over time. . . .” Ground Rule (e)(3)(D). Although documenting the amount of time that a claimant participated in each work hardening task is not mandated in the ground rules, some documentation or evidence of progress is required. STG Ground Rule (e)(3)(C). In this case there was none.

Furthermore, the MFG Medicine Ground Rules also provide that there be a exit/discharge summary. Ground Rule II. E. 9-10. Although Dr. Sloane performed an FCE on December 26, 2000, a final one was not performed that might have shown progress or whether Claimant was fit to return to work at the conclusion of the program.

Accordingly, the ALJ finds that Dr. Sloane has not established that the services provided met the definition of or requirements of the work hardening provisions in MFG Medicine Ground Rule II. E.The ALJ also finds that Carrier’s use of the denial codes N and T and the statement “must be interdisciplinary” sufficiently notified Dr. Sloane that he failed to supply adequate documentation showing that the treatment provided met the criteria of an interdisciplinary program as required by the MFG. Thus, the Carrier satisfied the requirements of 28 TAC 133.304(c) and Tex. Lab. Code Ann. § 408.027(d) (Vernon 1996 & Supp. 2002).

IV. FINDINGS OF FACT

  1. Claimant, an inspector, sustained a compensable injury on_______.
  2. At the time of the injury, Claimant’s employer had its workers’ compensation insurance through Underwriters Insurance Company (Carrier).
  3. Spencer Sloane, D.C. treated Claimant with approximately six weeks of work hardening, including a session on December 11, 2000.
  4. Dr. Sloane performed a functional capacity evaluation (FCE) on December 26, 2000, and requested preauthorization of two additional weeks of work hardening.
  5. The Carrier preauthorized ten visits.
  6. Claimant was treated with eight work hardening sessions between January 5 and 17, 2001.
  7. Dr. Sloane submitted a claim to the Carrier in the amount of $3681.60 for the services provided to Claimant.
  8. The Carrier denied reimbursement for the work hardening session that occurred on December 11, 2000, the eight work hardening sessions conducted between January 5 and 17, 2001, and the FCE performed on December 26, 2000.
  9. The Carrier denied payment for the services using either denial code N--not appropriately documented, or TB not sufficiently documented to support medical necessity outside the parameters of the treatment guidelines, and the phrase “must be interdisciplinary.”
  10. On November 7, 2001, Dr. Sloane appealed the Carrier’s reimbursement denial to the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission
  11. On July 10, 2002, the MRD concluded that Dr. Sloane failed to submit documentation: (1) establishing that the work hardening program was tailored to meet the physical demands required by Claimant’s job or to a job that she would most likely enter; (2) indicating that the treatment was interdisciplinary, including the participation of a licensed physical therapist or mental health provider; and (3) establishing the amount of time Claimant participated in each activity.
  12. On July 26, 2002, Dr. Sloane filed a request for a hearing.
  13. The Commission sent notice of the hearing to the parties on September 16, 2002. The hearing notice informed the parties of the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing was to be held; the statutes and rules involved; and the matters asserted.
  14. The primary goal of work hardening is to prepare an individual to return to work.
  15. Dr. Sloane failed to show that his program met provided Claimant with vocational assistance.
  16. Claimant’s job duties were not specified.
  17. The extent to which the injury prevented Claimant from doing her job is not known.
  18. Dr. Sloane failed to prepare an individualized treatment plan establishing specific goals for Claimant to achieve in the work hardening program to allow her to return her to work, including the job simulation activities that she would perform and the projected improvement hoped for.
  19. No documentation was presented detailing Claimant’s progress in the program or her response to the treatment, including duration of the tasks performed and what changes needed to be made in the treatment plan to bring about improvement.
  20. No FCE was performed that might have shown progress or whether Claimant was fit to return to work at the conclusion of the program.

V. 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. Dr. Sloane timely filed a notice of appeal of the MRD decision, 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. Dr. Sloane had the burden of proving the case by a preponderance of the evidence, pursuant to 28 TAC §148.21(h) and (i).
  6. The Carrier satisfied the requirements of 28 TAC 133.304(c) and Tex. Lab. Code Ann.§ 408.027(d) (Vernon 1996 & Supp. 2002) when it used denial codes N and T and the statement “must be interdisciplinary” to notify Dr. Sloane that his documentation was inadequate.
  7. Dr. Sloane failed to prove that the services rendered to Claimant were interdisciplinary in nature according to the work hardening provisions of the Medical Fee Guideline (MFG) Medicine Ground Rule II. E.
  8. Dr. Sloane failed to prove the services provided met the requirements of MFG Medicine Ground Rules II. E. 6 and 7.
  9. Dr. Sloane failed to meet the documentation requirements of MFG Medicine Ground Rule II. E. 8-10 and STG Ground Rule (e)(3)(C) and (D).
  10. Based on the foregoing findings of fact and conclusions of law, Dr. Sloane did not prove that his claim for $3481.60 should be reimbursed.

ORDER

It is hereby ordered that Dr. Spencer Sloane’s request for reimbursement is denied.

Signed this 6th day of January 2003.

KATHERINE L. SMITH
Administrative Law Judge
State Office of Administrative Hearing

  1. 28 Tex. Admin. Code § 134.1001.
  2. The MRD also ruled that services billed under CPT code 99082 were not entitled to reimbursement. Dr. Sloane withdrew his appeal of that ruling.
  3. Medical Fee Guideline Medicine Ground Rule II. E. at 28 Tex. Admin. Code §134.201.
  4. SOAP notes are narrative, usually hand-written notes made and maintained by a health care provider when a patient makes an office visit. “S” stands for subjective (patient’s description of condition); “O”stands for objective description (provider’s description, usually based on tests or examination performed by or at the direction of provider); “A”stands for the provider’s assessment; and “P” stands for the plan of treatment proposed by the provider.
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