DECISION AND ORDER

Main Rehab and Diagnostic (Main Rehab) seeks reimbursement of $1,644.00 for treatments and office visits provided a workers’ compensation claimant. The Administrative Law Judge (ALJ) orders reimbursement of the disputed amount, plus interest.

I. HISTORY AND ISSUES

The workers’ compensation claimant, ___(the Claimant), fractured her wrist when she slipped and fell on the job on ___. Her hand was placed in a cast for approximately six weeks. She was unable to return to work after that time, and began treatment with Main Rehab on February 15, 2002. She continued treatments through May 7, 2002.

The workers’ compensation carrier, Ace USA/ESIS (Ace), declined to reimburse Main Rehab for the services provided. The reasons for denial varied, and included Explanation of Benefits (EOB) Codes L (treatment not approved by treating doctor), R (treatment not related to the compensable injury), U (unnecessary treatment – without peer review), and V (unnecessary treatment – with peer review). Main Rehab filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission or TWCC), seeking reimbursement of $10,527.00. The Commission referred the medical necessity issues to an Independent Review Organization (IRO), which found some services were necessary and others not. The IRO did not

review all the disputed services, because Ace had not raised the issue of medical necessity for every date of service. The Commission’s Medical Review Division (the Division) implemented the IRO decision and reviewed the remaining disputes. It also found some services should be reimbursed and others not.

Ace did not request a hearing on the Division’s decision. Main Rehab requested a hearing regarding services and office visits for six dates, March 21-22 and 25-28, 2002. The Division had denied reimbursement, because it found Main Rehab had failed to provide documentation for those dates.^[1]

Main Rehab seeks reimbursement for the following services for each of the six dates:

CPT CodeMAR

99213 (office visitBproblems of low to moderate severity)$48.00

97265 (joint mobilization) 43.00

97250 (myofascial release/soft tissue mobilization) 43.00

97110 (4 units) (therapeutic procedures/exercises) 35.00 per unit

Multiplying those amounts over six dates produces the disputed amount of $1,644.

Ace had produced timely EOBs for only one of those dates, March 21, 2002. It had denied reimbursement for that date on the ground that the services were unrelated to the compensable injury (Code R).

After proper notice, the hearing was convened March 18, 2004. At the hearing, Ace argued the medical necessity of all services and treatments provided should be at issue, even though it had not sent timely EOBs questioning medical necessity for some of the dates and had not challenged the Division’s decision. The ALJ recessed the hearing to allow parties to brief those issues, and rejected

Ace’s arguments in Order No. 4, issued April 16, 2004. Therefore, the issues in the case were limited to the adequacy of the documentation, as raised by the Division in its decision, and to whether the services provided on March 21 were related to the compensable injury.

The hearing was reconvened July 27, 2004, and adjourned the same day.

II. ANALYSIS

Main Rehab argued the SOAP notes for all the disputed dates adequately documented the services rendered. Although the Division found no documentation for the disputed dates of service, SOAP notes for each of the dates are in evidence in this case. Ace contended the notes were inadequate because the language was identical from day to day. The diagnosis and treatments were identical each day, however. The ALJ would not expect a provider to compose a unique description for each day of identical services. The ALJ finds the SOAP notes adequately document the treatments and services provided the Claimant.

Ace concentrated especially on the office visits. CPT code 99213, under which Main Rehab seeks reimbursement, is described in the 1996 Medical Fee Guideline as:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; and expanded problem focused examination; medical decision-making of low complexity.

* * * *

Usually, the presenting problem(s) are of low to moderate complexity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

The SOAP notes do not expressly recite these elements for each date of service. However, the ALJ found the IRO’s discussion convincing on that subject. The IRO stated:

The office visits were all medically necessary, in that the doctor performed a brief exam, documenting objective findings, documenting case history or subjective complaints, and followed through on decision-making on every treatment date. The office visits documented objectively the need for therapeutic exercise for the dates of service 02/26/02 through 04/09/02.

The IRO did not address these particular dates, because Ace had not raised the issue of medical necessity for those dates. The SOAP notes for the dates the IRO addressed were identical to the notes for the disputed dates of service, however. Ace did not appeal the Division’s decision regarding the other dates. Nor did Ace challenge the adequacy of that documentation at the EOB level. Those facts, the IRO analysis, and the types of services provided lead the ALJ to find the documentation was adequate to support the 99213 office visit code for the disputed dates of service.

The ALJ finds Main Rehab adequately documented the office visits and services rendered the Claimant. The notes for March 21, 2002, also establish that the office visit and services rendered on that date were related to the compensable injury. Main Rehab should be reimbursed for the disputed dates of service.

III. FINDINGS OF FACT

1. The workers’ compensation claimant, ___(the Claimant), fractured her wrist when she slipped and fell on the job on ___.
2. The Claimant’s hand was placed in a cast for approximately six weeks. She was unable to return to work after that time, and began treatment with Main Rehab and Diagnostic (Main Rehab) on February 15, 2002.
3. The Claimant continued treatments with Main Rehab through May 7, 2002.
4. The workers compensation carrier, Ace USA/ESIS (Ace), declined to reimburse Main Rehab for the services provided.
5. The reasons for denial of reimbursement varied, and included Explanation of Benefits (EOB) Codes L (treatment not approved by treating doctor), R (treatment not related to the compensable injury), U (unnecessary treatment – without peer review), and V (unnecessary treatment – with peer review).
6. Main Rehab filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission or TWCC), seeking reimbursement of $10,527.00.
7. The Commission referred the medical necessity issues to an Independent Review Organization (IRO), which found some services were necessary and others not.
8. The IRO did not review all the disputed services, because Ace had not raised the issue of medical necessity for every date of service.
9. The Commission’s Medical Review Division (the Division) implemented the IRO decision and reviewed the remaining disputes. It also found some services should be reimbursed and others not.
10. Ace did not request a hearing on the Division’s decision.
11. Main Rehab filed a timely request for a hearing regarding services and office visits for six dates, March 21-22 and 25-28, 2002.
12. The Division had denied reimbursement for the six disputed dates, because it found Main Rehab had failed to provide documentation for those dates.
13. Main Rehab seeks reimbursement for the following services for each of the six dates:

CPT CodeMAR

99213 (office visitBproblems of low to moderate severity)$48.00

97265 (joint mobilization) 43.00

97250 (myofascial release/soft tissue mobilization) 43.00

97110 (4 units) (therapeutic procedures/exercises) 35.00 per unit

Multiplying those amounts over six dates produces the disputed amount of $1,644.

1. Ace produced timely EOBs for only one of the disputed dates, March 21, 2002.
2. Ace denied reimbursement for March 21, 2002, on the ground that the services were unrelated to the compensable injury (Code R).
3. Notice of the hearing was sent to the parties November 19, 2003.
4. 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.
5. The hearing was convened March 18, 2004, recessed for the parties to brief certain issues, and reconvened July 27, 2004. The hearing was adjourned and the record closed July 27, 2004.
6. Main Rehab adequately documented the treatments rendered the Claimant on the disputed dates of service.
7. Main Rehab adequately documented the use of CPT Code 99213 for the office visits on the disputed dates of service.
8. The office visit and services provided on March 21, 2002, were related to the Claimant’s compensable injury.

IV. CONCLUSIONS OF LAW

1. 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.
2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. ‘2001.052.
3. Under 28 TAC ‘148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to Tex. Lab. Code Ann.’413.031.
4. Main Rehab proved it is entitled to reimbursement of $1,644, plus interest, for office visits and services provided on the disputed dates of service.

ORDER

IT IS, THEREFORE, ORDERED, that Ace USA/ESIS reimburse Main Rehab and Diagnostic $1,644, plus interest, for office visits and services provided the Claimant on March 21-22 and 25-28, 2002.

Signed August 26, 2004.

HENRY D. CARD
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Main Rehab also requested a hearing regarding the Division’s denial of reimbursement for a paraffin bath provided February 25, 2002. At the hearing, it abandoned that request.↑