DECISION AND ORDER

East Texas Chiropractic (Petitioner) appealed the findings and decision of the Texas Workers’ Compensation Commission’s Medical Review Division’s (MRD) designee, an independent review organization (IRO), which upheld the State Office of Risk Management’s (SORM) denial of reimbursement for certain dates of service rendered as part of a work hardening program provided to a workers’ compensation claimant (Claimant). SORM denied reimbursement alleging the required documentation of services was lacking. This decision and order finds reimbursement should be paid because the documentation was adequate.

I. NOTICE, JURISDICTION, AND PROCEDURAL HISTORY

There were no contested issues of notice or jurisdiction. Therefore, those matters are set forth only in the Findings of Fact and Conclusions of Law without further discussion.

On February 28, 2005, the hearing in this matter convened at the State Office Of Administrative Hearings (SOAH), 300 W. 15^th Street, 4^th Floor, Austin, Texas, before SOAH Administrative Law Judge (ALJ) Ann Landeros. Petitioner was represented by its attorney,

William Maxwell. Deputy General Counsel Red Tripp represented SORM. Commission Staff chose not to participate in the hearing. After receipt of evidence and argument, the record closed that date.

II. DISCUSSION

A. Background

Claimant sustained a compensable injury in ___. In ___, Claimant’s treating doctor, Keith Calda, D.C., requested SORM grant preauthorization for a six-week work hardening program for Claimant. Petitioner billed for the program under CPT codes 97545-WH and 97546-WH. Citing to the Commission rule at 28 TEX. ADMIN. CODE § 133.1(a)(E)(i), SORM denied reimbursement for services on October 20, 24, 27-30, November 7, 18, and December 1-3, 5, 10, 11, and 13, 2003, claiming Petitioner’s supporting documentation was inadequate.

The Commission’s IRO found the documentation lacked the required progress, improvement, anticipated treatment types and dates, complications and expected release date. Petitioner timely appealed the MRD’s Medical Dispute Resolution decision issued July 6, 2004, which adopted the IRO’s findings.

B. Legal Standards

Petitioner has the burden of proof in this proceeding. 28 TEX. ADMIN. CODE (TAC) §148.21(h) and (i); 1 TAC § 155.41. Pursuant to the Act, an employee who has sustained 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 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). Health care includes all reasonable and necessary medical services including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. ‘ 401.011(31).

To be reimbursed for a work hardening program, the provider must submit a complete medical bill. As defined in 28 TAC § 133.1(a)(3)(E)(i), a complete medical bill for a work hardening program contains legible supporting documentation ( unless previously provided to the insurance carrier or its agents) that contains a copy of progress notes and/or SOAP (subjective/objective assessment plan/procedure) notes, which shall substantiate the care given and the need for further treatments or services, and indicate progress, improvement, the date of the next treatments or services, complications, and expected release dates,

C. Evidence and Argument

Petitioner and SORM presented approximately the same documentary evidence, consisting of the documents reviewed by the IRO. Petitioner also presented the testimony of Petitioner’s principal, Michael Fleck, D.C.

The issue in this case is whether Petitioner’s documentation supporting its billings constituted a complete medical bill as that term in defined in 28 TAC §133.1(a)(3)(E)(i).

The documentary evidence showed that Petitioner submitted the following documentation (either with its original bill or with its request for reconsideration):

1) Treatment plan and goals for work hardening/conditioning program. This document listed the patient’s name, the date of treatment, all the exercises performed by time, distance, or weight (e.g., stretch-30 min; bike 30 minutes/1 mile; ab crunch-50 lbs); the goals to be met by next team meeting (e.g., increase range of motion on knee; increase miles on treadmill); and was signed by the therapists involved in the treatment. This document was submitted for each date of service.

2) Work Hardening/Conditioning Schedule. This document listed the exercises and activities by half hour intervals (e.g., 8:30-9:00 stretches).

3) SOAP notes. This multi-page document listed the patient’s name; date of service; patient’s subjective reports (e.g., “the patient presents today with dull, achy left knee pain.”); pain scale rating; total time spent in the program that day; a lengthy description of the exercise (e.g., ROM stretching exercises for the lumbar spine with description of the purpose of each exercise-“the pelvic clock is to exercise, stretches and strengthen the lower back. The patient rotates the hips to the floor to receive lower back stretching benefits. . . .”). For exercises involving distance, time, sets, weights, or repetitions, that information was listed for each exercise. The types of exercises described include back stretches, active range of motion stretching for the knee, cybex equipment, treadmill, hoist machines, and aquatic therapy. This document was submitted for each date of service.

In the preauthorization request, Dr. Calda wrote the following information about Claimant’s need for the program:

1) the problem to be addressed in work hardening (her psychological issues regarding her physical ability to function at work without pain);

2) her perceived ability to progress and her desire to return to unrestricted work;

3) her reduced range of motion and other reduced physical abilities (e.g., weight bearing abilities);

4) the goals to be achieved in the work hardening program (e.g., improve her ability to lift from 35 lbs. to 65 lbs.; improve range of motion in knee by 20 degrees of flexion);

5) the exercises and activities to be used (e.g., swimming, walking on a treadmill, bicycling, etc) and how those activities were expected to effect Claimant’s condition (e.g., “cable flex exercises of the upper and lower extremity to specifically strengthen these muscles and improve muscle tonicity to this area”);

6) the expected outcome-an increased level of functioning that would enable Claimant to return to the Texas Department of Corrections, where she had worked for 13 years;

7) the length of the program (6 weeks); and

8) the expected complications (e.g., severe deconditioning; psychological issues).

Petitioner argued that a “complete medical bill” includes not only the material submitted with the bill (in this case, the treatment plan and goals, the SOAP notes, and the schedule) but also the information in the previously submitted preauthorization request. Taken together, this material satisfies the requisites of 28 TAC §133.1(a)(3)(E)(i), according to Petitioner.

SORM argued that Petitioner’s documentation was inadequate. In particular, SORM criticized Petitioner’s failure to document the amount of time Claimant spent in each kind of stretching exercise. According to SORM, to have adequate documentation that constitutes a complete medical bill under the rule, Petitioner should have recorded how long Claimant did the pelvic clock, the hamstring stretch, etc.

Petitioner is correct that the information in the previously submitted preauthorization request must be considered in determining whether the carrier had a complete medical bill. According to 28 TAC § 133.1(a)(3)(E)(i), to constitute a complete medical bill, the documentation submitted with the bill need only contain information not previously provided to the carrier. Therefore, the issue is whether, taken together, Petitioner’s treatment plan and goals, SOAP notes, schedule, and preauthorization request provided all the information required by 28 TAC §133.1(a)(3)(E)(i).

The evidence established that Petitioner submitted adequate documentation to support its billings. The purpose of the rule is to ensure a carrier has sufficient proof that the claimant received a day’s worth of activities reasonably related to conditioning the claimant to return to work and established the efficacy of the program so that continued therapy was justified. Petitioner submitted

a copy of the SOAP notes, which, along with the treatment plan and goals, substantiated the care given, the need for further treatment, and discussed Claimant’s progress and improvement. Because the work hardening program lasted six consecutive weeks, the date of the next treatment (the work day) was obvious from the SOAP and treatment plans. The expected release date was also obvious from the preauthorization request and the dates on the SOAP notes and treatment plan-it was six weeks from the first date of the program.

The preauthorization request explained in sufficient detail why Claimant needed the treatment; what the treatment consisted of; why it was anticipated those activities would be beneficial; what the goal of the program was; and what complicating factors existed. Reading these documents, SORM had sufficient information to determine that Claimant was participating in activities reasonably related to conditioning her to return to work, that the activities lasted throughout a work day, and that Claimant was benefitting from those activities.

There is no requirement in 28 TAC § 133.1 that renders documentation inadequate for failing to specify exactly how long a claimant holds a stretch. Petitioner’s general category of stretching exercises was sufficient. Additionally, SORM’s claim that Petitioner’s SOAH notes were inadequate because they were “canned” descriptions of the exercises is unwarranted. As the exercises were given repetitively over the course of six weeks, Petitioner’s use of prepared descriptions was an efficient technique for conveying the necessary information with a minimum of cost and effort. The Commission’s rules do not mandate that Petitioner write novel compositions to accompany each billing.

Petitioner submitted adequate documentation to support its billings under CPT codes 97545 and 97546 for the work hardening services rendered Claimant on October 20, 24, 27-30, November 7, 18, and December 1-3, 5, 10, 11, and 13, 2003.

III. FINDINGS OF FACT

1. In ___, Claimant sustained a knee injury compensable under the Texas Workers’ Compensation Act (Act).
2. At the time of the compensable inury, the State Office of Risk Management (SORM) provided workers’ compensation insurance for Claimant’s employer.
3. Claimant’s treating doctor, Keith Calda, D.C., wrote a letter to SORM dated January 23, 2001, requesting preauthorization for her to attend a work hardening program.
4. Dr. Calda’s preauthorization request contained the following information about Claimant’s participation in the work hardening program:

a) the problem to be addressed in work hardening (her psychological issues regarding her physical ability to function at work without pain);

b) her perceived ability to progress and her desire to return to unrestricted work;

c) her reduced range of motion and other reduced physical abilities (e.g., weight bearing abilities);

d) the goals to be achieved in the work hardening program (e.g., improve her ability to lift from 35 lbs. to 65 lbs.; improve range of motion in knee by 20 degrees of flexion);

e) the exercises and activities to be used (e.g., swimming, treadmills, bicycling, etc) and how those activities were expected to effect Claimant’s condition (e.g., “cable flex exercises of the upper and lower extremity to specifically strengthen these muscles and improve muscle tonicity to this area”);

f) the expected outcomeBan increased level of functioning that will enable Claimant to return to the Texas Department of Corrections, where she had worked for 13 years;

g) the length of the program (6 weeks); and

h) expected complications (e.g., severe deconditioning, psychological issues).

1. East Texas Chiropractic (Petitioner) provided Claimant work hardening services on October 20, 24, 27-30, November 7, 18, and December 1-3, 5, 10, 11, and 13, 2003.
2. Petitioner submitted the following information with each date of service billed for Claimant’s work hardening program:

a) Treatment plan and goals for work hardening/conditioning program. This document listed the patient’s name, the date of treatment, all the exercises performed by time, distance, or weight (e.g., stretch-30 min; bike 30 minutes/1 mile; ab crunch-50 lbs); the goals to be met by next date of service (e.g., increase range of motion on knee; increase miles on treadmill); and was signed by the therapists involved in the treatment. This document was submitted for each date of service.

b) Work Hardening/Conditioning Schedule. This document listed the exercises and activities by half hour intervals (e.g., 8:30-9:00 stretches).

c) SOAP notes. This multi-page document listed the patient’s name; date of service; patient’s subjective reports (e.g., the patient presents today with dull, achy left knee pain.); pain scale rating; total time spent in the program that day; a lengthy description of the exercise (e.g., ROM stretching exercises for the lumbar spine with description of the purpose of each exerciseBthe pelvic clock is to exercise, stretches and strengthen the lower back. The patient rotates the hips to the floor to receive lower back stretching benefits. . . .). For exercises involving distance, time, sets, weights, or repetitions, that information is listed for each exercise. The types of exercises described include back stretches, active range of motion stretching for the knee, cybex equipment, treadmill, hoist machines, and aquatic therapy. This document was submitted for each date of service.

1. After SORM denied its request for reimbursement for certain dates of service in Claimant’s work hardening program as lacking the required documentation, Petitioner requested the Texas Workers’ Compensation Commission review the denial. That review produced the Independent Review Organization’s (IRO) decision, adopted by the Commission’s Medical Review Division, dated July 6, 2004, which upheld the denial of reimbursement for lack of documentation.
2. Petitioner timely appealed the decision.
3. Pursuant to the Commission’s notice of hearing, all parties appeared or were represented at the hearing held February 28, 2005.

IV. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers’ Compensation Act (Act), TEX. LABOR 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 of the Act and TEX. GOV’T CODE ANN. ch. 2003.
3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV’T CODE ANN. ch. 2001 and the Commission’s rules, 28 TEX. ADMIN. CODE (TAC) ” 133.305 and 133.308.
4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. ” 2001.051 and 2001.052.
5. Petitioner had the burden of proof in this proceeding. 28 TAC ” 148.21(h) and (I); 1 TAC ‘ 155.41.
6. The IRO had authority to review the parties’ positions and issue a decision pursuant to the Commission’s rule at 28 TAC ” 133.305 and 133.308.
7. Pursuant to the Act, an employee who has sustained 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 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).
8. Health care includes all reasonable and necessary medical services, including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. § 401.011(31).
9. To be reimbursed for a work hardening program, the provider must submit a complete medical bill. As defined in 28 TAC ‘ 133.1(a)(3)(E)(i), a complete medical bill for a work hardening program contains legible supporting documentation ( unless previously provided to the insurance carrier or its agents) containing a copy of progress notes and/or SOAP
10. (subjective/objective assessment plan/procedure) notes, which shall substantiate the care given and the need for further treatments or services, and indicate progress, improvement, the date of the next treatment or services, complications, and expected release dates.
11. Petitioner’s request for preauthorization, coupled with the SOAP notes, treatment plan and goals, and schedule, submitted with the billing for each date of service in dispute constituted a complete medical bill under 28 TAC ‘ 133.1(a)(3)(E)(i).
12. Petitioner is entitled to reimbursement for the work hardening services provided Claimant.

ORDER

It is ORDERED that the State Office of Risk Management shall reimburse East Texas Chiropractic for work hardening services rendered to Claimant on October 20, 24, 27-30, November 7, 18, and December 1-3, 5, 10, 11, and 13, 2003.

Signed March 11, 2005.

ANN LANDEROS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS