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Title: 

453-04-8655-m5

Date: 

March 23, 2005

Type: 

Retrospective Medical Necessity

453-04-8655-m5

DECISION AND ORDER

SLT Chiropractic Associates (Provider) appealed the findings and decision of the Texas Workers’ Compensation Commission’s (Commission’s) designee, an independent review organization (IRO), which found that the treatments provided to ___a workers’ compensation claimant (Claimant), were not medically necessary health care. This decision finds that the treatments provided Claimant were not medically necessary.

I. NOTICE, JURISDICTION, AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction or notice. Those issues are set out in the Findings of Fact and Conclusions of Law.

The hearing in this matter convened on March 15, 2005, before State Office of Administrative Hearings Administrative Law Judge (ALJ) Katherine L. Smith. Sheryl Tollenaar, D.C., appeared on behalf of the Provider. Robert Josey, an attorney, represented Royal Insurance Company of America (Carrier). The record closed the same day.

II. DISCUSSION

A. Background

Claimant was employed as a data entry clerk when she sustained a compensable injury on____, to her right wrist and shoulder. She was diagnosed with over-use syndrome and carpal tunnel syndrome. Provider began treating Claimant in September 2001. The treatments in dispute were provided from February 12 to March 12, 2002. The Carrier denied reimbursement. Noting that there were no x-ray reports, special reports, office visit reports or therapy notes, the IRO upheld the denial because the medical records did not provide clinical documentation supporting the medical necessity of the procedures that were billed.

B. Analysis

Dr. Tollenaar testified particularly about the services provided on February 28, 2002, and billed under the following CPT[1] codes: 99199–unlisted special services ($600.00); 99082–travel ($7.08); and 99080-WC–special report ($25). According to Dr. Tollenaar, she checked into and was allowed to bill for accompanying Claimant to an independent medical examination (IME) performed by Hooman Sedighi, M.D., to observe and protect the Claimant. She testified that the need for her to attend was justified by the conflicting report that she wrote on March 4, 2002, of the examination in comparison to that written by Dr. Sedighi. Dr. Tollenaar claimed that the reports differ on what she observed and what Claimant said.

Despite Dr. Tollenar’s testimony, the necessity of her attending the IME is not apparent in her report. For example, no mention was made of what Claimant said. Furthermore, the differences between her report and Dr. Sedighi’s are not obvious to the lay reviewer. And although Dr. Tollenaar states that she was given permission to bill for her attendance, there is no evidence in the record of that permission.[2]

With regard to the three radiological exams provided on February 21, 2002, and billed as CPT codes 72070, 73070, and 73110, the ALJ notes, as did the IRO, that no x-ray reports were provided in support of the billing.

Provider also billed for office visits of February 12, 21 and March 7 and 12, using CPT code 99213, and for physical medicine treatments. When a healthcare provider bills for one of the three highest level office visits, which includes CPT code 99213, and for physical medicine treatment, the Commission’s rules require the healthcare provider to submit the following: progress or SOAP[3] notes substantiating the care given and the need for further treatment and services and indicating progress, improvement, the date of the next treatment and services, complications, and expected release date.[4] Moreover, use of CPT code 99213 is appropriate only when two of the following occurs: an expanded problem-focused history, an expanded focused examination, and medical decision making of low complexity.[5] Although Dr. Tollenaar testified that her hand written notes support the treatment provided, the notes document neither an expanded problem-focused history, nor an expanded focused examination. Furthermore, the notes contain no discussion about what was needed for further treatment and no indication of Claimant’s progress, improvement, or complications. In addition, the treatment notes do not document why joint mobilization and myofascial release were being provided on March 7 and 12, 2002.[6]

The ALJ finds, therefore, that Provider failed to prove that the medical treatments provided between February 12 to March 12, 2002, were medically necessary and denies reimbursement of the disputed claims.

III. FINDINGS OF FACT

  1. Claimant ___sustained a compensable injury on____, to her right wrist and shoulder. She was diagnosed with over-use syndrome and carpal tunnel syndrome.
  2. SLT Chiropractic Associates (Provider) began treating Claimant in September 2001.
  3. Royal Insurance Company of America (Carrier) denied reimbursement for treatments that Provider provided Claimant from February 12 to March 12, 2002.
  4. Provider appealed to the Texas Workers’ Compensation Commission (Commission), which referred the dispute to its designee, an independent review organization (IRO).
  5. The IRO upheld the denial in a decision issued July 16, 2004, because the medical records did not provide clinical documentation to support the medical necessity of the procedures that were billed.
  6. Provider appealed the MRD’s decision on August 5, 2004.
  7. On August 31, 2004, the Commission issued the notice of hearing, which stated the date, time, and location of the hearing and cited to the statutes and rules involved, along with a short, plain statement of the factual matters involved.
  8. Dr. Tollenaar’s report dated March 4, 2002, failed to document the need for her to accompany Claimant to the independent medical evaluation that Dr. Sedighi performed on February 28, 2002.
  9. No x-ray reports were provided to support the billing for three radiological exams provided on February 21, 2002.
  10. The medical records documenting the office visits provided Claimant on February 12, 21 and March 7 and 12, 2002, document neither an expanded problem-focused history, nor an expanded focused examination.
  11. The medical records documenting the office visits provided Claimant on February 12, 21 and March 7 and 12, 2002, do not substantiate the need for the care given.
  12. The treatment notes do not substantiate why joint mobilization and myofascial release were being provided Claimant on March 7 and 12, 2002.
  13. The treatments provided to Claimant between February 12 to March 12, 2002, were not shown to be reasonably required by the nature of Claimant’s injury.

IV. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction over this matter pursuant to the Texas Workers’ Compensation act (Act) to(k) of the Act and Tex. Lab.CodeAnn. § 413.031.
  2. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(k) of the Act and Tex. Gov’tCodeAnn. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
  4. Provider had the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i); 1 TAC § 155.41.
  5. When a healthcare provider bills for an office visit using CPT code 99213 and for physical medicine treatments, the healthcare provider must submit progress or SOAP notes substantiating the care given and the need for further treatment and services, and indicating progress, improvement, the date of the next treatment and services, complications, and expected release date. 28 Tex. Admin. CODE §133.1.
  6. Use of CPT code 99213 requires that two of the three occur during an office visit: an expanded problem-focused history, an expanded focused examination, and medical decision making of low complexity. 1996 Medical Fee Guideline, 28 TAC § 134.201.
  7. Based upon findings of fact nos. 8-13, the treatments provided to Claimant that included special services, radiological exams, office visits, joint mobilization, and myofascial release from February 12 to March 12, 2002, were not shown to be medically necessary health care under Tex. Lab. Code Ann. §§ 401.011 and 408.021(a).
  8. Based upon the foregoing findings of fact and conclusions of law, Provider failed to prove that the medical treatments provided to Claimant between February 12 to March 12, 2002, were medically necessary.

ORDER

IT IS THEREFORE, ORDERED that SLT Chiropractic Associates’ request for reimbursement in this case is denied.

Signed March 23, 2005.

KATHERINE L. SMITH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Current procedural terminology.↑
  2. See Pet. Ex. 1 at 31-34, 36-37.↑
  3. Subjective/objective/assessment/plan.↑
  4. 28 Tex. Admin. Code (TAC) § 133.1.↑
  5. 1996 Medical Fee Guideline, 28 TAC § 134.201.↑
  6. Pet. Ex. 1 at 27, 28, 42, and 43.↑