The state Medicaid agency properly found that an optometrist and his employer improperly upcoded, billing for comprehensive assessments after providing only intermediate assessments; the agency's decision to recoup the overpayments was correct. The regulations and CPT codes defining comprehensive assessment required the initiation of a diagnostic and treatment program, which included the prescription of medication and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services. The provider furnished refraction testing, the prescription of lenses and an order for a follow-up visit in one year, but did not arrange for any additional consultations, laboratory work or radiological services. These services did not constitute initiation of a diagnostic and treatment program under the definition. Therefore, the agency's determination that comprehensive assessments were not performed was supported by substantial evidence and not based on either an erroneous interpretation of the law or illogical reasoning.
Source: American Eyecare v. Department of Human Services, Iowa App., Oct. 15, 2008.
For more information on this and related topics, consult the CCH® Medicare and Medicaid Guide.
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