AMERICAN EYECARE, Petitioner - Appellant, vs. DEPARTMENT OF HUMAN SERVICES, Defendant - Appellee.
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IN THE COURT OF APPEALS OF IOWA
No. 8-712 / 07-1698
Filed October 15, 2008
AMERICAN EYECARE,
Petitioner-Appellant,
vs.
DEPARTMENT OF HUMAN SERVICES,
Defendant-Appellee.
________________________________________________________________
Appeal from the Iowa District Court for Lee (South) County, Michael J.
Schilling, Judge.
Petitioner appeals from the district court‟s judicial review of agency action
upholding the department of human services‟ finding that petitioner improperly
billed for comprehensive eye exams. AFFIRMED.
David A. Hirsch, Des Moines, for appellant.
Thomas J. Miller, Attorney General, and Diane M. Stahle, Assistant
Attorney General, for appellee.
Considered by Sackett, C.J., and Miller and Potterfield, JJ.
2
SACKETT, C.J.
American Eyecare, appeals from the district court‟s ruling denying its
petition for judicial review of the decision issued by the Department of Human
Services (DHS) that found American Eyecare incorrectly coded certain exams as
comprehensive
and
thus
over-billed
Medicaid.
DHS
determined
a
comprehensive eye exam required “the initiation of a diagnostic and treatment
program” and found American Eyecare‟s exams on a substantial number of
patients did not include such treatment but were nonetheless billed as
comprehensive exams. We affirm.
I.
BACKGROUND AND PROCEEDINGS.
American Eyecare provides
optometry services and treats patients covered by Medicaid. In order to be paid
for its services, it must submit bills to DHS describing the services and
procedures rendered for each Medicaid-covered patient.
DHS oversees the
operation of Iowa‟s Medicaid program and requires optometrists to categorize the
services given to patients according to certain codes. The codes, also called
CPTs, are defined and explained in a manual, the American Medical Association
Physicians‟ Current Procedural Terminology. As part of its oversight duties, DHS
performs audits to ensure proper billing and is authorized to seek reimbursement
when an audit reveals a Medicaid provider has been overpaid.
ACS State
Healthcare (ACS) performs the audits on behalf of DHS.
In 2005, ACS performed an audit on the billings submitted by Dr. Kevin
Jennings, an American Eyecare optometrist.
ACS determined Jennings had
overcharged Medicaid in several respects and sought reimbursement of the
3
overpayment. Specifically pertinent to this appeal, ACS alleged Jennings coded
and billed exams as “comprehensive ophthalmological services” when they
should have been coded and billed as “intermediate ophthalmological services.”
ACS sought to recoup $26,095.52 in overpayments for the “upcoding.” 1 ACS
extrapolated this figure by using an audit sample of two billing statements
containing the error and then inferring all bills that charged for comprehensive
exams during the audit period were improperly upcoded.
American Eyecare
denied any inappropriate billing and appealed ACS‟s findings.
An administrative hearing on the dispute was held on April 29, 2005. On
behalf of DHS, an ACS supervisor, a DHS program manager, and a DHS policy
specialist appeared. On behalf of American Eyecare, its operations manager
appeared. The administrative law judge found, and the agency agreed, that DHS
was entitled to recoupment for most of the errors ACS identified, including the
upcoding of examinations.2
American Eyecare petitioned for judicial review,
challenging only the finding that it improperly upcoded examinations. It urged the
exams in question were comprehensive and involved the “initiation of diagnostic
and treatment program[s]” because glasses were prescribed for the patients, and
1
At the time Jennings examined the patients, providers were reimbursed $71.14 for
each comprehensive examination and $47.24 for each intermediate examination. DHS
sought to recoup the difference between these amounts, $23.90, for approximately 964
patients.
2
The administrative law judge and agency determined DHS was entitled to recoup
funds from American Eyecare for (1) upcoding eye examinations, (2) failing to provide
proper documentation confirming services were actually rendered for services charged,
(3) inappropriate billing of the refractive state, and (4) inappropriate billing of the
dispensing fee. DHS was denied recoupment for “inappropriate use of the RP modifier”
because the administrative law judge and agency found that DHS‟s materials did not
give American Eyecare notice or instructions clarifying that “reimbursement for broken
glasses would be denied unless their . . . records documented the broken glasses could
not be repaired or indicated the extent of the damage to the frames.”
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refraction testing was done.
It reasoned the exams analyzed qualified as
comprehensive because Jennings‟s decisions to not provide treatment and
instead order a return visit in twelve months was the initiation of a treatment
program.
DHS maintained that these services did not meet the definition of
comprehensive exam under CPT codes in place in 2001 and 2002. It contended
that all services listed in the definition of a comprehensive exam must be
performed to qualify for this level of reimbursement, not just a prescription for
glasses. The district court affirmed. Noting the agency‟s interpretation of the
CPT definitions was entitled to deference, it found no irrational, illogical, or wholly
unjustifiable interpretation or application of law. It further concluded the agency‟s
finding was supported by substantial evidence and other relevant evidence was
not ignored. American Eyecare appeals.
II.
STANDARD OF REVIEW. Our judicial review of final agency action is for
correction of errors at law. Houck v. Iowa Bd. of Pharmacy Exam’rs, 752 N.W.2d
14, 16 (Iowa 2008). We apply the standards of the Administrative Procedure Act,
Iowa Code Chapter 17A, to the agency action to ascertain whether we reach the
same results as the district court. University of Iowa Hosps. & Clinics v. Waters,
674 N.W.2d 92, 95 (Iowa 2004). We will reverse or grant appropriate relief if
substantial rights of the person seeking relief have been prejudiced because the
agency has committed any of the errors listed in Iowa Code section 17A.19(10)
(2005).
American Eyecare has not specified which of these errors occurred
though we are able to discern the relevant sections from the substance of its
arguments. American Eyecare argues the court should not have deferred to the
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agency‟s interpretation of the codes, the services performed did meet the
definition of comprehensive exam contained in the CPT codes and DHS
manuals, and the agency‟s interpretation is absurd and illogical. Therefore, we
will analyze its claims according to sections 17A.19(10)(c), (f), and (i). These
sections allow us to grant the petitioner relief if the agency action is:
(c) [b]ased upon an erroneous interpretation of a provision
of law whose interpretation has not clearly been vested by a
provision of law in the discretion of the agency[,]
...
(f) [b]ased upon a determination of fact clearly vested by a
provision of law in the discretion of the agency that is not supported
by substantial evidence in the record before the court when that
record is viewed as a whole[, or]
...
(i) [t]he product of reasoning that is so illogical as to render
it wholly irrational.
Iowa Code § 17A.19(10)(c), (f), (i).
III.
ANALYSIS. Iowa‟s Medicaid program is governed by Iowa Code chapter
249A. It empowers and directs the DHS director to “adopt rules pursuant to
chapter 17A in determining the method and level of reimbursement for all
medical and health services referred . . . .” Iowa Code § 249A.4(9); Strand v.
Rasmussen, 648 N.W.2d 95, 102 (Iowa 2002). One such rule lists the services
optometrists are reimbursed for under the program and defines comprehensive
and intermediate exams.
Iowa Admin. Code r. 441-78.6.
However, Iowa
Administrative Code rule 441-79.1(7) states that physicians are reimbursed
according to a fee schedule “based on the definitions of medical and surgical
procedures given in the most recent edition of Physician‟s Current Procedural
Terminology (CPT).” (emphasis supplied). At the time Jennings performed the
6
exams that were audited, the distinguishing feature between the definitions of
intermediate
and
comprehensive
ophthalmological
services
was
that
comprehensive services required the “initiation of diagnostic and treatment
programs.”3 The 2001 American Medical Association CPT manual clarifies this
requirement:
3
The 2001 American Medical Association CPT manual provided the following:
Intermediate ophthalmological services describes an evaluation of a
new or existing condition complicated with a new diagnostic or
management problem not necessarily relating to the primary diagnosis,
including history, general medical observation, external ocular and
adnexal examination and other diagnostic procedures as indicated; may
include the use of mydriasis for ophthalmoscopy.
For example:
a. Review of history, external examination, ophthalmoscopy,
biomicroscopy for an acute complicated condition (e.g., iritis) not
requiring comprehensive ophthalmological services.
b. Review of interval history, external examination,
ophthalmoscopy, biomicroscopy and tonometry in established
patient with known cataract not requiring comprehensive
ophthalmological services.
Comprehensive ophthalmological services describes a general
evaluation of the complete visual system. The comprehensive services
constitute a single service entity but need not be performed at one
session. The service includes history, general medical observation,
external and ophthalmoscopic examinations, gross visual fields and basic
sensorimotor examination. It often includes, as indicated: biomicroscopy,
examination with cycloplegia or mydriasis and tonometry. It always
includes initiation of diagnostic and treatment programs.
Intermediate and comprehensive ophthalmological services constitute
integrated services in which medical decision making cannot be
separated from the examining techniques used. Itemization of service
components, such as slit lamp examination, keratometry, routine
ophthalmoscopy, retinoscopy, tonometry, or motor evaluation is not
applicable.
For example:
The comprehensive services required for diagnosis and treatment
of a patient with symptoms indicating possible disease of the visual
system, such as glaucoma, cataract or retinal disease, or to rule out
disease of the visual system, new or established patient.
(Underline emphasis supplied.)
7
Initiation of diagnostic and treatment program includes the
prescription of medication, and arranging for special
ophthalmological diagnostic or treatment services, consultations,
laboratory procedures and radiological services.
Special ophthalmological services describes services in which a
special evaluation of part of the visual system is made, which goes
beyond the services included under general ophthalmological
services, or in which special treatment is given.
Special
ophthalmological services may be reported in addition to the
general ophthalmological services or evaluation and management
services.
For example:
Fluorescein angioscopy, quantitative visual field examination,
refraction or extended color vision examination (such as Nagel‟s
anomaloscope) should be separately reported.
The parties have opposing views as to the meaning of “initiation of
diagnostic and treatment program.” DHS contends all of the services listed in the
definition must be performed to qualify as the initiation of a diagnostic and
treatment program. American Eyecare argues the definition only lists examples
of an initiation of a diagnostic and treatment program and that requiring all of the
listed services to be done to qualify for a comprehensive exam is an absurd
interpretation.
A.
Agency Discretion.
The parties first disagree as to whether
DHS‟s interpretation is entitled to deference under our judicial review. We “[s]hall
give appropriate deference to the view of the agency with respect to particular
matters that have been vested by a provision of law in the discretion of the
agency.” Iowa Code § 17A.19(11)(c). DHS argues, and the district court agreed,
its interpretation is entitled to deference because the department has been
clearly vested with discretion to construe the Medicaid Act. We agree that DHS
8
is charged with adopting rules to implement Medicaid and obliged to enforce the
program rules through audits. See Iowa Code § 249A.4 (mandating the director
of DHS to adopt rules for reimbursement of Medicaid service providers); Iowa
Code § 249A.7 (requiring the department of inspections and appeals to
cooperate with DHS to ensure audits comply with federal and state medical
assistance laws). However, these statutes do not explicitly give DHS ultimate
discretion in statutory and rule interpretations. See State v. Public Employment
Relations Bd., 744 N.W.2d 357, 360 (Iowa 2008); Mosher v. Dep’t of Inspections
& Appeals, Health Facilities Div., 671 N.W.2d 501, 508-09 (Iowa 2003) (finding
general delegations of regulatory power are not clear grants of discretion to
interpret laws). Nonetheless, we will give an agency‟s interpretations of statutes
and rules within its expertise limited deference. Madrid Home for the Aging v.
Iowa Dep’t of Human Servs., Div. of Med. Servs., 557 N.W.2d 507, 510-11 (Iowa
1996); see also Al-Khattat v. Eng’g & Land Surveying Examining Bd. of the State
of Iowa, 644 N.W.2d 18, 23 (Iowa 2002) (“[W]e defer to an agency‟s construction
of statutes and rules within the agency‟s expertise, unless the interpretation is
erroneous or unreasonable.”).
In our attempt to discern the meaning of “initiation of diagnostic and
treatment program,” “[w]e seek a reasonable interpretation that will best effect
the purpose of the statute and avoid an absurd result.” Public Employment
Relations Bd., 744 N.W.2d at 361. But our interpretation should not render any
part of the law superfluous. Id. If possible, we should give effect to every clause
and word of the rule and give plain meaning to words, phrases, and
9
punctuations. TLC Home Health Care, L.L.C. v. Iowa Dep’t of Human Servs.,
638 N.W.2d 708, 713 (Iowa 2002) (citations omitted). Turning to the definition of
“initiation of diagnostic and treatment program,” we note the words “includes” and
the conjunctive use of, “and,” indicate multiple types of services listed must be
performed to qualify as the initiation of a diagnostic and treatment program and
thus must be performed to be billed as a comprehensive exam.
The word
“includes” can operate to enlarge or restrict the meaning of a word. Id. “„Where
a general term is followed by the word „including,‟ which is itself followed by
specific terms, the intent may be one of limitation.‟”
Id. (quoting State Pub.
Defender v. Iowa Dist. Ct., 633 N.W.2d 280, 283 (Iowa 2001)). Here the general
term “initiation of diagnostic and treatment program” is followed by the word
“includes,” suggesting an intent to limit the class of services reimbursed as
comprehensive exams to those services listed.
Also, “[o]rdinarily, the word „and‟ is used as a conjunctive, requiring
satisfaction of both listed conditions.” Casteel v. Iowa Dep’t of Transp., Motor
Vehicles Div., 395 N.W.2d 896, 898 (Iowa 1986). We will disregard such strict
grammar rules if necessary to reach the legislative intent of a law but see no
reason to ignore the common meaning in this context. See id. (applying “and” as
conjunctive when there was no indication a contrary meaning was intended) and
compare In re Detention of Altman, 723 N.W.2d 181, 187 (Iowa 2006) (applying
“and” as disjunctive to achieve legislative purpose). Therefore, giving limited
deference to DHS‟s interpretation and under our rules of statutory construction,
we conclude the “initiation of a diagnostic and treatment program” in the 2001
10
CPT manual requires (1) the prescription of medication, (2) the arranging of
special ophthalmological diagnostic or treatment services, (3) consultations, (4)
laboratory procedures, and (5) radiological services.
B.
Substantial Evidence.
American Eyecare next contends the
services provided during the exams did meet the requirements of the “initiation of
a diagnostic and treatment program.” It argues that prescribing lenses qualifies
as the prescription of medication, and refraction testing constitutes “special
ophthalmological diagnostic or treatment service.” It also contends ordering a
return visit within twelve months should be considered the initiation of a
diagnostic and treatment program.
If the agency‟s findings of fact are “supported by substantial evidence in
the record as a whole,” we are bound by them. Grant v. Dep’t of Human Servs.,
722 N.W.2d 169, 173 (Iowa 2006). “Substantial evidence means the quantity
and quality of evidence that would be deemed sufficient by a neutral, detached,
and reasonable person . . . .”
Iowa Code § 17A.19(10)(f)(1).
The ultimate
question is not whether the evidence supports an alternative finding, but whether
the record supports the findings the agency actually made. Grant, 722 N.W.2d at
173; City of Hampton v. Iowa Civil Rights Comm’n, 554 N.W.2d 532, 536 (Iowa
1996).
As explained above, there are multiple requirements to satisfy the
“initiation of a diagnostic and treatment program” definition. Even if American
Eyecare performed some services, it did not perform others under the definition.
The patient records audited show no arrangements for consultations, laboratory
11
procedures, or radiological services. American Eyecare does not dispute that it
billed for comprehensive exams and was reimbursed at the comprehensive exam
rate. We find substantial evidence supports the agency findings that American
Eyecare did not initiate diagnostic and treatment programs for the exams in
question and was improperly reimbursed for the exams at the comprehensive
rate for which DHS is entitled to recoupment.
C.
Illogical Interpretation. American Eyecare‟s final argument is that
the agency‟s interpretation of “initiation of diagnostic and treatment program” is
the product of illogical reasoning. It contends DHS‟s interpretation requiring all
services, including x-rays, to be done under the definition of “initiation of
diagnostic and treatment program” is absurd. It reasons that comprehensive
exams “will virtually never” be performed under these requirements. However,
American Eyecare does not dispute that the definitions listed above were the
ones in effect during the time at issue. It does not dispute that it did not order
radiological services, arrange for consultations, or order laboratory work during
either examination. We do not find it absurd to give meaning to those words in
the CPT code definitions rather than disregard them as optional parts of a
comprehensive exam and conclude the agency‟s interpretation was not the
product of illogical reasoning.
IV.
CONCLUSION. We affirm the district court. Granting limited deference to
DHS‟s interpretation of “initiation of a diagnostic and treatment program” and
applying statutory rules of construction indicates the agency‟s determination is
not based on an erroneous interpretation of law and is not the product of illogical
12
reasoning.
We further conclude the record provides substantial evidence to
support DHS‟s finding that American Eyecare did not initiate any diagnostic or
treatment program during the exams at issue. Therefore, American Eyecare‟s
billing for comprehensive services on examinations where only intermediate
services were provided was improper and DHS is entitled to recoup the amount
overpaid.
AFFIRMED.
Miller, J., concurs specially; Potterfield, J., concurs.
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MILLER, J. (concurs specially)
I concur in the result.
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