The Issue Whether Petitioner was overpaid for those Medicaid claims which, according to the post-hearing submissions of the parties, remain in dispute.
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: Jay's Medical Center Jay's Medical Center (hereinafter referred to as "JMC") is a medical clinic located in a low income area in Miami. It is staffed by three physicians, including Shelley Wolland, D.O., the clinic's Medical Director, 6/ and several support staff. In general, the community JMC serves is poorly educated and has a relatively high incidence of medical problems. Approximately 7,000 members of the community receive medical services at JMC, with anywhere from 40 to 80 patients receiving services in a single day. Many of the clinic's patients are Medicaid recipients. The Provider Agreement JMC is now, and has been since May of 1990, when it entered into a Non- Institutional Professional and Technical Medicaid Provider Agreement with the Department, authorized to provide physician services, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) services, and family planning services to its Medicaid patients eligible to receive such services. The provider agreement between JMC and the Department provided as follows: The provider agrees that services will be provided to recipients of the Florida Medicaid Program without regard to race, color, religion, national origin, or handicap. The provider agrees to keep for 5 years complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and billing made under the Medicaid program and agrees to furnish the State Agency and Medicaid Fraud Control unit upon request such information regarding any payments claimed for providing these services. Access to the pertinent patient records and facilities by authorized Medicaid program representatives will be permitted upon reasonable request. All records relating to Medicaid recipients are to be held confidential as provided under 42 CFR 431.305 and 306. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, Medicaid compensable and of quality comparable to those furnished by the provider's peers, and the services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting a claim. The provider agrees to submit Medicaid claims in accordance with program policies and that payment by the program for services rendered will be based on the payment methodology in the applicable Florida Administrative Rule. The provider in executing this agreement acknowledges that he understands that payment of Florida Medicaid claims is made from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. The providers of Independent Laboratory, Portable X-Ray Services, Home Health Services, Hospice and Rural Health Clinic Services agree to furnish the Office of Licensure and Certifi- cation a completed copy of Form HCFA-1513 (Ownership and Control Interest Disclosure Statement) in accordance with 42 CFR 455.104. The providers of Prescribed Drug Services agree to bill the Medicaid program no more than usual and customary charges and on request, to provide access to usual and customary pricing information. The Department agrees to notify the provider of any major changes in Federal or State rules and regulations relating to Medicaid. Payment made by the State Agency shall constitute full payment for services rendered to recipients under the Medicaid program. This includes situations when no payment is made to physicians when Medicare coinsurance claims are adjudicated due to Medicaid's payment methodology. The only exception is in specific programs when Medicaid coinsurance is required from the recipient. The provider and the Department agree to abide by the Florida Administrative Code, Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and regulations. The agreement may be terminated upon thirty days written notice by either party. The Department may terminate this agreement in accordance with Chapter 120, F.S. This agreement becomes effective the date the signature of the authorized agent of the Office of Medicaid is affixed. The provider eligibility will be established at the latter of the date of licensure of the provider, if applicable, or ninety (90) days prior to receipt of the application. The provider shall be responsible for assuring that the signature on the claim form is appropriate for authorization. Persons authorized to submit Medicaid claims on behalf of the provider shall be limited to the provider, the provider's employees or authorized agent. Handbook Provisions Among the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement was the Medicaid Physician Provider Handbook (hereinafter referred to as the "MPP Handbook"). Chapter 10 of the MPP Handbook addressed the subject of "provider participation." Section 10.9 of this chapter provided as follows: RECORD KEEPING You must retain physician records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, treatment plans, prior authorization information, any third party claim information, x-rays, fiscal records, and copies of sterilization and hysterectomy consents. Medical records must contain the extent of services provided. The following is a list of minimum requirements: history, physical examination, chief complaint on each visit, diagnostic tests and results, diagnosis, a dated, signed physician order for each service rendered, treatment plan, including prescriptions for medications, supplies, scheduling frequency for follow-up or other services, signature of physician on each visit, date of service, anesthesia records, surgery records, copies of hospital and/or emergency records that fully disclose services, and referrals to other services. If time is a part of the procedure code prescription being billed, then duration of visit shown by begin time and end time must be included in the record. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the MPP Handbook addressed the subject of "covered services and limitations." Section 11.1 of this chapter provided as follows: INTRODUCTION The physician services program pays for services performed by a licensed physician or osteopath within the scope of the practice of medicine or osteopathy as defined by state law. The services of this program must be performed for medical necessity for diagnosis and treatment of an illness on an eligible Medicaid recipient. Delivery of the services in this manual must be done by or under the personal supervision of a physician or osteopath at any place of service. Personal supervision is defined as the physician being in the building when the service was rendered. The physician must sign and date the medical record either on the date of service or within 24 hours. Each service type listed has special policy requirements that apply specifically to it. These must be adhered to for payment. HCPCS CODES and ICD-9-CM CODES Procedure codes listed in Chapter 12 are HCPCS (Health Care Financing Administration Common Procedure Coding System) codes. These are based on the Physician's Current Procedural Terminology, Fourth Edition. Determine which procedure describes the service rendered and enter that code and description on your claim form. HCPCS codes described as "unlisted" are used when there is no procedure among those listed that describes the service rendered. Physician's Current Procedural Terminology, Fourth Edition, Copyright 1977, 1980, 1981, 1982, 1983, 1984, 1985, 1986, 1987 by the American Medical Association (CPT-4) is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. The Health Care Financing Administration Common Procedure Coding System (HCPCS) includes CPT-4 descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials contained in CPT-4 which are copyrighted by the American Medical Association. The Diagnosis Codes to be used are found in the International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM). A diagnosis code is required on all physician claims. Use the most specific code available. Fourth and fifth digits are required when available. There are six levels of service associated with the visit procedure codes. They require varying skills, effort, responsibility, and medical knowledge to complete the examination, evaluation, diagnosis, treatment and conference with the recipient about his illness or promotion of optimal health. These levels are: . Minimal is a level of service supervised by a physician. . Brief is a level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and exam. . Limited is a level of service used to evaluate a circumscribed acute illness or to periodically reevaluate a problem including a history and examination, review of effectiveness of past medical management, the ordering and evaluation of appropriate diagnostic tests, the adjustments of therapeutic management as indicated and discus- sion of findings. . Intermediate level of service pertains to the evaluation of a new or existing condition compli- cated with a new diagnostic or management problem, not necessarily related to the primary diagnosis, that necessitates the obtaining of pertinent history and physical or mental status findings, diagnostic tests and procedures, and ordering appropriate therapeutic management; or a formal patient, family or a hospital staff conference regarding the patient's medical management and progress. . Extended level of service requires an unusual amount of effort or judgment including a detailed history, review of medical records, examination, and a formal conference with the patient, family, or staff; or a comparable medical diagnostic and/or therapeutic service. . Comprehensive level of service provides for an in-depth evaluation of a patient with a new or existing problem requiring the development or complete reevaluation of medical data. This service includes the recording of a chief complaint, present illness, family history, past medical history, personal review, system review, complete physical examination, and ordering appropriate tests and procedures. 7/ Section 11.2 of Chapter 11 of the MPP Handbook provided in part, that "[t]reatment of an illness found by a physician during an EPSDT screening that requires considerable office time (30 minutes or more) to treat, may also be billed as an office visit on the appropriate claim form." Another of the "manuals of the Florida Medicaid Program" referenced in paragraph 8. of the provider agreement between JMC and the Department was the Medicaid EPSDT Provider Handbook (hereinafter referred to as the "EPSDT Handbook"). Chapter 10 of the EPSDT Handbook addressed the subject of "provider participation." Section 10.8 of this chapter provided as follows: RECORD KEEPING You must retain EPSDT records on services provided to each Medicaid recipient. You must also keep financial records. Keep the records for five (5) years from the date of service. Examples of the types of Medicaid records that must be retained are: Medicaid claim forms and any documents that are attached, Treatment plans, Prior authorization information, Any third party claim information, X-rays, Fiscal records, and Copies of sterilization and hysterectomy consents. Authorized state and federal staff or their authorized representatives may audit your Medicaid records. You may convert your paper records to microfilm or microfiche. However, your microfilm or microfiche must be legible when printed and viewed. Chapter 11 of the EPSDT Handbook addressed the subject of "covered services and limitations." Sections 11.3 and 11.5 of this chapter provided that the components of an EPSDT preventive health screening examination were: a health and developmental history; unclothed physical assessment or examination; nutritional assessment; updating of routine immunizations, "as indicated by the recipient's age, health history, or population group;" laboratory tests, "as indicated by the recipient's age, health history, or population group;" development assessment, vision, hearing and dental screening; and health education. Section 11.7 of Chapter 11 provided, in part, as follows: Under federal regulations the state must provide for medically necessary treatment services diagnosed as a result of screening. Once the EPSDT recipient is screened and referred for treatment, any further diagnosis and/or treatment is then provided through the individual treatment service program. For example, if an EPSDT recipient is found to have an abnormal laboratory test result, such as tuber- culin (TB) skin test, any further referral, diagnosis and treatment is considered diagnostic treatment under physician services. Billing for a treatment visit at the time of a screening visit is only allowed when the illness is discovered during the screening examination. This treatment visit must be at least 30 minutes or more. Treatment visits completed in conjunction with a screening visit must be billed on the HFCA-1500 and the fact that the visit is screening related must be noted on the claim form. Treatment procedure codes should be related to screening results as noted on the EPSDT 221 claim form. An EPSDT screening should not routinely be completed on an obviously ill child, as the illness may distort the screening results. Sound professional judgment should be exercised in determining the appropriate- ness of screening an ill child. If screening results are questionable, treatment should be provided and the screening appointment rescheduled. If, however, an illness is detected during a screening examination, the screening may be completed and treatment provided on the same date, billing the treatment on the appropriate Medicaid claim form. Billing for treat- ment on the same day as the screening evaluation should be done only when a detected illness or condition requires significant time and procedures in addition to the time usually spent for a screening evaluation. The Audit Commencing in 1992, the Department conducted an audit of Medicaid claims submitted by JMC for services rendered from July 1, 1990, through December 31, 1991. During the course of the audit, the Department examined the files of 40 patients (Patients 1 through 19 and 21 through 41, hereinafter also referred to by their initials) who had received services during the audit period. Patient 1 (S.M.) January 16, 1991, Visit On January 16, 1991, S.M. presented at the clinic complaining of a sore throat and fever. The attending physician determined that S.M. had an upper respiratory tract infection, as well as vaginitis. Treatment was provided. JMC billed this as a "comprehensive" visit (procedure code 90020) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one (procedure code 90060), as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 29, 1991, Visit S.M. next visited the clinic on January 29, 1991. JMC billed this visit as a "limited" one (procedure code 90050) and payment was made accordingly. Respondent does not dispute the appropriateness of such billing and payment. 8/ April 23, 1991, Visit On April 23, 1991, S.M. presented at the clinic complaining of blood in her urine. She further indicated that she had recently had a Pap smear test, the results of which reflected a possible precancerous condition. A pregnancy test revealed that S.M. was pregnant. She was also diagnosed as having an upper respiratory tract infection, for which she was treated. A gynecological referral was made. JMC billed this visit as a "extended" one (procedure code 90070) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 9, 1991, Visit and Streptococcal Test S.M. visited the clinic again on October 9, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. It also sought and obtained separate payment for a streptococcal (hereinafter referred to as "strep") test (procedure code 86317) given during the visit. Both parties are now in agreement that the billing and payment for the strep test was appropriate 9/ and that the office visit should have been billed and paid, not as an "extended" visit, but as an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. November 6, 1991, Visit Cerumen Removal and Strep Test On November 6, 1991, S.M. presented at the clinic complaining of sinus problems and pustules on her nose. She was diagnosed as having folliculitis, pharyngitis and sinusitis. Treatment was provided. JMC billed this visit as a "extended" one and payment was made accordingly. It also sought and obtained separate payment for impacted cerumen removal (procedure code 69210) and a strep test. The parties are in agreement that the billings and payments for the impacted cerumen removal and strep test were appropriate. 10/ A dispute still exists, however, as to the appropriateness of JMC billing and receiving payment for an "extended" visit. JMC's medical records pertaining to the visit, to the extent that they are legible, document that the visit was not an "extended" visit, but was merely an "intermediate" visit, as described in Chapter 11 of the MPP Handbook. Moreover, these records were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. 11/ Accordingly, JMC should not have received any payment for this office visit. Patient 2 (O.R.) October 7, 1991, Billings JMC billed and was paid for a "comprehensive" visit and other services (procedure codes 86317, 94010 and 94664) it claimed it rendered Patient 2, O.R., on October 7, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that, on that date, O.R. was seen at the clinic by a physician or that she received the other billed for services. Accordingly, payment should not have been made to Petitioner for an office visit of any type or for any of the other services Petitioner claimed it rendered O.R. on October 7, 1991. October 22, 1991, Visit On October 22, 1991, O.R. presented at the clinic with a fever, sore throat and high blood pressure. In addition, she complained that she was wheezing, suffering from headaches and had a runny nose. At the time of the visit, O.R. was five feet, two inches tall and weighed 206 pounds. The attending physician determined that O.R. was suffering from asthma. Using a nebulizer, he treated her with Ventolin. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit, Routine Venipuncture and Therapeutic Injection O.R. returned to the clinic two days later, on October 24, 1991, with respiratory problems. She was coughing and wheezing severely. Her throat was red. The attending physician determined that O.R. had pharyngitis, pneumonia and severe asthma. Treatment was provided. Medications were prescribed and oral instructions regarding medication administration and compliance were given. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC also sought and obtained separate payment for a routine venipuncture (procedure code 36415) and a therapeutic injection for asthma (procedure code 90782). The parties are in agreement that the routine venipuncture was appropriately billed and paid. The appropriateness of the billing and payment for a therapeutic injection, however, is still in dispute. JMC's medical records, to the extent that they are legible, do not document that O.R. was given the billed and paid-for therapeutic injection on October 24, 1991. Accordingly, it should not have been paid for this service. Patient 3 (T.F.) January 31, 1991, Visit On January 31, 1991, Patient 3, T.F., a ten-year old girl who had already begun menstruating, presented at the clinic with complaints of vomiting for the past two days, as well as cramps and abdominal pain. She further indicated that she had had her last menstrual period two weeks previous. A physical examination, which included the genital and rectal areas, was conducted, a history was taken and a strep test was given. The results of the strep test were positive. The attending physician determined that T.F. had strep throat, for which she received treatment. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 19, 1991, Visit On September 19, 1991, T.F. presented at the clinic complaining of a high fever and a sore throat. She further indicated that she had vomited earlier in the morning. A physical examination, which did not include the genital area, was conducted, an updated history was taken and a strep test was given. The attending physician determined that T.F. had tonsillitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 4 (K.W.) October 3, 1991, Visit On October 3, 1991, Patient 4, K.W., presented at the clinic. He had lower back pain, an upper respiratory tract infection, trauma to his right ankle and folliculitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 4, 1991, Billings JMC billed and was paid for an "extended" visit and another service (procedure code 86317) it claimed it rendered K.W. on November 4, 1991, but the medical records maintained by JMC do not contain legible, physician-signed and dated documentation substantiating that, on that date, K.W. was seen at the clinic by a physician or that he received the other billed-for service. Accordingly, payment should not have been made to Petitioner for any type of office visit or for the other service Petitioner claimed it rendered K.W. on November 4, 1991. Patient 5 (S.W.) October 19, 1990, Visit JMC billed and was paid for a "comprehensive" office visit, in addition to an EPSDT screen (procedure code W9881), for services rendered to Patient 5, S.W., on October 19, 1990. The parties are in agreement that the EPSDT screen was appropriately billed and paid. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. The medical records maintained by JMC do not contain legible, physician-signed and dated documentation justifying JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. October 29, 1990, Visit S.W. again visited the clinic on October 29, 1990. This was a follow- up visit. She had been to the clinic four days previous with a high fever and complaining of a headache, stuffiness and a cough. JMC billed S.W.'s October 29, 1990, visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 14, 1991, Visit On May 14, 1991, S.W. presented at the clinic complaining of a cough. She was diagnosed as having an upper respiratory tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit Two weeks later, on May 29, 1991, S.W. returned to the clinic for a follow-up visit. She was still coughing. Tests taken before the visit revealed that, in addition to her respiratory problems, S.W. was suffering from iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 12, 1991, Visit On June 12, 1991, S.W. paid another follow-up visit to the clinic. During the visit, she admitted that she had not taken her medication "properly." A spirometry test taken before the visit revealed "severe obstruction." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 6 (B.F.) July 12, 1990, Visit On July 12, 1990, Patient 6, B.F., a 32-year old woman, presented at the clinic complaining of chest palpitations and abdominal pain. A physical examination, which included an examination of the vaginal and pelvic areas, was conducted, a history was taken, tests were ordered and treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, a "comprehensive" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. January 14, 1991, Visit B.F. visited the clinic on January 14, 1991, complaining of lower abdominal discomfort, which, she claimed, she had been experiencing for the past two weeks. The attending physician determined that, in addition to the abdominal discomfort B.F. was experiencing, she also had vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 28, 1991, Visit On January 28, 1991, B.F. presented at the clinic complaining of general malaise and a cough that she claimed she had had for four or five days. The attending physician determined that B.F. was suffering from acute bronchitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 24, 1991, Visit On April 24, 1991, B.F. presented at the clinic complaining of chest pain, headaches and dizziness she had been experiencing for several days. She also had shortness of breath. A physical examination, which included an examination of the genital and rectal areas, was conducted, an updated history was taken and tests were ordered. The chest pain was determined to be non-cardiac in nature. It was thought to be caused by a tender rib. Medication was prescribed to combat B.F.'s headaches and dizziness. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, B.F. paid a followup visit to the clinic. She reported that she was still experiencing dizziness, but no longer had any chest pain or headaches. She further advised that she was unable to tolerate the medication that had been prescribed on the previous visit. A rhythm strip test was administered. A new medication was prescribed to combat B.F.'s dizziness. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 7 (C.C.) July 23, 1991, Visit On July 23, 1991, Patient 7, C.C., visited the clinic for the removal of a lesion from her nose by electrodesiccation. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 8 (L.F.) October 21, 1991, Visit On October 21, 1991, Patient 8, L.F., presented at the clinic complaining of a skin rash. The attending physician determined that L.F. was suffering from impetigo, as well as bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 9 (L.A.) November 26, 1990, Visit On November 26, 1990, Patient 9, L.A., presented at the clinic complaining of chest pain. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that such billing and payment was appropriate and thus JMC was not overpaid for this visit. March 28, 1991, Visit On March 28, 1991, L.A. presented at the clinic complaining of chest and abdominal pain. 152. The attending physician determined that the chest pain was non- cardiac in nature and that L.A. was suffering from gastritis. 153. Medication was prescribed. 154. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 6, 1991, Visit On May 6, 1991, L.A. visited the clinic to obtain birth control pills. JMC billed this visit as an "extended" one. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 17, 1991, Visit On June 17, 1991, L.A. presented to the clinic complaining of a sore throat and back pain. The latter ailment was the result of her having been hit in the back with a chair that was thrown at her at work. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 8, 1991, Debridement On August 8, 1991, L.A. presented to the clinic complaining of a gash on her left leg that she had received the night before, as well as a headache and continuing back pain. The leg wound was cleaned. Necrotic tissue around the edge of the wound was removed. JMC billed for a debridement (procedure code 11042) and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC. JMC was therefore appropriately paid for this procedure. September 27, 1991, Visit On September 27, 1991, L.A. presented at the clinic complaining of diarrhea, a cold and postnasal drip. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 28, 1991, Visit On October 28, 1991, L.A. presented to the clinic complaining of a sore throat. She further indicated that she had been exposed to the flu. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 10 (B.W.) February 26, 1991, Visit and EPSDT Screen On February 26, 1991, Patient 10, B.W., who was then twelve years old, presented at the clinic for an EPSDT screen. complaining of an abscess behind her ear and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 12/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. March 1, 1991, Billing JMC billed and was paid for services rendered B.W. during an "intermediate" office visit it claimed took place on March 1, 1991, but the physician signed-medical records maintained by JMC, to the extent that they are legible, do not document that B.W. was seen that day at the clinic by a physician. Payment for such an office visit therefore should not have been made. March 13, 1991, Visit On March 13, 1991, B.W. presented at the clinic with multiple, yet relatively uncomplicated, medical problems, including iron deficiency. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. June 24, 1991, Visit On June 24, 1991, B.W. presented at the clinic complaining of a skin rash. She also had a slightly elevated temperature. The attending physician determined that B.W had dermatitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 27, 1991 Visit Three days later, on June 27, 1991, B.W. again visited the clinic. This time she had an abscess in the area of her left armpit. The abscess was drained. JMC billed this visit as an "extended" one and payment was made accordingly. 13/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit and EPSDT Screen On October 18, 1991, B.W. presented at the clinic for an EPSDT screen complaining of an abscess in the area of her right armpit and a sore throat. The screen was performed. In addition, B.W.'s abscess was drained and her sore throat was treated. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 14/ JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that, as claimed by JMC, a complete EPSDT screen, as described in Chapter 11 of the EPSDT Handbook, was performed. The billing and payment for such a screen therefore was appropriate. These medical records, however, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 11 (T.M.) October 30, 1990, Visit On October 30, 1990, Patient 11, T.M., who was then six years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, a wart was discovered on T.M.'s left wrist. The wart was removed. The procedure took approximately 15 minutes. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 15/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. May 9, 1991, Visit T.M. presented at the clinic on May 9, 1991, with an elevated temperature. The attending physician determined that he had an upper respiratory tract infection. Medication was prescribed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 12 (D.W.) November 30, 1990, Visit On November 30, 1990, Patient 11, D.W., who was then three months old, presented at the clinic for an EPSDT screen. He had a stuffy nose. The screen was performed. The physician performing the screen determined that D.W. was suffering from an upper respiratory tract infection and otitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 14, 1990, Visit On December 14, 1990, D.W. presented at the clinic. His mother reported that D.W. had a persistent cough. D.W. was given a strep test, the results of which were negative. The attending physician determined that D.W. still had an upper respiratory tract infection and otitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 17 and 27, 1990, Visits D.W. visited the clinic on December 17, 1990, and again on December 27, 1990. JMC billed these visits as "intermediate" ones and payments were made accordingly. The parties agree that these billings and payments were appropriate. January 21, 1991, Visit On January 21, 1991, D.W. returned to the clinic with his mother. He had a fever of 102 degrees Fahrenheit, which, his mother reported, he had had for the past four days. Following an examination and a strep test, the attending physician determined that D.W. had a strep throat and an ear infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 7, 1991, Visit On June 7, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was discovered that D.W had an ear problem, for which he received treatment. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office on this date. June 21, 1991, Visit 254. D.W. returned to the clinic on June 21, 1991, with an ear infection and a rash behind his right ear. 255. Treatment was provided. 256. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as JMC claimed, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. July 23, 1991, Visit On July 23, 1991, D.W. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that D.W. was suffering from diaper rash. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, is still in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 13 (J.H.) December 29, 1990, Visit and EPSDT Screen On December 29, 1990, J.H., who was then three years of age, presented at the clinic for an EPSDT screen. She was suffering from constipation. During the screen, the attending physician determined that J.H. also had vaginitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, there is no indication that J.H.'s teeth and gums were examined during the visit. Accordingly, JMC was not entitled to receive any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 4, 1991, Visit On January 4, 1991, J.H. presented at the clinic. She looked ill and had glassy eyes. It was reported that her temperature (taken with a rectal thermometer) had reached 104 degrees Fahrenheit at home. When her temperature was taken (again rectally) at the clinic, however, it was only 99.2 degrees Fahrenheit. The attending physician determined that J.H. had a urinary tract infection and pharyngitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 14 (J.Y.) April 20, 1991, Visit On April 20, 1991, Patient 14, J.Y., a 25-year old woman suffering from obesity and hypertension, presented at the clinic to obtain a refill of medication that she had been given on a previous visit. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 15 (K.C.) September 20, 1991, Visit On September 20, 1991, Patient 15, K.C., who was then four years of age, presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that K.C. was suffering from an upper respiratory ailment. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "intermediate" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "intermediate" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 16 (D.W.) December 17, 1991, Visit On December 17, 1991, Patient 16, D.W., who was then eight years of age, presented to the clinic for an EPSDT screen. During the screen, the attending physician determined that D.W. was suffering from dermatitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks adequate supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 17 (R.G.) There are no issues in dispute concerning any billings and payments made in connection with services JMC rendered to Patient 17, R.G. Patient 18 (C.F.) February 12, 1991, Visit On February 12, 1991, C.F., a 25-year old woman, presented at the clinic complaining of profuse menstrual bleeding. The attending physician determined that C.F. was simply having irregular menstrual periods and that medical intervention was not warranted. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 18, 1991, Visit On November 18, 1991, C.F. returned to the clinic. She still had irregular menstrual periods and, in addition, she complained of a heavy discharge of breast milk from both of her breasts. Tests were ordered. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991, Visit On December 9, 1991, C.F. again visited the clinic. This time she had an upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 19 (J.R.) September 17, 1990, Visit On September 17, 1990, Patient 19, J.R., who was then six months old, visited the clinic. 16/ He had, what his mother described as, a "bad cold." The attending physician determined that J.R. had an upper respiratory tract infection and bronchitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 31, 1991, Visit On January 31, 1991, J.R. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, the attending physician determined that J.R. was suffering from a rash, a mild upper respiratory ailment, and a sore throat. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for an "extended" office visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. February 26, 1991, Visit On February 26, 1991, J.R. again visited the clinic. He had an ear infection and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 1, 1991, Visit On May 1, 1991, J.R. paid another visit to the clinic. Diaper rash was still a problem. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. May 29, 1991, Visit J.R. returned to the clinic on May 29, 1991. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that any of JMC's staff physicians provided medically necessary services to J.R. on this date. While these records do reflect that J.R. received an abbreviated physical examination during his visit to the clinic, they do not reveal why the examination was conducted or what conclusions the attending physician reached as a result of the examination. Accordingly, JMC should not have received any payment for an office visit on this date. Patient 21 (T.M.) April 26, 1991, Visit On April 26, 1991, Patient 21, T.M., who was then five years of age, presented at the clinic for an EPSDT screen. He had sickle cell anemia, but was doing well. The screen was performed. Following the screen, the attending physician recommended that T.R. continue taking folic acid and vitamins. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 22 ( K.C.) August 28, 1990, Visit On August 28, 1990, Patient 22, K.C., who was then six months old and had recently been exposed to hepatitis B, presented at the clinic for an EPSDT screen. The screen was performed. The attending physician did not believe that K.C. had contracted hepatitis B. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 23 ( K.G.) July 10, 1990, Visit On July 10, 1990, Patient 23, K.G., presented at the clinic complaining of a vaginal discharge. The attending physician determined that K.G. was suffering from vaginitis. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 15, 1990, Visit On October 15, 1990, K.G. presented at the clinic complaining of a rash in the area of her groin. The attending physician determined that K.G. had folliculitis. Treatment was provided. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. February 15, 1991, Visit On February 15, 1991, K.G. presented at the clinic complaining of swelling in her legs. 17/ The attending physician determined that she had pinworms. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. March 8, 1991, Visit On March 8, 1991, K.G. presented at the clinic complaining of rectal pain and a persistent cough. The attending physician determined that K.G. had pharyngitis, pneumonia and an anal fissure. Treatment, which included the use of an aerosol spray, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 18/ 372. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore not overpaid for this visit. June 6, 1991, Visit On June 6, 1991, K.G. visited the clinic complaining of weight gain and pain in her left side. The attending physician determined that the pain was caused by gas and prescribed medication to combat the problem. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 28, 1991, Visit On June 28, 1991, K.G. presented at the clinic complaining of a sore throat and a cough producing yellowish sputum. She claimed that she had had the sore throat for three to four days. A strep test was given, the results of which were negative. The attending physician determined that K.G. had bronchitis and pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. August 1, 1991, Visit On August 1, 1991, K.G. presented at the clinic. 19/ She had a pararectal abscess and a urinary tract infection. The abscess was drained. In addition, treatment was provided for the urinary tract infection. JMC billed this visit as an "extended" one and payment was made accordingly. 20/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 5, 1991, Visit On September 5, 1991, K.G. presented at the clinic. She had a cough and sore throat. A strep test was given, the results of which were negative. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 24 (L.W.) December 10, 1990, Visit On December 10, 1990, Patient 24, L.W., who was then five years of age, presented at the clinic for an EPSDT screen. The screen was performed. As part of the screen, her weight was taken. She weighed only 30 pounds. 401. Because she had a persistent cough and a runny nose, a strep test was given, the results of which were positive. 402. JMC billed for an EPSDT screen and a "comprehensive" visit. 403. The parties agree that the billing and payment for an EPSDT screen was appropriate. The billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. July 2, 1991, Visit On July 2, 1991, L.W. presented at the clinic. 21/ Her right breast was enlarged. In addition, she had pharyngitis and impacted cerumen in her ears. A strep test was given, the results of which were negative. Treatment, which included the removal of the impacted cerumen, was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 22/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 25 (R.W.) October 3, 1991, Visit On October 3, 1991, Patient 25, R.W., who was then four months old, presented at the clinic for an EPSDT screen. 23/ He had an asthmatic condition and bronchitis. The screen was performed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 24/ JMC therefore should not have received any payment for an office visit on this date. October 10, 1991, Visit On October 10, 1991, R.W. presented at the clinic for another EPSDT screen. His asthma and bronchitis were much improved. The screen was performed. No new problems were discovered. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. 25/ JMC therefore should not have received any payment for an office visit on this date. October 16, 1991, Visit On October 16, 1991, R.W. returned to the clinic. His condition had worsened and he was crying in his mother's arms. In addition to the problems he had had previously, he now also had an ear infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 24, 1991, Visit R.W. paid a follow-up visit to the clinic on October 24, 1991. His condition had improved since his last visit to the clinic on October 16, 1991. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that this visit, like R.W.'s prior visit to the clinic, was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 26 (E.W.) September 16, 1991, Visit On September 16, 1991, Patient 26, E.W., who was then four months old, presented at the clinic with a cold and cough. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen lacks sufficient supporting documentation. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 27 (C.S.) 26/ November 4, 1991, Visit and EPSDT Screen On November 4, 1991, Patient 27, C.S., who was then seven months old, presented at the clinic. She was suffering from a cold. Treatment was provided. JMC billed for an EPSDT screen and an "extended" visit. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete screen was performed. For example, these records contain no nutritional or developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received any payment for an EPSDT screen. Furthermore, these medical records document that the visit was not an "extended" one, but was merely a "brief" or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 28 (S.S.) 27/ May 15, 1991, Visit On May 15, 1991, Patient 28, S.S., presented at the clinic complaining of keloid skin masses on both of her ears which, she indicated, she wanted removed. JMC billed this visit as a "comprehensive" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as an "intermediate" one and that therefore JMC was overpaid for this visit. May 29, 1991, Visit On May 29, 1991, S.S. returned to the clinic for evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on May 29, 1991. June 12, 1991, Visit On June 12, 1991, S.S. paid another visit to the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on June 12, 1991. July 10, 1991, Visit On July 10, 1991, S.S. again visited the clinic for further evaluation and treatment of her keloids. JMC billed this visit as an "intermediate" one and payment was made accordingly. The parties now agree that the visit should have instead been characterized as a "limited" one. In any event, the medical records of this visit were not signed by the attending physician "on the date of service or within 24 hours," as required by Chapter 11 of the MPP Handbook. Accordingly, payment should not have been made to Petitioner for any level of service rendered S.S. on July 10, 1991. August 7, 1991, Visit S.S. went back to the clinic on August 7, 1991, for further evaluation and treatment of her keloids. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 12, 1991, Visit On September 12, 1991, S.S. presented at the clinic for additional evaluation and treatment of her keloids, which were scheduled to be removed the following day. She also had a sore throat. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed as a "limited" one and that therefore JMC was overpaid for this visit. September 19, 1991, Visit Only one of the keloids, the one on her left ear, was removed on September 13, 1991. Six days later, on September 19, 1991, S.S. visited the clinic for a postsurgical examination and to discuss the removal of the keloid on her right ear. She presented at the clinic with a sore throat and earache. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 26, 1991, Visit S.S. returned to the clinic on September 26, 1991. She had an abscess on her ear. The abscess was incised and drained. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 28/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "brief" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Debridement On October 7, 1991, S.S. presented at the clinic complaining of continuing skin problems on and behind her ears. An abscess and "raggedy" skin were discovered. The abscess was incised and drained and the "raggedy" skin was removed. JMC billed and was paid for a debridement. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the billed and paid-for debridement was performed, as claimed by JMC, and that therefore JMC was entitled to the payment it received for the debridement. Patient 29 (T.J.) January 28, 1991, Visit On January 28, 1991, Patient 29, T.J., who was then one month old, was seen at the clinic. She had congenitally deformed ("toe[d] in") feet, multiple insect bites and diaper rash. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 30, 1991, Visit T.J. returned to the clinic two days later. She had been vomiting for the past two days. In addition, she had a sore throat and an earache. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 22, 1991, Visit On April 22, 1991, T.J. presented at the clinic for an EPSDT screen. The screen was performed. During the screen, it was determined that T.J. had dermatitis caused by insect bites. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 24, 1991, Visit On April 24, 1991, T.J. again visited the clinic. Her dermatitis was still causing her some discomfort. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 30 (G.D.) March 11, 1991, Visit On March 11, 1991, Patient 30, G.D., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed that G.D. had upper respiratory problems, as well as an umbilical hernia. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. April 22, 1991, Visit G.D. was next seen at the clinic on April 22, 1991. He had pharyngitis. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. June 3, 1991, Visit G.D. next visited the clinic on June 3, 1991. He had a mild upper respiratory tract infection. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 31 (H.C.) October 15, 1990, Visit On October 15, 1990, H.C., who was then 18 years old, presented at the clinic complaining of delayed menstruation. She was given a pregnancy test, the results of which revealed that she was pregnant. JMC billed and was paid for an EPSDT screen and an "extended" visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 32 (R.M.) February 12, 1991, Visit On February 12, 1991, Patient 32, R.M., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in R.M.'s ears. The impacted cerumen was removed. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 29/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 33 (C.W.) December 3, 1990, Visit On December 3, 1990, Patient 33, C.W., who was then four years old, presented at the clinic for an EPSDT screen. The screen was performed. The screen revealed impacted cerumen in C.W.'s ears and that R.M. had pharyngitis. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 30/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. August 22, 1991, Visit 534. On August 22, 1991, C.W. presented at the clinic complaining of a headache. 535. The attending physician determined that C.W. had pharyngitis. 536. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 7, 1991, Visit On October 7, 1991, C.W. again visited the clinic. JMC billed this visit as an "extended" one and payment was made accordingly. The parties now agree that the visit should have instead been billed and paid for as a "limited" one, as described in Chapter 11 of the MPP Handbook. October 10, 1991, Visit Three days later, on October 10, 1991, C.W. returned to the clinic. She had tonsillitis, pharyngitis and an upper respiratory infection. Her temperature was 103.4 degrees Fahrenheit. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" office visit. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 34 (K.K.) September 19, 1990, Visit On September 19, 1990, Patient 34, K.K., who was then three years old, presented at the clinic for an EPSDT screen. He had a runny nose and a cough. His mother also complained that he was hyperactive. 549. The screen was performed. 550. The screen revealed that K.K. had impacted cerumen in his ears. 551. provided. Treatment, including the removal of the impacted cerumen, was 552. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 31/ The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. December 17, 1990, Visit On or about December 17, 1990, K.K. returned to the clinic. He had dermatitis, as well as impacted cerumen in his ears. In addition, his mother was concerned about his behavior. Treatment, including the removal of the impacted cerumen, was provided. JMC billed this visit as an "extended" one and payment was made accordingly. 32/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. January 3, 1991, Visit On January 3, 1991, K.K. returned to the clinic for a physical examination for school. During the visit, his mother complained that K.K.'s appetite for food had decreased. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. Patient 35 (T.B.) November 15, 1990, Visit On November 15, 1990, Patient 35, T.B., presented at the clinic for a physical examination for work. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 20, 1990, Visit T.B. returned to the clinic on December 20, 1990, complaining that she was not feeling well. During the visit, impacted cerumen was removed from her ears. JMC billed this visit as a "comprehensive" one and payment was made accordingly. 33/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. July 18, 1991, Visit On July 18, 1991, T.B. went to the clinic to obtain "medical certificates." A routine physical examination was performed, but no history was taken. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "brief or "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 4, 1991, Visit On December 4, 1991, T.B. presented at the clinic with "pink eye." Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 36 (D.W.) January 2, 1991, Visit On January 2, 1991, Patient 36, D.W., who was then 19 years of age, visited the clinic for a checkup. The attending physician determined that D.W. had an iron deficiency and anemia, for which treatment was provided. During the visit, family planning issues were also addressed. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit On April 17, 1991, D.W. presented at the clinic complaining that she had been feeling ill for two days. 34/ 592. A strep test was given, the results of which were negative. The attending physician determined that D.W had tonsillitis and was still suffering from anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. September 16, 1991, Visit On September 16, 1991, D.W. presented at the clinic. She had a sore throat and vaginitis. 35/ In addition, she was now pregnant and still anemic. Treatment was provided. JMC billed and was paid for an EPSDT screen and an "extended" visit. 601. The parties agree that the billing and payment for an EPSDT screen was not appropriate. The appropriateness of the billing and payment for an "extended" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not an "extended" one, but was merely an intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 17, 1991, Visit On October 17, 1991, D.W., who was still pregnant at the time, made a follow-up visit to the clinic. She complained of shortness of breath and tightness in her chest, as well as a sore throat. A fetal examination was conducted. A strep test was given, the results of which were negative. The attending physician determined that D.W. had a urinary tract infection, sinusitis, pharyngitis and anemia. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 14, 1991, Visit and Echography D.W. returned to the clinic on November 14, 1991. She was in approximately the thirty-second week of her pregnancy and she was still suffering from a urinary tract infection and anemia. Her sinus condition was improving. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. It also sought and received separate payment for an echography (procedure code 76855). The parties now agree that JMC should not have been paid for an echography. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was not a "comprehensive" one, but was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 3, 1991, Visit A still-pregnant D.W. visited the clinic again on December 3, 1991, complaining of shortness of breath. The attending physician determined that she was still suffering from a urinary tract infection and anemia. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 10, 1991, Visit A week later, on December 10, 1991, with her anticipated date of delivery approaching, D.W. returned to the clinic complaining of vaginal irritation and pain in her left wrist. Her urinary tract infection was improving. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 37 (E.A.) September 27, 1991, Visit On September 27, 1991, Patient 37, E.A., who was then seven weeks old, presented at the clinic with an upper respiratory infection, pharyngitis and thrush. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. October 18, 1991, Visit E.A. returned to the clinic on October 18, 1991, for an EPSDT screen. 633. The screen was performed. The screen revealed that he still had an upper respiratory infection and thrush. Treatment was provided. JMC billed for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, do not justify JMC billing for any office visit in addition to an EPSDT screen. JMC therefore should not have received any payment for an office visit on this date. November 20, 1991, Visit E.A. visited the clinic again on November 20, 1991. He had a bad cough and a green discharge from his eyes and nose. The attending physician determined that E.A. had an upper respiratory infection and pharyngitis, as well as a "foreign body" in his nose. Treatment, including the removal of the "foreign body," was provided. 36/ JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore entitled to the payment it received for this visit. November 21, 1991, Incision and Removal JMC billed and was paid for an incision and removal of a "foreign body" (procedure code 10120) it claimed had been performed on E.A. at the clinic on November 21, 1991, but the medical records maintained by JMC, to the extent that they are legible, do not document that E.A. received an incision and removal at the clinic on this date. Accordingly, payment should not have been made to JMC for this billed-for service. Patient 38 (O.S.) December 2, 1991, Visit and EPSDT Screen On December 2, 1991, Patient 38, O.S., who was then three months old, presented at the clinic for an EPSDT screen. She had a cold and blotches all over her body and her hair was falling out. The screen revealed that O.S. had tinea capitis, otodynia, and pharyngitis, as well as impacted cerumen in her ears. Treatment, including the removal of the impacted cerumen, was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. 37/ JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, do not document that a complete EPSDT screen was performed. For example, these records contain no developmental assessment, nor do they indicate that there was any health education given. Accordingly, JMC should not have received payment for an EPSDT screen. Furthermore, these medical records document that the visit was not a "comprehensive" one, but was merely an "extended" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 9, 1991 O.S. returned to the clinic a week later on December 9, 1991. She had a new rash on her left arm. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 39 (T.G.) September 5, 1991, Visit On September 5, 1991, Patient 39, T.G., who was then three months old, presented at the clinic for an EPSDT screen. She had a stuffy nose and was crying. According to his mother, he had been crying for the past 12 hours. The screen was performed. A strep test was given, the results of which were negative. The attending physician determined that T.G. had an ear infection, an upper respiratory tract infection and phayrngitis. Treatment was provided. JMC billed and was paid for an EPSDT screen and a "comprehensive" visit. The parties agree that the billing and payment for an EPSDT screen was appropriate. The appropriateness of the billing and payment for a "comprehensive" visit, however, remains in dispute. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, justify JMC billing and receiving payment for, in addition to an EPSDT screen, only an "intermediate" office visit and not a "comprehensive" one. JMC was therefore overpaid for this visit. September 19, 1991, Visit T.G. returned to the clinic for a follow-up visit on September 19, 1991. He had diaper rash. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 40 (T.B.) November 26, 1991, Visit On November 26, 1991, T.B., a 62-year old man with a history of heart disease, hypertension and stroke, presented at the clinic with a periorbital abscess. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. 38/ JMC was therefore overpaid for this visit. November 29, 1991, Visit Three days later, on November 29, 1991, T.B. returned to the clinic again complaining about the abscess. The attending physician reevaluated the problem and referred T.B. to Jackson Memorial Hospital for treatment. JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. Patient 41 (L.B.) January 25, 1991, Visit On January 25, 1991, Patient 41, L.B., who was then 19 years of age and had history of mental illness, presented at the clinic stating that she was pregnant and complaining, among other things, of abdominal pain. She appeared to be confused and it was difficult to obtain an accurate history from her. Treatment was provided. JMC billed this visit as an "extended" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. April 17, 1991, Visit L.B. returned to the clinic on April 17, 1991, complaining of continuing abdominal pain, vaginal discharge, breast tenderness and nausea. The attending physician determined that L.B. had vaginitis and a urinary tract infection. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely an "intermediate" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. November 25, 1991, Visit L.B. visited the clinic again on November 25, 1991. On this visit she complained of a rash. The attending physician determined that L.B. had dermatitis. 694. Treatment was provided. JMC billed this visit as a "comprehensive" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, however, to the extent that they are legible, document that the visit was merely a "limited" one, as described in Chapter 11 of the MPP Handbook. JMC was therefore overpaid for this visit. December 6, 1991, Visit On December 6, 1991, L.B. presented at the clinic claiming that there were things crawling on her scalp. The attending physician determined that L.B. was demented. He filled out a Social Security Administration form indicating that it was his opinion that L.B. was "not medically competent." JMC billed this visit as an "intermediate" one and payment was made accordingly. JMC's physician-signed, medical records pertaining to this visit, to the extent that they are legible, document that the visit was, as claimed by JMC, an "intermediate" one, as described in Chapter 11 of the MPP Handbook. Simple Mistake or Fraud? There has been no allegation made, nor proof submitted, that any of the overbillings referenced above were the product of anything other than simple mistake or inadvertence.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency for Health Care Administration adopt the findings made by the Hearing Officer regarding the sampled claims remaining in dispute in the instant case and use these findings to redetermine the total amount of Medicaid overpayments made to Petitioner during the audit period and the amount of the fine Petitioner should be required to pay for its erroneous billings during this period of time. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 22nd of May, 1995. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 22nd day of May, 1995.
The Issue The issue is whether respondent's license as a practical nurse should be disciplined for the reasons cited in the administrative complaint.
Findings Of Fact Based upon the entire record, the following findings of fact are determined: At all times relevant hereto, respondent, Ruthie Mae Owens Brooks (Brooks or respondent), was licensed as a practical nurse having been issued license number PN 0877941 by petitioner, Department of Professional Regulation, Board of Nursing (Board). She has been licensed as a practical nurse since 1987. There is no evidence that respondent has been the subject of disciplinary action prior to this occasion. When the events herein occurred, respondent was an agency nurse for Underhill Personnel Services, Inc., an agency that furnished nurses to various health care facilities, including Methodist Medical Center in Jacksonville, Florida. She was employed at all times as a licensed practical nurse. On November 17, 1990, respondent was scheduled to work the 11 p.m. - 7 a.m. shift at Methodist Medical Center. Although her duty shift began at 11:00 p.m., respondent arrived a few minutes late and reported directly to the medical-surgical- orthopedic wing instead of signing in at the nursing office as required by hospital rules. After reporting to her work area, respondent went to the assignment board to review her assignment for that evening. Her specific duties that evening were to care for five patients in the medical-surgical-orthopedic wing. While respondent was at the assignment board, a registered nurse, Lynn Ivie, came to the board to ascertain her assignment. At that time, Ivie reported that she smelled a "strong odor of alcohol" on respondent's breath. However, Ivie said nothing at that time since she wanted to give respondent the benefit of the doubt. Around midnight, one of respondent's patients awoke in his room with severe chest pains. Both Ivie and respondent immediately went to the room. Although Ivie instructed Brooks to get a vital signs machine (also known as the Dynamap), Brooks ignored the instruction and "wiped the patient's face with a wet cloth". Ivie then brought the machine into the room and respondent was instructed by Ivie to take the patient's vital signs (blood pressure, temperature and pulse). This merely required her to place an attachment around the patient's arm and push a button to start the machine. The operation of the machine is considered a basic nursing skill. According to Ivie, respondent could not focus on the machine and did not seem to remember how to operate it. After waiting a few moments with no response from Brooks, Ivie finally took the patient's vital signs herself. During this encounter, Ivie again smelled alcohol on respondent's breath and concluded that her inability to assist in the care of the patient and to operate the machine was due to alcohol. Within a few moments, the patient was transferred to the intensive care unit (ICU) on another floor. Before accompanying the patient to the ICU, Ivie instructed respondent to chart the incident and action taken in the nurse's notes and then meet her in the ICU with the completed notes. These notes should be completed in an expedited manner so that the nurses in the ICU wing can utilize them in providing follow-up care to the patient. However, respondent did not chart the incident nor bring the notes to the ICU. Indeed, she failed to chart the notes on any of the patients assigned to her that night. By failing to chart any notes that evening, respondent contravened the requirement that a nurse file a report or record (nursing notes). Around 1:30 a.m. on November 18, Ivie and Joyce Biddix, the nursing supervisor, went to the room of one of the patients assigned to respondent and found the patient, a confused elderly male, sitting nude in a chair with the bed stripped of all linens. He had previously been tied to the bed to prevent him from falling. The linens were soiled with urine and were lying in a heap on the floor. Although respondent had taken the patient out of the bed, disrobed him, and removed the linens, she had left him unattended in the room and had not returned. Biddix called down the hall for someone to bring fresh linens and observed respondent "floating" down the hall saying "I can't find the linens" in a "singsong" voice. When she got closer to respondent, Biddix smelled alcohol on respondent's breath. It may reasonably be inferred from the evidence that respondent's conduct with this patient was unprofessional and constituted a departure from acceptable and prevailing nursing practice. After being confronted by Biddix regarding the alcohol, respondent told her she had drunk one beer with her meal around 10:30 p.m., or just before reporting to duty that evening. However, she denied she was intoxicated or unable to perform her duties. Respondent was then told to leave work immediately. The incident was later reported to Underhill Personnel Services, Inc. and that agency contacted the Board. After an investigation was conducted by the Board, an administrative complaint was filed. At hearing, respondent did not contest or deny the assertion that by reporting to work with alcohol on her breath, she was acting in an unprofessional manner and deviated from the standards of acceptable and prevailing nursing practice. In this regard, she acknowledged that she had drunk alcohol (which she claimed was only one tall beer) with her meal around 10:30 p.m., or just before reporting to duty. However, she contended that all of her previously scheduled shifts at the hospital had been cancel led and she assumed her shift that evening might also be cancelled. In response to the allegation that she could not operate the vital signs machine, respondent offered a different version of events and suggested that the machine in the patient's room was inoperative. Therefore, it was necessary for Ivie to bring a Dynamap into the room and Ivie took the vital signs without respondent's assistance. She justified leaving the elderly patient alone without clothes in his room on the grounds there was no clean gown, the patient was not combative, and she was only gone from the room for a few moments. Finally, she contended that she charted the notes for one of her patients but did not chart the others because the remaining patients were removed from her care by Ivie and Biddix when she was sent home at 1:30 a.m. However, these explanations are either deemed to be not credible or, if true, nonetheless do not justify her actions. Although there was no testimony concerning the specific issue of whether respondent is unable to practice nursing with reasonable skill and safety by reason of use of alcohol, taken as a whole respondent's conduct on the evening of November 17, 1990, supports a finding that her capacity was impaired that evening by virtue of alcohol. Accordingly, it is found that respondent was unable to practice nursing with reasonable skill and safety by reason of use of alcohol.
Recommendation Based upon the foregoing findings of facts and conclusions of law, it is, RECOMMENDED that respondent be found guilty of violating Subsections 464.018(1)(f), (h), and (j), Florida Statutes (1989), and that her nursing license be suspended for six months but that such suspension be stayed upon respondent's entry into and successful completion of the Intervention Program for Nurses. Respondent's failure to remain in or successfully complete the program will result in the immediate lifting of the stay and imposition of the six-month suspension. Thereafter, said license shall not be reinstated until such time as respondent appears before the Board and can demonstrate that she can engage in the safe practice of nursing. DONE and ENTERED this 16th day of December, 1991, in Tallahassee, Florida. DONALD R. ALEXANDER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 16th day of December, 1991. APPENDIX TO RECOMMENDED ORDER CASE NO. 91-5033 Petitioner: Partially adopted in finding of fact 1. Partially adopted in finding of fact 3. Partially adopted in finding of fact 8. Partially adopted in finding of fact 3. 5-6. Partially adopted in finding of fact 4. 7-10. Partially adopted in finding of fact 5. 11-14. Partially adopted in finding of fact 6. 15-16. Partially adopted in finding of fact 7. 17-18. Partially adopted in finding of fact 8. COPIES FURNISHED: Roberta L. Fenner, Esquire 1940 North Monroe Street, Suite 60 Tallahassee, Florida 32399-0792 Ruthie Mae Owens Brooks 1604 S.W. 40th Terrace, #A Gainesville, Florida 32607 Jack L. McRay, Esquire 1940 North Monroe Street, Suite 60 Tallahassee, Florida 32399-0792 Judie Ritter, Executive Director 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202
The Issue The issue is whether Respondent's license as a practical nurse should be disciplined for the reasons given in the Administrative Complaint.
Findings Of Fact Based upon all of the evidence, the following findings of fact are determined: In this disciplinary proceeding, Petitioner, Department of Health, Board of Nursing (Board), has alleged that Respondent, Sheila Key, a licensed practical nurse, failed to conform to minimal standards of acceptable nursing practice while employed as a practical nurse at Florida Christian Health Center (FCHC), in Jacksonville, Florida, in the Fall of 1999. Respondent holds license number PN 0792331 issued by the Board. The allegations against Respondent arose as a result of a routine Agency for Health Care Administration (AHCA) licensure survey of the facility on October 1, 1999. On that date, an AHCA survey team found an elderly resident with a head injury whose nursing notes had not been properly charted; a resident in the recreation area with blood on her gown and requiring medical attention; and a third resident with unattended sores on his ankles. All were under the direct care of Respondent. As to the first resident, the Board charged Respondent with failing to document the resident's head injury or condition in her nursing notes. In the second case, she was charged with failing to notify a physician or other responsible party in a timely manner about the injury and applying "steri-strips without a physician's order." Finally, Respondent was charged with failing and refusing "to comply with the surveyors' request" that she "remove [the patient's] socks so the ankle area on his feet could be observed." Each of these charges will be discussed separately below. Around 5:15 p.m. on September 30, 1999, A. B., an eighty-seven-year-old male resident at FCHC, acidentally fell and sustained an injury to his head that required emergency room treatment. A. B. returned to FCHC from the emergency room sometime after 9:00 p.m. Respondent reported for duty at 7:00 p.m. that same evening. Although good nursing practice dictated that Respondent promptly perform a neurological check on A. B. after he returned from the hospital, she failed to do so and did not perform one until 7:00 a.m. the next day (October 1). Even then, she failed to document any of her findings in the resident's nursing notes. By failing to document "the fall or his condition" in the nursing notes until the morning following the injury, Respondent failed to conform to the minimal standards of acceptable prevailing nursing practice. Around 7:40 a.m. on October 1, 1999, M. C. suffered a laceration on her neck while being transferred from her bed to a wheelchair. Respondent applied steri-strips to the wound, but she did not have a physician's order to do so. Also, she failed to document the neck wound or her treatment of the wound until 10:45 a.m., or more than three hours later. Finally, M. C.'s physician was not notified about the injury until around 12:15 p.m. FCHC has a written policy entitled "Changes in a Resident's Condition Status," which requires that the nurse promptly notify the resident, the resident's physician, and the resident's family of changes in the resident's condition. Thus, a nurse must notify the resident's attending physician and family whenever the resident is involved in any accident or incident that results in an injury. If the injury is of an emergency nature, such notification is required within thirty minutes to an hour. The evidence establishes that M. C.'s injury was of a type that required notification within this short time period. By waiting for almost five hours to notify M. C.'s physician about the injury, Respondent failed to conform with minimally acceptable nursing practices. She also violated the same standard by applying steri-strips to the injury without a doctor's order. Finally, she failed to conform to minimally acceptable nursing practices by not charting the injury in the nursing notes until more than three hours had elapsed. During the October 1, 1999, inspection, a member of the survey team asked Respondent to remove the socks and dressings on J. R., a resident. The request was made since the team could see a brown discharge on the inner aspects of his socks. Respondent would not do so, and eventually an assistant director of nursing performed that task. After the socks were removed, the survey team found old dressings through which drainage had soaked. They also observed sores that had thick yellow or serosanguinous drainage. Even though the sores had been there for at least a week or so, dressings had been previously applied, and the soaked socks were clearly visible, Respondent had failed to check the resident and was therefore unaware of his condition. Despite this omission, however, Respondent was only charged with failing and refusing "to comply with the surveyors' request," and not with inappropriate conduct with respect to the care of the resident. By failing to respond to a reasonable and legitimate request to remove the resident's socks so that a suspicious area could be observed, Respondent failed to conform to minimally acceptable standards of prevailing nursing practice. Respondent failed to admit responsibility for any of the foregoing violations. As to the resident with the neck wound, Respondent contended that the wound was not serious. However, it was serious enough that the resident's physician believed emergency room treatment was necessary. Respondent also contended that the assistant director of nursing (Widhalm) advised her that she (Widhalm) would call M. C.'s physician, an assertion which Widhalm credibly denied. Respondent further contended that she failed to chart A. B.'s nursing notes because the chart was in the hands of the surveyors. Under those circumstances, however, acceptable protocol requires that the nurse request the return of the notes so that essential information can be timely recorded. Finally, Respondent contended that the surveyor had told her that she could finish her "medication pass" before removing the socks and could do so whenever she had time. This assertion is not deemed to be credible.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Nursing enter a final order finding that Respondent is guilty of the violations described in the Administrative Complaint. It is further recommended that Respondent be fined $1,000.00, given a reprimand, and placed on probation for two years subject to such conditions as the Board deems appropriate. DONE AND ENTERED this 7th day of November, 2000, in Tallahassee, Leon County, Florida. DONALD R. ALEXANDER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 7th day of November, 2000. COPIES FURNISHED: Ruth R. Stiehl, PhD., R.N., Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Diane K. Kiesling, Esquire Agency for Health Care Administration Building 3, Room 3231A 2727 Mahan Drive Tallahassee, Florida 32308 Sheila Key 3651 Dignan Street Jacksonville, Florida 32254 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way Bin A02 Tallahassee, Florida 32399-1701
Findings Of Fact The Respondent, Cindy Louise Jirak, was licensed as a Registered Nurse pursuant to Florida law on May 14, 1979. Her license was last actively renewed to May 30, 1983, and now is in a lapsed status. P. Ex. 1. The Respondent was employed as a licensed Registered Nurse at the Central Florida Regional Hospital in Sanford, Florida, during the six month period up to and including October, 1986. On July 8, 1986, the Respondent was on duty as a licensed Registered Nurse and improperly set up intravenous fluids for a patient. The Respondent set up a previously ordered fluid, stating that the currently ordered fluid was not available. The correct procedure when a currently ordered fluid is not available is to hang a normal saline solution. By hanging the previously ordered solution, the Respondent's procedure was below minimally acceptable nursing practice. On October 6, 1986, the Respondent failed to turn on an intravenous solution pump after hanging an intravenous solution. The patient, therefore, did not receive the fluid that had been hung. The Respondent's action in failing to turn on the pump on October 6, 1986, was below minimally acceptable nursing practice. On August 23, 1986, the Respondent signed out 10 milligrams of morphine (one ampule) to be administered to a patient. Only 6 milligrams had been ordered for that patient. The procedure is to waste the excess before the narcotic is administered, and to have that act of wasting witnessed. The "waste and/or destroyed narcotic disposition record" shows that 4 milligrams were properly wasted since only 6 milligrams had been ordered for this patient. The records show that the 6 milligrams were then refused by the patient, but there is no subsequent entry to show that the 6 milligrams of morphine were properly wasted by the Respondent. The Respondent's failure to record the wasting of the 6 milligrams of morphine on August 23, 1986, was below minimally acceptable nursing practice. On August 22, 1986, the Respondent left two doses of Bumax in her cart with no explanation as to why the medication was not given. She was responsible for administration of that medication to a patient under her care, and the medication had been ordered for the patient. The medication was not given to that patient as ordered on that evening, and the Respondent did not make an entry in the records that the medication had not been administered. The Respondent's failure to administer the prescribed medication, or to chart that failure to do so, is below minimally acceptable nursing practice.
Recommendation It is recommended that the Department of Professional Regulation, Board of Nursing, enter its final order suspending the registered nursing license of Cindy Louise Jirak for a period of two years. DONE and ENTERED this 31st day of August, 1987. WILLIAM C. SHERRILL, JR. Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 31st day of August, 1987. COPIES FURNISHED: Judie Ritter, Executive Director Board of Nursing Department of Professional Regulation Room 504, 111 East Coastline Drive Jacksonville, Florida 32201 Van Poole, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Joseph Sole, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 John Namey, Esquire 22 East Pine Street Orlando, Florida 32801 Cindy Jirak 2718 Dellwood Drive Eustis, Florida 32726 =================================================================
