What is a Medicare Medically Necessary Service?

Urologists may be audited for having their patients give a urine specimen BEFORE being seen by the physician.  The theory of these audits is that Medicare medical necessity is being determined in advance of face to face physician or P.A. patient encounters.

By analogy, chiropractors who order X-rays on every patient before seeing them may also be subject to charges of renderingunnecessary services.

What is a medically necessary item or service is NOT based upon the clinical judgment of the physician but is determined instead by the governments after the fact medical necessity determination made during an investigation or audit.

Over the years doctors have been convicted for implanting cardiac stints,  for doing unnecessary angioplasty, and for rendering not medically necessary diagnostic tests conducted before examining the patient.

What is more alarming for all physicians is that Medicare does not clearly define what is a Medicare necessary item or test.  Medicare is only specific in saying that a physician attests to rendering reasonable and necessary items and services for the diagnosis or treatment of an illness or injury; or to improve the functioning of a malformed body member.  This is the certification a physician signs when submitting claims for payment.

Providers who do not document to substantially justify the items and services rendered may be subject to civil or CRIMINAL charges or physicians may be subject to both proceedings at the same time.

With the new ICD-10 coding system (which increases the number of diagnostic codes from 13,000 to 69,000 possible choices of diagnostic menus), providers must be very precise in their selection of codes and have correct documentation.  Even an honest mistake could lead to civil fraud which carries substantial penalties.