EVERYDAY, IT seems, I get a call from a physician or an insurance carrier to discuss coding the use of specific clinical technology or the proper and appropriate utilization of said technology.

In the era of health care reform, it is important to understand the very simple concept that is driving the use of technology: Who can deliver the best outcomes for the least cost per patient? This concept is rooted in a fundamental concept that we are well familiar with: medical necessity.


To review, the concept of medical necessity means: The medical record must clearly demonstrate the service, procedure or test ordered and performed was absolutely necessary to diagnose, treat or monitor the treatment of the patient’s condition. Put in basic terms – you must document what test you want to do with the patient, why you want to do it and how it will add to the patient’s clinical outcome. Most importantly, you must do this before you perform the test.

For far too long, the economic benefit has driven utilization of clinical testing. However, with carriers and the public monitoring our individual utilization rates, there is a definite crackdown by the carriers to pay for tests not properly justified in the medical record. If you haven’t checked out your own statistical breakdown of CPT utilization on sites like or on the CMS website, I encourage you to do so. You can also see if you are within the mean utilization of your peer group or a few standard deviations away, thus an outlier. Unfortunately, outliers are getting a lot of attention — unwanted attention — in the form of audits by the carrier.


The razor’s edge of technology advancement and measuring outcomes demands that each of us reexamine how we utilize technology in our practices. If you are in the habit of running a number of tests on a patient just because he or she has a specific diagnosis, and your clinical testing pattern looks identical on each patient, you probably need to pay closer attention to the needs of the individual patient and order tests that clinically aid you in delivering the best outcome for that specific patient. If you are billing an insurance company for taking fundus photographs (92250, not screening photos) on patients just to document a normal baseline retina, or if you are taking serial photos of a retinal pathology for which there is no demonstrable change, then you should reexamine your clinical testing patterns.


The technology available to us today in clinical practice is phenomenal, however indiscriminate use of this technology just to drive revenues without the proper medical necessity established in the record puts you at risk. Harnessing this technology to drive appropriate clinical outcomes will not only help you, but will benefit your patient and the health care system at large. OM