I believe Medicare follows the same guidelines as those in the CPT book. 2 of the 3 must be met; however, medical necessity must also be a contributing factor. Does the nature of the presenting problem, what it takes for the phyisican to work it up, and course of treatment constitue a higher or lower level of medical necessity. A good question for the doctor to ask himself would be "What would my peers do?" in the same case situation (must compare apples to apples!)
For example as work up/tx of a possible UTI in a healthy 35yo woman who has had UTIs in the past is most likely a bit less complicated than that of a 78yo shut-in with confusion and not other presenting symptoms.
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