It has been said that the reason for visit (RFV) “drives the bus” for an encounter. That is to say that doctors should carefully tailor their case history, physical exam, and medical decision making based on the reason the patient is being seen. As an example, a patient presenting for an irritated right eye likely requires a different exam than one who complains of recent onset of flashes and floaters. In both instances, a case history, physical exam, and assessment and plan will take place. However, “how” the doctor proceeds through the visit will be quite different and it is that “how” that should determine the final coding for the encounter.
Auditors know this as well. If the patient presenting for an irritated right eye has a comprehensive case history and physical exam performed, the doctor can expect some questions in an audit surrounding the necessity of that level of service given the reason for visit. If the doctor can provide a valid rationale, great. If they cannot, however, recovery of money by the third party should be expected.
In the end, if the doctor provides exactly what is necessary to evaluate and manage the reason the patient is being seen that day, no more and no less, then they will be in great shape. This all starts with a clear and specific reason for visit so be sure that you are including that within documentation.