Practice Quiz

Medical Coding

Category - Evaluation and Management

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In order for a physician to appropriately code for a consultation service, three things must be documented. What are those three things?
  1. The referral or request from the PCP, the rendering of the opinion by the specialist or consultant, and the written report or findings sent from the specialist to the PCP.
  2. The rendering of the specialty service to the patient, the referral of the patient from the specialist to an additional specialist, and the written report of the findings provided to the specialist.
  3. The specialist request of a second opinion regarding the patient, the PCP’s advice regarding which second specialist the patient should see, and the second specialist’s report or findings.
  4. The referral from the PCP to the specialist, an additional referral from the specialist to another specialist, and the written report or findings sent from the specialist to the PCP.
Explanation
Answer: A - In order for a physician to appropriately code for a consultation service, three things must be documented. These three things are: the referral or request from the PCP, the rendering of the opinion by the specialist or consultant, and the written report or findings sent from the specialist to the PCP. These three things can be easily remembered by the “Three R’s:” “Referral to Specialist,” “Rendering of Service” and “Report to PCP.”
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