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In order for a service to be considered a consultation, the following four criterias must be met and documented:

The consultation request

The reason for the request

The services rendered

The report from the consultant physician

Remember these as the four R's: request, reason, render and report.

The requesting physician should document the request for consultation in the patient record, noting the specific reason for the consultation and how the consultant physician was contacted (e.g., phone, fax or letter). Likewise, the consultant physician should document that the consultation was requested, by whom and why.

The consultation services rendered should be documented following the established guidelines for evaluation and management.

The consultant physician should provide a written report of services provided, findings and recommendations or planned follow-up. Where the requesting physician and consultant physician share a common patient record, this documentation can be included in the patient's progress notes. Otherwise, a copy of the consultant's written report should be included in the patient's record.

Whether you are the requesting physician or the consultant physician, documentation is important. Consultations are valued more highly than other office visits or outpatient visits and may become subject to payer scrutiny.

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