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Anesthesia Coding Alert

Consult Checklist

Published on Wed Aug 16, 2006

Before you can code any type of consult, your physician must document the four R's of consultations:
 
• The consultation request (whether verbal or written) must be documented in the patient's medical record. The documentation must include the name of the requesting physician (or another appropriate source).

• The request must include the reason for the consult.

• The consulting physician must render an opinion and make recommendations for the patient's care. He must also document any services performed as part of the consultation.

• The consulting physician must send a written report to the requesting physician and include a copy of the report in the patient's record. This report can be in the form of a letter, a completed hospital preoperative form, or a copy of the patient's progress notes.
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