For each consultation, documentation should include:

✓ Requesting Provider – Name and specialty

✓ Reason for Consultation – Clear clinical question

✓ History of Present Illness (HPI) – Detailed and relevant to the problem

✓ Physical Examination – problem-focused or extended based on patient acuity

✓ Physical Exam Findings – Problem-focused or comprehensive 

✓ Medical Decision Making (MDM)

• Number/complexity of problems
• Data reviewed, ordered, or analyzed
• Risk of complications or morbidity

✓ Assessment & Plan – Consultant’s opinion, differential diagnosis, recommendations

✓ Communication – Document discussion / recommendations with requesting provider

✓ Time-Based Coding Option – If counseling / care coordination dominates (≥50%), total time may determine code. Document time spent, activities, and participants.