Preoperative consultation is an important intervention that likely has most benefits for intermediate-risk to high-risk patients undergoing major surgery. Consultation rates are likely increasing and there is significant practice variation in the use of consultation. Consultations should be available within a well-organized and coordinated process of preoperative assessment. Preoperative consults should be accessible to anesthesia and surgical teams involved in the procedure and to the providers involved in postoperative care. The role of preoperative consultation should evolve as a rational approach and emerge as a value-based service. New payment methodologies are likely to facilitate appropriate use of this important resource.