Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care
CPT4 code
Name of the Procedure:
Office Consultation for a New or Established Patient
Summary
An office consultation is a medical appointment for new or established patients that involves an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making. This consultation also includes any necessary counseling and coordination of care.
Purpose
The purpose of an office consultation is to assess, diagnose, and create a treatment plan for the patient's medical condition or concern. The goal is to provide a clear path to better health through initial assessment, intervention, or referral to a specialist.
Indications
- New symptoms or health concerns
- Follow-up on ongoing medical issues
- Need for specialist referral
- Health check-ups and screenings
- Coordination of care among multiple healthcare providers
Preparation
- Gather medical history, including current medications and prior treatments.
- No specific preparation needed unless directed by the healthcare provider.
- May need to bring previous medical records, lab results, or imaging reports.
Procedure Description
- Expanded Problem-Focused History: The healthcare provider will discuss the patient's medical history, focusing on the specific problem or symptoms.
- Expanded Problem-Focused Examination: A thorough physical examination will be conducted, targeting the areas related to the patient's symptoms or concerns.
- Medical Decision Making: Based on the history and examination, the provider will make straightforward medical decisions, which may involve diagnosing the condition, prescribing treatment, or ordering tests.
- Counseling and Coordination of Care: The provider will offer advice and coordinate further care if necessary, including specialist referrals or follow-up appointments.
Duration
Typically, the consultation lasts 15 to 30 minutes.
Setting
The consultation is performed in an outpatient clinic or a doctor's office.
Personnel
- Primary Healthcare Provider (e.g., General Practitioner, Family Doctor)
- Nurses or Medical Assistants (for vitals and preliminary assessments)
Risks and Complications
- Minimal risk as it is a non-invasive consultation
- Potential for misdiagnosis if key information is not shared or known
Benefits
- Accurate diagnosis and tailored treatment plan
- Early detection and management of health issues
- Comprehensive care coordination Benefits are typically realized immediately following the consultation, with further outcomes depending on subsequent treatment.
Recovery
- No recovery time needed as the consultation is non-invasive.
- Follow post-consultation instructions provided by the healthcare provider.
- Schedule follow-up visits as recommended.
Alternatives
- Telemedicine consultation
- Visiting an urgent care clinic for immediate but less comprehensive consultations
- Seeking a second opinion from another healthcare provider Alternatives may offer varying levels of detail and follow-up compared to a thorough office consultation.
Patient Experience
- During the consultation, the patient may undergo a detailed discussion and a focused physical exam.
- Generally, the process is comfortable, but some discussions or physical examinations might cause mild discomfort.
- Any discomfort is usually brief and manageable without the need for sedation or anesthesia.
Pain management is typically unnecessary, and measures are taken to ensure the patient's comfort throughout the visit.