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Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

CPT4 code

Name of the Procedure:

Online Digital Evaluation and Management Service for Established Patient (Telemedicine Follow-up)

Summary

This procedure involves a healthcare provider evaluating and managing an established patient's medical condition through digital communication platforms over a 7-day period, with cumulative time spent of 5-10 minutes. This is often referred to as a telemedicine follow-up.

Purpose

This procedure addresses ongoing medical issues or follow-up needs for patients who have previously been seen by their healthcare provider. The main goal is to monitor the patient's condition, adjust treatment plans if necessary, and provide medical advice without the need for an in-person visit.

Indications

  • Chronic disease management (e.g., diabetes, hypertension)
  • Post-treatment follow-up
  • Minor illnesses or conditions that do not require physical examination
  • Medication management and adjustments
  • Review and interpretation of laboratory or diagnostic test results

Preparation

  • Ensure access to a reliable internet connection and a communication device (computer, smartphone, tablet).
  • Gather any medical records or information relevant to your condition.
  • Prepare a list of questions or concerns to discuss with your healthcare provider.

Procedure Description

  1. Initiation: The patient logs into a secure digital platform as directed by their healthcare provider.
  2. Communication: Using messaging, video conferencing, or email, the patient exchanges information with their provider.
  3. Evaluation: The healthcare provider reviews the patient's symptoms, test results, and any other relevant information.
  4. Management: The provider offers medical advice, adjusts treatment plans, prescribes medications if necessary, and schedules any required tests.
  5. Follow-up: Continuous communication may happen over the span of 7 days, totaling 5-10 minutes of the provider’s time during this period.

Tools used include secure digital communication platforms and electronic health records (EHR) systems. No anesthesia or sedation is required.

Duration

5-10 minutes cumulative time over up to 7 days.

Setting

This procedure is performed remotely, typically from the patient’s home and the healthcare provider’s office or another secure location.

Personnel

  • Primary healthcare provider (e.g., doctor, nurse practitioner, physician assistant).

Risks and Complications

  • Miscommunication or misunderstanding of symptoms.
  • Technical issues such as poor internet connection.
  • Delayed diagnosis due to lack of physical examination.

Benefits

  • Convenient access to healthcare.
  • Timely medical advice without the need for an in-person visit.
  • Continuity of care for ongoing medical conditions.
  • Reduced exposure risk, particularly important during infectious disease outbreaks.

Recovery

There is no physical recovery process needed. Patients should follow their provider's advice and any prescribed treatment plan. Any necessary follow-up appointments will be scheduled as needed.

Alternatives

  • In-person visit: Provides direct physical examination but requires travel and time.
  • Telephone consultation: Convenient but lacks visual assessment.
  • Urgent care or emergency room visit: Necessary for acute or severe symptoms but may involve longer wait times and higher costs.

Patient Experience

Patients may experience convenience and ease with digital communications. Occasionally, technical difficulties might cause frustration. Patients should feel minimal discomfort and are encouraged to communicate any issues or concerns with their healthcare provider promptly.

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