Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service pro
CPT4 code
Name of the Procedure:
Telephone Evaluation and Management Service
Common Names: Telephone consult, Telehealth evaluation
Summary
A telephone evaluation and management service involves a healthcare professional evaluating and providing management advice to an established patient, parent, or guardian over the phone. This remote consultation aims to address health issues without requiring a physical visit.
Purpose
Medical Conditions Addressed:
- Routine follow-up on chronic conditions
- Minor acute issues that can be managed remotely
- Monitoring and advice for ongoing treatments
Goals and Expected Outcomes:
- Convenient and timely medical advice
- Effective management of minor health concerns
- Reduced need for in-person visits
- Improved accessibility to healthcare
Indications
Symptoms or Conditions Warranting the Procedure:
- Mild symptoms such as cold, flu, minor injuries
- Chronic disease management (e.g., diabetes, hypertension)
- Medication management or adjustments
- Follow-up after a prior in-person visit
Patient Criteria:
- Established relationship with the healthcare provider
- Non-emergency health concerns
Preparation
Pre-procedure Instructions:
- Have medical history and current medication list available
- Be prepared to describe symptoms clearly
Diagnostic Tests or Assessments:
- May require prior diagnostic results, but not typically necessary
Procedure Description
- Scheduling: The patient schedules a telephone consultation.
- Initial Contact: The healthcare professional calls at the designated time.
- Health Evaluation:
- Review of symptoms and medical history
- Discussion of current health status
- Management Plan:
- Provide medical advice
- Adjust medications if necessary
- Discuss follow-up actions or referrals if needed
- Documentation: The healthcare professional documents the interaction in the patient’s medical record.
Tools, Equipment, Technology:
- Telephone
Anesthesia or Sedation:
- Not applicable
Duration
Typically lasts 10-30 minutes, depending on the complexity of the patient's needs.
Setting
Conducted via telephone, typically while the healthcare professional is in a private, confidential setting like an office or home office.
Personnel
- Physician or other qualified healthcare professional (e.g., nurse practitioner, physician assistant)
Risks and Complications
Risks:
- Miscommunication due to lack of physical examination
- Potential for missing a more serious condition
Complications:
- Misdiagnosis or delayed diagnosis if symptoms are not accurately described
Benefits
- Increased convenience and accessibility
- Reduced need for travel
- Quicker access to healthcare advice
- Continuity of care
Recovery
Post-Procedure Care:
- Follow any advice or medication adjustments provided
- Schedule follow-up appointments if necessary
Expected Recovery Time:
- Immediate advice provided, no physical recovery needed
Restrictions:
- Follow any specific instructions given during the call
Alternatives
Other Treatment Options:
- In-person visits to a clinic or hospital
- Video telehealth consultations
Pros and Cons:
- In-Person Visits: Provide a more thorough evaluation but require travel and time.
- Video Consultations: Offer visual assessment capabilities but need internet access and technology.
Patient Experience
During Procedure:
- Expect a thorough discussion of your health concerns.
- Be prepared to answer questions about your symptoms and medical history.
After Procedure:
- Immediate access to medical advice.
- Minimal to no discomfort or pain associated with the procedure.
- Follow instructions for any further care or medication adjustments.