99452 Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes

Name of the Procedure:

Interprofessional Telephone/Internet/Electronic Health Record Referral Service(s) by Treating/Requesting Physician or Other Qualified Health Care Professional, 30 minutes
Common Name: Interprofessional Referral Consultation

Summary

This procedure involves a healthcare professional consulting with another physician or specialist over the phone, via internet communication, or through an electronic health record system. The purpose is to get expert advice or support regarding a patient's care for about 30 minutes.

Purpose

The primary aim of this procedure is to address complex medical issues or questions that a treating physician might have regarding a patient's condition. The goals include accurate diagnosis, optimal treatment planning, and improved patient outcomes.

Indications

• Unclear diagnosis that requires specialist insight
• Complex treatment planning needing interdisciplinary collaboration
• Patient conditions that are not responding to standard treatments
• Pre-surgical evaluations or clarifications
• Coordination of care for patients with multiple conditions

Preparation

• Ensure all relevant patient information and medical records are available.
• If needed, patients may be asked to undergo certain diagnostic tests.
• Patients should be informed about the referral and its purpose.

Procedure Description

1. The treating physician prepares a detailed brief about the patient’s case.
2. They contact a relevant specialist or healthcare professional via phone, internet communication, or a secure electronic health record system.
3. Both professionals discuss the patient’s case, including medical history, current symptoms, and previous treatments.
4. Together, they develop a care plan or determine the next steps in the patient’s treatment.
5. Notes from the consultation are documented in the patient’s medical records.

Duration

The consultation typically takes 30 minutes.

Setting

This procedure occurs remotely and can be facilitated from the physician’s office, outpatient clinic, or any healthcare setting with appropriate communication capabilities.

Personnel

• Treating/Requesting Physician
• Consulting Specialist/Qualified Health Care Professional

Risks and Complications

While generally low-risk, potential issues include:

• Miscommunication or misunderstandings due to lack of face-to-face interaction.
• Incomplete medical histories if relevant patient information is not available.
• Technical difficulties with communication systems.

Benefits

• Access to specialist expertise without the need for patient travel.
• Timely and coordinated care, leading to potentially quicker and more accurate diagnoses and treatment plans.
• Better management of complex or ambiguous medical conditions.

Recovery

Patients are usually not directly involved in this procedure, so there is no recovery period. However, the outcome of the consultation may lead to new treatment plans or additional follow-ups.

Alternatives

• Direct referral for an in-person specialist consultation.
• Multidisciplinary team meetings or case reviews.
• Use of decision-support tools or guidelines without specialist input.

Pros of Alternatives: Direct specialist input, comprehensive team review.
Cons of Alternatives: May require more time, patient travel, and scheduling coordination.

Patient Experience

Patients might not be directly involved, but they may experience the benefits through improved care plans. Any subsequent changes in treatment or additional consultations will be communicated by the treating physician.