Consultation, comprehensive, with review of records and specimens, with report on referred material
CPT4 code
Name of the Procedure:
Consultation, comprehensive, with review of records and specimens, with a report on referred material Common name: Comprehensive medical consultation
Summary
A comprehensive medical consultation involves a thorough examination and review of a patient's medical records and specimens, culminating in a detailed report. This procedure is essential for diagnosing complex conditions and formulating an effective treatment plan.
Purpose
This procedure is used to diagnose and manage complex or unclear medical conditions. The goal is to provide a thorough assessment and generate a comprehensive report, guiding future treatment and care.
Indications
- Patients with undiagnosed symptoms
- Complex medical histories or multiple chronic conditions
- Need for a second opinion on diagnosis or treatment
- Pre-surgical assessment and planning
Preparation
- Bring all relevant medical records, including imaging results and pathology reports.
- List all current medications, including doses and schedules.
- Fast if lab tests requiring fasting will be part of the consultation.
Procedure Description
- Initial patient interview and medical history review.
- Physical examination to assess current health status.
- Detailed review of medical records and specimens (e.g., biopsy samples, imaging results).
- Specialist may consult with other experts as necessary.
- Comprehensive report generation, summarizing findings and recommendations.
Tools/Equipment: Medical records, imaging studies, laboratory specimens Anesthesia: Not applicable
Duration
Typically 1-2 hours.
Setting
Outpatient clinic or specialized consultation center.
Personnel
- Primary care physician or referring specialist
- Consulting specialist(s)
- Nurses or medical assistants
- Pathologists or radiologists as needed
Risks and Complications
- Minimal risks, primarily associated with any diagnostic tests performed.
- Rare complications could involve anxiety or discomfort from the thorough review process.
Benefits
- Accurate diagnosis and effective treatment plan.
- Comprehensive understanding of medical issues.
- Personalized care recommendations.
Recovery
- No recovery time needed.
- Follow-up appointments as recommended for further tests or treatments.
- Adherence to any new treatment plans or medication regimens.
Alternatives
- Basic consultation without an in-depth review
- Referral to another specialist for a second opinion
Self-research and management (not recommended for complex cases)
Pros and cons: Thorough consultations provide detailed insights but are more time-consuming and potentially costly compared to basic consultations.
Patient Experience
- Patients may feel reassured by the detailed attention to their medical history.
- Some anxiety may occur while waiting for the final report.
- Comfort measures include a supportive environment and clear communication from healthcare providers. Pain management: Not applicable