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Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
CPT4 code
Name of the Procedure:
Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes.
Summary
This procedure involves an online digital assessment and management conducted by a qualified nonphysician healthcare professional for an established patient over a cumulative period of up to 7 days. The total time spent on the assessment and management activities ranges from 11 to 20 minutes.
Purpose
The medical condition or problem it addresses:
- Chronic disease management
- Acute symptom evaluation
- Follow-up assessments for ongoing treatments
The goals or expected outcomes of the procedure:
- To provide timely medical advice and management
- To adjust treatment plans as necessary based on the patient's reported symptoms and conditions
- To ensure continuity of care and prevent unnecessary hospital visits
Indications
Specific symptoms or conditions that warrant the procedure:
- Mild to moderate exacerbations of chronic conditions
- Post-operative symptom check-ins
- Monitoring and adjustment of medication
Patient criteria or factors that make the procedure appropriate:
- Established patients who need follow-up care
- Patients preferring digital communication for convenience
- Individuals with access to necessary digital devices and internet
Preparation
Pre-procedure instructions for the patient:
- Ensure access to a stable internet connection
- Have a list of current medications and any recent changes ready
- Prepare notes on symptoms and any specific concerns to discuss
Any diagnostic tests or assessments required beforehand:
- No specific tests required beforehand unless indicated by ongoing treatment
Procedure Description
Detailed step-by-step explanation:
- Scheduling: The patient schedules an online assessment.
- Digital Communication: Interaction occurs through a secure digital platform (e.g., patient portal, video call, secure messaging).
- Medical History Review: The professional reviews the patient’s medical history and recent reports.
- Symptom Assessment: The patient describes symptoms and concerns.
- Management Plan: The professional offers advice, adjusts medications, or recommends further tests as needed.
- Documentation: All interactions and changes are documented for continuity of care.
Tools, equipment, or technology used:
- Secure digital communication platforms
- Electronic Health Records (EHR) systems
Anesthesia or sedation details, if applicable:
- Not applicable
Duration
The cumulative time for assessment and management over up to 7 days ranges from 11 to 20 minutes.
Setting
- Online, from the patient's home or any place with internet access.
Personnel
- Qualified nonphysician healthcare professionals such as nurse practitioners or physician assistants.
Risks and Complications
Common and rare risks associated with the procedure:
- Miscommunication due to lack of physical examination
- Potential for missed symptoms requiring in-person evaluation
Possible complications and their management:
- If symptoms worsen or new issues arise, patients may be advised to seek in-person care or emergency services.
Benefits
Expected benefits:
- Convenience and time-saving for patients.
- Prompt medical advice without needing to visit the clinic.
- Continuity of care and regular monitoring.
How soon they might be realized:
- Benefits can often be realized immediately after the interaction, especially if changes in management are needed.
Recovery
Post-procedure care and instructions:
- Follow the advice and management plan provided.
- Report any new or worsening symptoms promptly.
Expected recovery time and any restrictions or follow-up appointments:
- No recovery time as it’s a non-invasive digital procedure.
- Follow-up appointments as advised by the healthcare professional.
Alternatives
Other treatment options available:
- In-person visits for assessment and management
- Telephone consultations
Pros and cons of alternatives compared to the described procedure:
- In-person visits: More thorough physical examination (Pro), requires travel and time (Con).
- Telephone consultations: Convenient (Pro), no visual assessment (Con).
Patient Experience
What the patient might feel or experience during and after the procedure:
- Comfort of staying at home while accessing care.
- Potential concerns about the adequacy of digital assessments compared to in-person visits.
Pain management and comfort measures:
- Generally not applicable as the procedure is non-invasive and digital.