Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coor
CPT4 code
Name of the Procedure:
Subsequent Hospital Care, Per Day (CPT Code 99233)
Summary
This is a daily medical service provided to patients already admitted to the hospital. It involves a detailed evaluation and ongoing management of the patient’s condition by a healthcare provider. The process includes taking an in-depth medical history, conducting a thorough physical examination, and making complex medical decisions regarding the patient's treatment plan.
Purpose
The purpose of this procedure is to manage and monitor patients who are hospitalized. The goals are to assess the progress of the patient's illness or condition, adjust treatment plans as necessary, and ensure optimal recovery. It is crucial for identifying any new issues, complications, or needed changes in therapy.
Indications
- Patients with severe or complex medical conditions requiring daily monitoring.
- Individuals undergoing treatment for chronic or acute conditions needing continual assessment.
Hospitalized patients with unstable or shifting clinical statuses.
Preparation
- No special preparation is usually required from the patient.
- Patients should provide any new symptoms or medical information to their healthcare provider.
- Routine vital signs and lab tests may be performed as needed for ongoing assessment.
Procedure Description
- The healthcare provider will review the patient’s medical records, including any lab results, imaging studies, and notes from other healthcare professionals.
- The provider will conduct a detailed interval history to gather information on new symptoms, changes in current symptoms, overall progress, and patient's concerns.
- A detailed physical examination will be performed to assess the patient’s status.
- The provider will make medical decisions regarding the treatment plan, which may include ordering additional tests, adjusting medications, or planning for further interventions.
- Counseling or coordination of care with other healthcare providers may also be provided.
Duration
Each daily evaluation and management session typically lasts between 15 to 30 minutes, though this can vary based on the patient's condition and complexity of care required.
Setting
This procedure is performed in an inpatient hospital setting.
Personnel
- Attending physician or hospitalist
- Nursing staff supporting the physician
- Specialists or consultants if needed
Risks and Complications
- There are minimal direct risks associated with the evaluation itself.
- Potential risks lie in the interpretation of patient data and decision-making impact on the treatment plan.
- High-risk medical decision making may involve procedures or treatments with their own associated risks.
Benefits
- Close monitoring to manage and address health issues promptly.
- Personalized adjustments to treatment plans based on the latest patient information.
- Improved outcomes through coordinated and responsive medical care.
Recovery
- No recovery period is associated directly with the evaluation process.
- Follow-through with the amended or new treatment plans is essential.
- Any specific post-procedure care and instructions will depend on the patient’s evolving treatment plan.
Alternatives
- Outpatient follow-ups if the patient's condition stabilizes and hospitalization is no longer required.
- Telehealth consultations for less critical conditions or if allowed by the patient's situation and hospital policy.
- The alternative of a less frequent in-person evaluation may risk delayed response to changes in the patient's condition.
Patient Experience
- Patients may experience reassurance from regular face-to-face interactions with their healthcare provider.
- Any discomfort would generally arise from the physical examination itself, not the evaluation.
- Pain management and comfort measures will be addressed as necessary, depending on the patient’s condition and treatment plan.