Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physician
CPT4 code
Name of the Procedure:
Office Consultation for New or Established Patient
Common name(s): Office Visit, Medical Evaluation
Technical/Medical terms: Evaluation and Management (E&M) services
Summary
An office consultation for either new or established patients involves a comprehensive evaluation, including a focused history and physical examination. The goal is to make straightforward medical decisions, and the consultation may include counseling and coordination of care with other healthcare professionals.
Purpose
The procedure addresses various medical conditions or symptoms that need initial evaluation or ongoing management. The goals are to diagnose or follow up on health issues, develop a treatment plan, and provide necessary medical advice or referrals.
Indications
- New symptoms or concerns such as pain, infections, or abnormal lab results
- Chronic conditions like diabetes, hypertension, and asthma requiring monitoring
- Need for a second opinion or specialist referral
- Follow-up visits for previously diagnosed conditions
Preparation
- Bring a list of current medications, allergies, and past medical history.
- Keep a symptom diary if relevant.
- Prepare any previous medical records or test results.
- Fasting or special preparation is generally not required unless otherwise instructed for specific diagnostic tests.
Procedure Description
- History Taking: The healthcare provider will discuss your symptoms, medical history, and any relevant lifestyle factors.
- Examination: A focused physical examination will be conducted based on the reported symptoms.
- Decision Making: The provider will review the findings and make straightforward medical decisions such as prescribing medication, ordering tests, or referring to specialists.
- Counseling/Coordination: If needed, the provider will offer counseling, discuss the care plan, and coordinate with other healthcare professionals.
Tools/Equipment: Basic diagnostic tools such as a stethoscope, blood pressure cuff, otoscope, and examination bed.
Anesthesia: Not applicable.
Duration
Typically ranges from 15 to 30 minutes.
Setting
Outpatient setting, usually performed in a physician’s office or clinic.
Personnel
- Primary healthcare provider (Family Physician, Internist)
- Medical assistant or nurse
Risks and Complications
Very minimal risks. Potential issues could include:
- Misdiagnosis due to incomplete information.
- Delayed diagnosis if symptoms are not fully disclosed.
Benefits
- Accurate diagnosis and management of health conditions.
- Immediate medical advice and treatment plans.
- Coordination with other healthcare providers for comprehensive care.
- Benefits can be realized immediately as a treatment plan is developed during the visit.
Recovery
- No specific recovery needed; patients can resume normal activities immediately.
- Follow-up appointments may be scheduled based on the initial evaluation and medical plan.
Alternatives
- Telemedicine consultation: convenient but may limit physical examination.
- Emergency room visit: appropriate for urgent or severe symptoms.
- Specialist consultation directly, if dealing with specific symptoms that may require specialized care.
Patient Experience
During the visit, patients may feel relieved to discuss and address their health concerns directly with a provider. Minimal discomfort, primarily during the physical examination. There will be ample opportunity for patients to ask questions and understand their health condition and treatment plan. Comfort measures such as sitting or lying down during the visit will be provided to ensure a relaxed experience.