Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qua
CPT4 code
Name of the Procedure:
Office Consultation for a New or Established Patient
Common name(s): Medical Consultation, Patient Evaluation
Technical term: Evaluation and Management (E/M) Service
Summary
This is a comprehensive medical consultation where a healthcare provider evaluates a patient's health by taking a detailed medical history, performing a thorough physical examination, and making medical decisions of low complexity based on the findings. Counseling and coordination of care with other healthcare professionals are also commonly involved.
Purpose
The purpose of this consultation is to assess and manage the patient's health concerns, provide a diagnosis, develop a treatment plan, and coordinate further care as needed. The expected outcome is to understand the patient’s health status and to initiate a management plan suited to their needs.
Indications
- New or worsening symptoms that require evaluation
- Ongoing medical conditions needing follow-up
- Referral from another physician for specialized care
- General wellness check-ups for preventive health
Preparation
- Patients may be asked to bring a list of current medications and previous medical records.
- Some patients might need to fast or undergo basic diagnostic tests prior to the consultation.
- Complete any pre-consultation forms provided by the office.
Procedure Description
- Detailed History: The provider will ask about your medical history, family history, lifestyle, and current symptoms.
- Detailed Examination: A thorough physical examination, including vital signs measurement, will be performed.
- Medical Decision Making: Low complexity decisions regarding diagnosis and treatment options will be made based on the history and examination.
- Counseling and Coordination: Discussions with other healthcare providers and counseling about further management or tests may occur.
Tools and Equipment:
Stethoscope, blood pressure cuff, thermometer, otoscope, and other examination tools.
No anesthesia or sedation is typically required for this consultation.
Duration
The consultation generally takes between 30 to 60 minutes.
Setting
This procedure is performed in an outpatient setting, such as a medical office or clinic.
Personnel
- Primary care physician or specialist
- Nurses or medical assistants to assist with history taking and vital signs
Risks and Complications
- There are minimal risks associated with an office consultation. Potential discomfort might occur during physical examination but is typically brief and manageable.
Benefits
- Accurate diagnosis and tailored treatment plan
- Early detection of possible health issues
- Comprehensive management of ongoing medical conditions Benefits are usually realized immediately following the consultation and through the ensuing treatment plan.
Recovery
- Immediately after the consultation, patients can resume normal daily activities unless specific tests or treatments are needed.
- Follow-up appointments may be planned based on the initial findings.
Alternatives
- Telehealth consultation for remote patients
- Urgent care visits for acute symptoms
- Specialist referral for specific health issues Each alternative has its set of pros and cons, particularly regarding accessibility, thoroughness, and immediacy of care.
Patient Experience
During the consultation, patients might experience questions about their health and some physical contact during the examination. Post-consultation discomfort is minimal. Any pain or discomfort during examination (e.g., checking for tender spots) is usually brief and temporary. Comfort measures and clear communication are used to ensure the patient feels at ease.