99245 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians

Name of the Procedure:

Office Consultation for a New or Established Patient

Summary

An office consultation typically involves a thorough review of a patient's medical history, a comprehensive physical examination, and a medically complex decision-making process to create an appropriate treatment plan. This may also include counseling and coordination of care with other healthcare providers.

Purpose

This procedure addresses various medical conditions and concerns requiring in-depth evaluation. The goals are to diagnose or better understand the patient's condition, establish or modify a treatment plan, and coordinate care for optimal outcomes.

Indications

• New patients presenting with undiagnosed symptoms.
• Established patients with new or worsening symptoms.
• Chronic disease management requiring a complex care plan.
• Patients needing expert opinion or a second opinion.
• Situations where multidisciplinary coordination is essential.

Preparation

• Patients may need to bring prior medical records, including test results and medication lists.
• Fasting or specific preparations may be required if certain diagnostic tests are scheduled.
• Patients may need to adjust or withhold medications as advised.

Procedure Description

1. Comprehensive History: Detailed discussion of the patient's medical, surgical, family, and social history along with current symptoms.
2. Comprehensive Examination: Full physical examination focusing on relevant body systems.
3. Medical Decision Making: Involves evaluating complex data, formulating diagnoses, and creating treatment plans.
4. Counseling and Coordination: Discussion of findings, treatment options, possible referrals, and coordination with other healthcare providers as necessary.

Duration

Typically ranges from 30 to 60 minutes.

Setting

Conducted in an outpatient clinic or office setting.

Personnel

• Primary care physician or specialist
• Nursing staff for assistance and patient preparation

Risks and Complications

The procedure itself carries minimal risk. However, potential risks may include:

• Emotional discomfort from discussing sensitive health issues.
• Minor physical discomfort during the examination.
• Miscommunication leading to misunderstanding or incorrect treatment plans.

Benefits

• Accurate diagnosis and appropriate treatment plan.
• Improved management of complex or chronic conditions.
• Enhanced coordination of care leading to better health outcomes.
• Immediate feedback and advice during the consultation.

Recovery

• The patient may resume normal activities immediately following the consultation.
• Follow-up appointments are often scheduled to monitor progress and adjust treatment plans.

Alternatives

• Telemedicine consultations.
• Specialist consultations for specific conditions.
• Routine check-ups with primary care provider.

Pros of alternatives include convenience and focused care, while cons may involve reduced comprehensiveness and coordination in comparison to an in-depth office consultation.

Patient Experience

During the procedure:

• The patient may feel comfortable as they discuss their health concerns.
• Mild discomfort during the physical examination depending on the areas examined.

Post-procedure:

• The patient should feel informed and supported with a clear path for managing their health.
• Pain management is typically unnecessary, but emotional support and follow-up are essential for addressing any concerns.