Subsequent nursing facility 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 moderate complexity. Counseling
CPT4 code
Name of the Procedure:
Subsequent Nursing Facility Care, per day, for the Evaluation and Management of a Patient
Summary
This procedure involves daily evaluation and management of a patient in a nursing facility. It requires at least two of the following three components: a detailed interval history, a detailed examination, and medical decision-making of moderate complexity. Additionally, counseling may be provided as part of the care.
Purpose
The procedure addresses ongoing medical conditions or emerging health issues in patients residing in a nursing facility. The goal is to monitor and manage the patient's health, adjust treatment plans as needed, and improve overall well-being.
Indications
- Chronic or acute medical conditions requiring continuous monitoring
- Post-surgical recovery
- Aging-related health issues
- Frequent medication adjustments
Preparation
- Ensure patient's medical records are up-to-date.
- Review recent diagnostic tests and assessments.
- No specific patient preparation is usually required unless specified by the healthcare provider.
Procedure Description
- Detailed Interval History: Review the patient's medical history since the last visit, including any new symptoms or changes in condition.
- Detailed Examination: Conduct a thorough physical examination to assess the patient's current health status.
- Medical Decision Making: Based on the findings, make decisions regarding the continuation, adjustment, or introduction of treatments or interventions.
- Counseling: Provide counseling and education to the patient and/or family members about the patient's condition, treatment plans, and any lifestyle or care modifications.
Duration
Each session typically takes about 15-30 minutes.
Setting
The procedure is performed in a nursing facility where the patient resides.
Personnel
- Primary care physician or geriatric specialist
- Nursing staff
- Support staff, if necessary
Risks and Complications
- Misinterpretation of the patient's symptoms or condition due to limited information
- Medication side effects or interactions
- Delayed response to acute medical situations
Benefits
- Continuous monitoring and timely intervention for medical issues
- Enhanced patient care and management of chronic conditions
- Improved quality of life for the patient
Recovery
- Ongoing daily care with adjustments made based on the patient's needs
- Regular follow-up visits and communication with the healthcare team
Alternatives
- Home health care services
- Outpatient clinic visits for specific medical concerns
- Telemedicine consultations
Patient Experience
Patients can expect regular interactions with healthcare professionals who will assess their health, provide necessary treatments, and offer guidance. Pain management and comfort measures are always a priority to ensure the patient feels well-cared-for in the nursing facility.