Name of the Procedure:

Prolonged Evaluation and Management Service before and/or after Direct Patient Care; First Hour (CPT Code 99358)

Summary

This procedure involves an extended assessment and management of a patient's health condition, both before and after direct patient care. It typically lasts for the first hour and includes an in-depth review of medical records, coordinating care, or discussing treatment plans.

Purpose

The procedure addresses complex medical conditions requiring thorough and detailed evaluation. The goal is to ensure comprehensive understanding and management of the patient's health, improving overall treatment outcomes.

Indications

• Chronic illness management (e.g., diabetes, heart disease)
• Complex diagnostic cases requiring extensive review
• Coordination of multidisciplinary care plans
• Preparation for major surgical procedures

Preparation

• Patients may need to provide comprehensive medical history and previous records.
• Specific diagnostic tests may be required beforehand, as per the healthcare provider’s recommendations.
• No special physical preparation like fasting is generally needed.

Procedure Description

1. Review and analysis of extensive medical records and patient history.
2. Consultations and discussions with other healthcare professionals involved in the patient's care.
3. Development or adjustment of detailed care plans or treatment strategies.
4. Communication with the patient and family about the care plan and next steps.
   • Tools: Computer systems for electronic medical records, telecommunication devices, and printed patient records.
   • No anesthesia or sedation is required as it is an evaluative service.

Duration

The initial session typically lasts for 1 hour. Follow-up sessions, if needed, may vary in length.

Setting

The procedure is usually performed in an office setting, outpatient clinic, or hospital.

Personnel

• Primary care physicians or specialists
• Nurses or nurse practitioners
• Medical assistants
• Administrative staff for coordination

Risks and Complications

There are minimal risks as the procedure is non-invasive. However, misunderstanding the assessment could delay appropriate treatment:

• Miscommunication between different healthcare providers
• Potential for incomplete or incorrect patient information leading to misinformation

Benefits

• Comprehensive understanding of complex medical conditions
• Coordination of multidisciplinary care plans
• Improved decision-making and tailored treatment strategies
• Expected benefits are often realized immediately following the procedure or as part of an ongoing treatment plan.

Recovery

• Minimal recovery time as the procedure is non-invasive
• Immediate resumption of daily activities
• Follow-up appointments may be scheduled for additional assessments.

Alternatives

• Standard evaluation and management services, which may not be as extensive
• Brief consultations with multiple specialists, which could be less coordinated
• Pros and cons will depend on the complexity of the case and need for detailed management.

Patient Experience

Patients may feel the procedure involves a lot of discussion and review but should not experience any physical discomfort. It provides an opportunity for patients to be highly involved in their care plan and to ask questions about their treatment and care. Comfort measures include a supportive environment and clear communication.