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Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each addit

CPT4 code

Name of the Procedure:

Prolonged Clinical Staff Service (beyond the highest time in the range of total time of the service) during an Evaluation and Management Service in the Office or Outpatient Setting, Direct Patient Contact with Physician Supervision; Each Additional 30 Minutes

Summary

This procedure involves additional time spent by clinical staff, beyond the typical duration, providing direct patient care in the office or outpatient setting under the supervision of a physician. This extra time allows for thorough evaluation and management of complex medical conditions.

Purpose

The procedure is aimed at offering extended medical attention to patients requiring more intensive evaluation and management beyond the usual consultation time.

Goals and Expected Outcomes:
  • Comprehensive assessment and management of complex medical conditions.
  • Improved patient care through personalized and extended attention.
  • Enhanced patient satisfaction by addressing all health concerns thoroughly.

Indications

  • Patients with multiple or complex medical issues requiring detailed evaluation.
  • Cases needing intensive management or frequent monitoring.
  • Situations where standard consultation time is insufficient to address the patient’s needs.

Preparation

  • No specific fasting or medication adjustments are required.
  • Patients should bring all relevant medical records and a list of current medications.
  • Complete any prescribed diagnostic tests or assessments before the appointment.

Procedure Description

  1. Initial Evaluation: The physician supervises the initial evaluation and management.
  2. Prolonged Service: Clinical staff provide direct patient care beyond the designated time, continuing the evaluation and management process under the supervision of the physician.
  3. Documentation: Every additional 30 minutes of extended service is documented accurately.
Tools and Technology:
  • Standard medical examination tools (stethoscope, blood pressure monitor, etc.).
  • Electronic Health Record (EHR) system for documentation.
Anesthesia or Sedation:
  • Not applicable.

Duration

  • Typically, this procedure extends the service time by increments of 30 minutes beyond the standard consultation.

Setting

  • Office or outpatient clinic.

Personnel

  • Clinical staff (nurses or physician assistants) provide direct patient care.
  • Supervision by a physician.

Risks and Complications

Common:
  • No significant risks or complications are usually associated with this extended service.
Rare:
  • Possibility of prolonged patient fatigue due to extended consultation.
  • Potential for overlapping scheduling issues due to extended time requirements.

Benefits

  • More comprehensive medical evaluation and management.
  • Tailored healthcare addressing all aspects of the patient's condition.
  • Immediate feedback and adjustments to treatment plans.

Recovery

  • No special recovery post-procedure.
  • Normal daily activities can be resumed immediately.
  • Follow-up appointments as necessary based on the outcome of the evaluation.

Alternatives

  • Standard evaluation and management within the usual time frame, possibly resulting in multiple visits.
  • Specialized referral to other healthcare providers for specific issues.
Pros and Cons:
  • Prolonged Service:
    • Pros: Comprehensive care, thorough evaluation in one session.
    • Cons: Time-consuming, may require longer wait time.
  • Standard Service:
    • Pros: Shorter consultation time, more convenient for routine issues.
    • Cons: May need multiple visits for complex conditions.

Patient Experience

  • During the procedure, patients may feel assured by the extended attention and thoroughness.
  • After the procedure, patients typically appreciate the comprehensive care and detailed management plan.
  • Pain management is not usually needed unless specific medical interventions are performed.
Comfort Measures:
  • Ensuring a comfortable setting and frequent updates on the progress during the extended consultation.
  • Providing breaks if the consultation is particularly long or intense.

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