Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service pro
CPT4 code
Name of the Procedure:
Telephone Evaluation and Management Service (Telephonic E/M, Telehealth E/M)
Summary
A telephone evaluation and management service is a consultation provided by a physician or other qualified health care professional over the phone. It's specifically for established patients, their parents, or guardians and is not related to a previous evaluation and management (E/M) service.
Purpose
This service addresses medical concerns or health questions that a patient or their caregiver has when an in-person visit isn't necessary or feasible.
Goals/Expected Outcomes:
- To provide immediate medical advice and management.
- To determine if an in-person visit or further testing is necessary.
- To offer continuity of care and timely intervention.
Indications
Symptoms/Conditions:
- Mild to moderate symptoms such as a sore throat, cough, minor injury, or rash.
- Management of chronic conditions (e.g., diabetes, hypertension).
- Follow-up on test results or treatment plans.
Patient Criteria:
- Established patients only.
- Situations where a visit to the office isn't required immediately.
Preparation
Pre-procedure Instructions:
- Be in a quiet and private location during the call.
- Have a list of symptoms, questions, and medications at hand.
- Ensure your phone is charged and has good reception.
Diagnostic Tests/Assessments:
- None usually required prior to the call unless specified by the healthcare provider.
Procedure Description
- The healthcare provider will call the patient at the scheduled time.
- Discuss symptoms, medical history, and any concerns.
- The provider may offer medical advice, prescribe medication, or recommend further action.
- Document the call and recommendations.
Tools/Equipment:
- Telephone or mobile phone.
Anesthesia/Sedation:
- Not applicable.
Duration
Typically 5-30 minutes depending on the complexity of the issue.
Setting
The patient's location via phone. The healthcare provider could be calling from any clinical setting like a hospital, clinic, or home office.
Personnel
- Physician or other qualified health care professional (e.g., nurse practitioner, physician assistant).
Risks and Complications
Common Risks:
- Miscommunication or misunderstandings over the phone.
- Limitations in assessing physical symptoms.
Rare Risks:
- Delay in diagnosis or treatment if the call is insufficient to address the issue appropriately.
Management:
- Follow-up with an in-person appointment or additional diagnostics if needed.
Benefits
- Quick access to medical advice.
- Convenience and comfort of being at home.
- Reduced need for travel and time off work/school.
Recovery
Post-procedure Care:
- Follow any instructions given during the call.
- Monitor symptoms and seek in-person care if necessary.
Expected Recovery Time:
- Immediate; no physical recovery needed.
Restrictions/Follow-Up:
- Depends on the advice given during the call.
Alternatives
Other Options:
- In-person consultation.
- Telehealth video consultation.
- Urgent care visit.
Pros and Cons of Alternatives:
- In-person visits allow for a physical exam, which can be more thorough.
- Video consultations provide visual assessment but require internet access.
- Urgent care visits are immediate but might be more costly and time-consuming.
Patient Experience
During the procedure, patients might experience:
- Feeling more at ease due to being in a familiar environment.
- Relief from receiving immediate professional advice.
Pain Management/Comfort Measures:
- Not applicable as this is a non-invasive service.
During and After:
- Expect clear communication and a personalized plan based on the discussion.