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
- Commonly referred to as "telehealth consult" or "phone consultation."
Summary
A telephone evaluation and management service involves a physician or another qualified healthcare professional communicating with an established patient, parent, or guardian by phone. This service is separate from any other related in-person visits and aims to assess and manage the patient's health condition.
Purpose
The procedure addresses various non-emergency medical issues that do not require an in-person visit. The goals include providing timely medical advice, adjusting treatment plans, and managing ongoing health conditions from the comfort of the patient's home.
Indications
- Non-emergency symptoms or health concerns
- Follow-up on chronic conditions
- Medication management
- Minor illnesses such as colds, allergies, or minor infections
- Health advice and education
Preparation
- No specific preparations or fasting required.
- Patients may need to have their medical records, a list of current medications, and any symptoms or questions ready for discussion.
Procedure Description
- The patient or guardian contacts the healthcare provider's office to schedule a telephone consultation.
- At the scheduled time, the healthcare provider calls the patient.
- The provider reviews the patient’s medical history and discusses the current health concern.
- The provider may ask a series of questions to evaluate symptoms and determine the best course of action.
- Based on the evaluation, the provider gives medical advice, prescribes medications if necessary, or recommends further in-person evaluation.
- The call is documented in the patient's medical record.
Duration
The typical duration of a telephone evaluation is approximately 10-30 minutes.
Setting
The procedure is conducted over the phone, allowing patients to be in a location of their choosing, typically at home.
Personnel
- Physician
- Nurse Practitioner
- Physician Assistant
Risks and Complications
- Miscommunication due to the lack of visual cues
- Incomplete assessment compared to an in-person visit
- Potential for missed diagnoses
Benefits
- Convenience and accessibility for patients
- Avoids the need for travel and time off work
- Quickly addresses health concerns
- Reduces the risk of exposure to infectious diseases
Recovery
- No physical recovery needed as this is a non-invasive service.
- Patients should follow any medical advice or instructions provided.
- Possible follow-up appointments if further evaluation is needed.
Alternatives
- In-person office visit: Provides a more thorough physical examination.
- Video consultation: Allows for visual assessment.
- Urgent care visit: Best for more acute symptoms requiring immediate attention.
- Emergency room visit: Necessary for severe or life-threatening conditions.
Patient Experience
During the call, the patient will discuss their health concerns in detail. They may feel reassured by receiving prompt medical advice. No physical discomfort is expected during or after the procedure. If recommended, pain management will be advised through appropriate measures and medications.