Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total
CPT4 code
Name of the Procedure:
Office or Other Outpatient Visit for the Evaluation and Management of a New Patient (15-29 minutes)
Summary
This is a medical appointment for new patients where the doctor conducts an initial evaluation and management of the patient's condition. This visit includes gathering a detailed health history and performing a basic physical examination, along with making straightforward medical decisions about further diagnostics or treatments.
Purpose
The purpose of this procedure is to establish a new patient’s medical history, assess their current health status, and devise an initial management plan. It aims to detect any urgent health issues, provide a baseline for future visits, and guide immediate treatment or diagnostic steps.
Indications
- Patients experiencing new symptoms or health issues.
- Individuals needing a general health assessment.
- Patients requiring the setup of a medical record for ongoing care.
- Situations where a medical evaluation is necessary to determine further steps in diagnosis or treatment.
Preparation
- Patients should bring any prior medical records, if available.
- A list of current medications and supplements should be provided.
- No specific fasting or medication adjustments are typically required unless advised by the doctor beforehand.
Procedure Description
- Initial Greeting and Registration:
- Patient checks in and completes necessary paperwork.
- Medical History Taking:
- Doctor or nurse gathers detailed personal and family medical history.
- Physical Examination:
- Basic examination including checking vital signs (e.g., blood pressure, heart rate).
- Medical Decision Making:
- Discussing symptoms and concerns.
- Determining initial diagnostic tests or treatments, if needed.
- Providing health advice and preventive care recommendations.
Duration
This visit typically takes between 15 and 29 minutes.
Setting
The procedure is performed in an outpatient setting such as a doctor's office or clinic.
Personnel
- Physician or Nurse Practitioner (conducts the history-taking, examination, and decision making).
- Nurse or Medical Assistant (assists with vitals and initial patient intake).
Risks and Complications
- Generally, there are no significant risks associated with this office visit.
- Potential discomfort during physical examination.
Benefits
- Establishes a medical record and baseline for the patient.
- Identifies any urgent medical concerns early.
- Provides a plan for follow-up care and treatment, offering peace of mind.
Recovery
- No significant recovery is needed post-visit.
- Follow-up appointments or additional tests may be scheduled based on findings during the visit.
Alternatives
- Telemedicine: Virtual consultations can be an alternative for initial assessments but may be limited by the inability to perform physical exams.
- Urgent Care Visits: For more immediate concerns, although these are typically more focused on acute issues rather than comprehensive evaluations.
Patient Experience
- During the visit, the patient might experience a thorough but non-invasive examination.
- Minimal discomfort, mostly involving talking and having vitals checked.
- Pain management is generally not a concern for this procedure, and measures are taken to ensure comfort throughout the visit.