99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minute

Name of the Procedure:

Office or other outpatient visit for the evaluation and management of an established patient

Summary

This procedure involves a routine visit to a healthcare provider’s office or an outpatient clinic, where an established patient undergoes a medically appropriate history and/or examination. The visit requires moderate complexity in medical decision making and generally lasts between 30 and 39 minutes.

Purpose

• Medical Condition or Problem Addressed: Provides ongoing evaluation and management of chronic conditions, acute illnesses, or other health concerns.
• Goals or Expected Outcomes: To assess the patient's current health status, manage ongoing treatment plans, adjust medications, and address any new or existing health issues.

Indications

• Symptoms or Conditions: Chronic conditions like diabetes, hypertension, or asthma; follow-up for acute illnesses; management of ongoing treatment; new health concerns.
• Patient Criteria: Established patients requiring routine follow-up, monitoring, or management of complex health issues.

Preparation

• Pre-procedure Instructions: Patients may be instructed to bring a list of current medications, previous medical records, and any recent test results. Fasting or medication adjustments are usually not required unless specified.
• Diagnostic Tests or Assessments: Prior lab results, imaging studies, or other diagnostic tests may be reviewed or ordered based on the patient's health status.

Procedure Description

• Step-by-step Explanation:
  1. Patient check-in and vitals recording by a nurse or medical assistant.
  2. Review of medical history and current medications.
  3. Discussion of symptoms, health concerns, and any new developments.
  4. Physical examination as needed.
  5. Diagnostic testing or lab work if indicated.
  6. Evaluation of current treatment plan and adjustments as necessary.
  7. Planning for next steps, including follow-up visits or referrals.
• Tools and Equipment: Stethoscope, blood pressure cuff, thermometer, computer or tablet for electronic health records, examination table, otoscope, and other basic medical instruments.
• Anesthesia or Sedation Details: Not typically required for this procedure.

Duration

The procedure typically takes between 30 and 39 minutes.

Setting

The procedure is performed in an outpatient clinic or medical office.

Personnel

• Primary care physician or specialist.
• Nurses or medical assistants for vital signs and initial patient intake.
• Administrative staff for scheduling and documentation.

Risks and Complications

• Common Risks: Minimal, as this is a routine office visit.
• Rare Risks: Potential for misdiagnosis or oversight of a significant health issue, which can be managed with careful follow-up and attention to detail.

Benefits

• Expected Benefits: Improved management of chronic conditions, early detection of new health issues, personalized adjustments to treatment plans.
• Realization of Benefits: Can be immediate, especially if new medication or treatment adjustments are made.

Recovery

• Post-procedure Care: Usually minimal; follow-up instructions may include lifestyle changes, new prescriptions, or further diagnostic testing.
• Expected Recovery Time: Not applicable for this type of visit.
• Restrictions: Generally none, unless specific tests or treatments are performed that require special follow-up.

Alternatives

• Other Treatment Options: Telehealth visits, urgent care centers for acute issues, specialist visits for complex conditions.
• Pros and Cons:
  • Telehealth Visits: Convenient but may lack the thoroughness of an in-person exam.
  • Urgent Care Centers: Useful for acute issues but may not provide continuity of care.
  • Specialist Visits: More focused care but may require referral and longer wait times.

Patient Experience

• During the Procedure: The patient will engage in discussion with the healthcare provider, undergo any necessary examinations, and may have diagnostic tests performed.
• After the Procedure: Patients may experience relief from understanding and addressing their health concerns. Comfort measures include addressing any discomfort during physical examinations or minor tests.

Pain management and additional comfort measures are generally not needed for this type of visit.