Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counselin
CPT4 code
Name of the Procedure:
Domiciliary or Rest Home Visit for Evaluation and Management of an Established Patient
Summary
In this procedure, healthcare providers visit patients in their homes or residential care facilities to evaluate and manage ongoing medical conditions. The visit includes taking a detailed medical history, performing a thorough physical examination, and making moderate complexity medical decisions to update and adjust treatment plans as necessary. Counseling may also be provided during the visit.
Purpose
This procedure is designed to manage chronic illnesses or conditions, prevent disease progression, and address any new symptoms or concerns that arise. The goal is to maintain or improve the patient’s health and overall quality of life by providing personalized care outside of traditional clinical settings.
Indications
- Chronic disease management (e.g., diabetes, hypertension, heart disease)
- Mobility issues preventing the patient from visiting a clinic
- Post-hospitalization follow-up
- Cognitive impairment or dementia requiring regular monitoring
- Palliative or end-of-life care
Preparation
- Ensure a list of current medications and any recent changes are available.
- Prepare any recent medical records, lab results, or imaging reports for review.
- No specific fasting or special preparations are needed unless instructed.
Procedure Description
- Review the patient’s detailed interval history, noting any changes or new symptoms.
- Conduct a detailed physical examination, focusing on relevant health issues.
- Make medical decisions of moderate complexity, which may include adjusting medications or ordering further tests.
- Provide counseling and education on managing conditions and implementing lifestyle changes.
- Document findings and update the patient’s medical records.
Tools and Equipment:
- Stethoscope, blood pressure cuff, thermometer, and other basic diagnostic tools.
- Portable electronic health record (EHR) system.
Anesthesia or Sedation:
- Not applicable.
Duration
Typically lasts 30 to 60 minutes, depending on the complexity of the patient’s needs.
Setting
Performed in the patient’s home or a residential care facility.
Personnel
- Primary care physician or nurse practitioner
- Medical assistant or nurse, if necessary
- Caregiver or family member for support
Risks and Complications
- Minimal risk involved; however, possible delays in emergency care if severe issues are identified.
- Potential for miscommunication if medical records are not up-to-date.
Benefits
- Personalized and convenient care in the comfort of the patient’s home.
- Enhanced management of chronic conditions and prevention of complications.
- Improved patient adherence to medical advice and treatment plans.
Recovery
- No specific recovery is needed.
- Follow-up visits or telehealth appointments may be scheduled for further monitoring.
Alternatives
- Clinic visits: May offer more immediate access to diagnostic tools but less convenience for patients with mobility issues.
- Telemedicine: Offers convenience but may lack the thoroughness of an in-person physical examination.
Patient Experience
- Patients typically feel more relaxed and comfortable at home.
- The visit is generally non-invasive and relatively stress-free.
- Patients should communicate any discomfort or concerns during the visit for immediate attention.
Pain management and comfort measures are generally not necessary, but any issues should be promptly addressed by the visiting healthcare provider.