Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total ti
CPT4 code
Name of the Procedure:
Office or Other Outpatient Visit for Evaluation and Management of a New Patient (High Complexity)
Summary
This procedure involves a thorough evaluation and management of a new patient, which includes obtaining a detailed medical history, conducting a physical examination, and making high-level medical decisions. The visit typically lasts between 60 to 74 minutes.
Purpose
The procedure is designed to diagnose and manage new or complex health issues. The goals are to establish a comprehensive understanding of the patient's health, make accurate diagnoses, and develop an effective treatment plan.
Indications
- New symptoms or medical conditions
- Complex or multiple health issues that require extensive evaluation
- Patients needing a thorough second opinion or diagnosis confirmation
Preparation
- Patients may need to bring previous medical records and a list of current medications.
- No specific fasting or medication adjustments unless specified by the healthcare provider.
Procedure Description
- Medical History: The healthcare provider will take a detailed medical history, including past medical conditions, family history, lifestyle habits, and any current symptoms.
- Physical Examination: A comprehensive physical exam will be performed to assess the patient's overall health and identify any physical signs of illness.
- Medical Decision Making: The provider will analyze the gathered information, possibly order diagnostic tests, and develop a treatment plan.
- Tools used can include stethoscopes, blood pressure cuffs, otoscopes, and various diagnostic tools.
- Typically, no anesthesia or sedation is involved.
Duration
The visit usually takes between 60 to 74 minutes.
Setting
This procedure is performed in an outpatient clinic or doctor's office.
Personnel
- Primary Care Physician or Specialist
- Licensed Nurse or Medical Assistant
Risks and Complications
- Minimal risk as it primarily involves consultation and non-invasive examination.
- Potential for discomfort during physical exam procedures.
Benefits
- Accurate diagnosis and tailored treatment plans.
- Opportunity to ask questions and receive personalized health advice.
- Early detection and intervention can prevent complications and improve outcomes.
Recovery
- No specific recovery time since it's an outpatient visit.
- Follow-up instructions may include additional tests, referral to specialists, or initiating treatment plans.
- Patients should adhere to follow-up appointments as recommended.
Alternatives
- Telehealth consultation (less detailed due to inability to perform physical exams).
Urgent care visits (typically less comprehensive for new patient evaluations).
Patient Experience
- During the visit, patients may undergo multiple assessments and answer detailed questions.
- Some procedures might cause brief discomfort, such as blood pressure measurement or throat examination.
- Pain management and comfort measures are typically not needed. Expect reassurance and comprehensive care from the healthcare provider.