Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes
CPT4 code
Name of the Procedure:
Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient
Summary
This procedure involves a medical office or outpatient clinic visit for an established patient, focusing on a relevant history and/or examination followed by straightforward medical decision-making. The visit typically lasts between 10-19 minutes based on time used for code selection.
Purpose
This visit addresses ongoing or new health issues and aims to manage and evaluate the patient's current medical conditions.
Indications
- Chronic disease follow-up (e.g., hypertension, diabetes)
- Management of acute symptoms (e.g., cough, mild pain)
- Medication management or adjustments
- Routine health check-ups
- Monitoring after hospitalization or surgery
Preparation
- No fasting or special preparation is usually required.
- Patients should bring a list of current medications and any recent test results.
- A brief description of any new symptoms or issues.
Procedure Description
- Patient check-in and update of medical records.
- A medically appropriate history is taken and/or a physical examination is performed.
- Discussion of symptoms, medical history, and any recent changes.
- Medical decision-making to address any health concerns is based on gathered information.
- May include ordering of tests, prescribing medications, or providing a treatment plan.
Tools: Patient records, blood pressure cuff, stethoscope, basic diagnostic tools.
Duration
Typically lasts 10-19 minutes.
Setting
Performed in a doctor's office or outpatient clinic.
Personnel
- Primary Healthcare Provider (e.g., Doctor, Nurse Practitioner)
- Medical Assistant (for initial intake and vitals)
Risks and Complications
Generally, there are minimal risks associated with a standard office visit. Rarely, miscommunication or incomplete history might lead to inadequate treatment.
Benefits
- Effective management of ongoing health conditions.
- Early detection of potential new health issues.
- Personalized healthcare advice and intervention.
Recovery
- No specific recovery period is necessary as the visit is non-invasive.
- Patients may need to follow specific advice or treatment plans provided during the visit.
Alternatives
- Telemedicine visits for minor conditions or follow-ups.
- Urgent care visits for more immediate but non-emergent issues.
Patient Experience
- The visit may involve discussing personal health information and a physical examination.
- Generally painless; minor discomfort may be experienced during certain examinations (e.g., ear, throat).
Pain management and comfort measures: Typically, these visits are not painful, and any discomfort from examination is brief and minimal.