Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of
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 healthcare provider evaluating and managing an established patient's medical condition through a medically appropriate history and/or examination. It includes a low level of medical decision-making and typically takes between 20 and 29 minutes.
Purpose
This visit is designed to manage ongoing medical conditions, address new or worsening symptoms, and monitor the effectiveness of current treatments. The goal is to maintain or improve the patient's health status.
Indications
- Follow-up on chronic conditions like diabetes, hypertension, or asthma
- Evaluation of new symptoms such as a persistent cough or mild pain
- Monitoring side effects or effectiveness of current medications
- Preventive care and wellness check-ups
Preparation
- Bring a list of current medications and dosages
- Have a summary of current symptoms or medical concerns
- Complete any pre-visit forms or questionnaires provided by the healthcare facility
Procedure Description
- Check-in: The patient arrives at the clinic, checks in, and waits to be called.
- Clinical Assessment: A nurse or medical assistant may take vital signs (e.g., blood pressure, temperature).
- History and Examination: The healthcare provider reviews the patient's medical history, discusses symptoms, and performs a physical examination, if necessary.
- Discussion: The provider discusses findings and may recommend further tests, prescribe medications, or suggest lifestyle changes.
- Documentation: The visit is documented in the patient's medical record.
Duration
20 to 29 minutes.
Setting
Outpatient clinic or office.
Personnel
- Primary healthcare provider (e.g., family doctor, internist)
- Nurse or medical assistant
Risks and Complications
- Minimal risks, primarily related to any diagnostic tests or new medications prescribed
- Rarely, misdiagnosis or delayed diagnosis due to the complexity of symptoms
Benefits
- Accurate management and monitoring of health conditions
- Early detection of new or worsening symptoms
- Personalized advice and treatment plans
Recovery
- No specific recovery period is required.
- Follow-up instructions will be provided based on the visit's findings.
- Patients may have follow-up appointments or additional tests scheduled.
Alternatives
- Telemedicine visits for those who cannot make it to the clinic
- Urgent care for more immediate but non-emergency issues
- Specialist referrals for more complex conditions
Patient Experience
Patients may feel a sense of assurance from addressing health concerns with their provider. Any discomfort is minimal and typically related to physical examination components. Effective communication of symptoms and concerns can lead to a more satisfying and productive visit.