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Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Coun
CPT4 code
Name of the Procedure:
Subsequent Nursing Facility Care, per Day
- Common names: Daily Nursing Home Evaluation, Follow-up Nursing Facility Care
- Technical terms: Subsequent Nursing Facility Care, Evaluation and Management
Summary
This daily follow-up visit in a nursing facility involves a comprehensive check of the patient's health status. It includes reviewing medical history, performing a thorough physical examination, and making high-complexity medical decisions based on the patient's current condition.
Purpose
- Medical conditions it addresses: Chronic illnesses, post-acute care, ongoing medical management in a nursing facility.
- Goals: To monitor and manage the patient's health condition, adjust treatments as necessary, and ensure optimal care delivery in a nursing home setting.
Indications
- Specific symptoms: Unstable chronic conditions, recent significant health changes, complex medication management, new symptoms requiring evaluation.
- Patient criteria: Residents of a nursing facility needing ongoing, complex medical care and evaluation.
Preparation
- Pre-procedure instructions: Generally, no special preparation is required for the patient. Normal daily living activities continue.
- Diagnostic tests: Review of recent lab results, imaging, or other pertinent tests may be needed beforehand.
Procedure Description
- Comprehensive Interval History: The healthcare provider reviews the patient's medical history since the last visit, noting any new symptoms or changes.
- Comprehensive Examination: A thorough physical examination is conducted to assess the patient's current health status.
- Medical Decision Making: High complexity decisions regarding the patient's treatment plan may involve medication adjustments, further diagnostic testing, or referrals to specialists.
- Tools/Equipment: Stethoscope, blood pressure cuff, medical charts/electronic health records.
- Anesthesia/Sedation: Not applicable.
Duration
- Typically takes 15 to 30 minutes per patient visit.
Setting
- Performed within the nursing facility where the patient resides.
Personnel
- Primary healthcare professionals: Physicians, nurse practitioners, or physician assistants.
- Support staff: Nurses, nursing aides.
Risks and Complications
- Common risks: Minimal risk involved in the assessment itself.
- Possible complications: Delays in detecting significant changes in health if visits are missed or insufficiently thorough.
Benefits
- Regular monitoring and timely adjustments to treatment plans.
- Early detection of new or worsening conditions.
- Improved overall health management.
Recovery
- Post-procedure care: No specific recovery required as it is a routine evaluative procedure.
- Follow-up: Typically involves daily visits or as needed depending on patient condition.
Alternatives
- Outpatient follow-up: May be an option for less complex cases but requires patient transport.
- Telehealth visits: Useful for some assessments, though limited by the inability to perform a physical examination.
Patient Experience
- During the procedure: Patients may experience a routine health check-up, similar to regular doctor visits.
- Pain management: Generally no pain involved, and comfort measures are standard practice.