Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnos
CPT4 code
Name of the Procedure:
Initial Comprehensive Preventive Medicine Evaluation and Management
Common names: Yearly physical, Annual checkup
Technical terms: Preventive health examination, Well visit
Summary
An Initial Comprehensive Preventive Medicine Evaluation and Management is a thorough health check-up designed to evaluate an individual's overall health status. It includes a complete health history, physical examination, counseling on lifestyle and risk factors, and the ordering of various lab tests if needed.
Purpose
To assess general health and catch any potential health issues early. The goals are to prevent diseases, promote healthy living, and provide anticipatory guidance tailored to the patient's age and gender.
Indications
- Age-specific wellness check-ups or annual physical exams.
- Assessment for risk factors including family medical history, lifestyle habits, and existing health conditions.
- Individuals seeking preventive care to maintain optimal health.
Preparation
- Follow any specific instructions provided by your doctor, such as fasting for blood tests.
- Bring a list of current medications, allergies, and your medical history.
- Wear comfortable clothing for the physical exam.
Procedure Description
- Health History: Detailed collection of personal and family medical history.
- Physical Examination: Comprehensive examination including vital signs, cardiovascular, respiratory, gastrointestinal, musculoskeletal, neurological, and dermatological assessments.
- Counseling/Guidance: Discussion on healthy lifestyle choices, diet, exercise, mental health, and risk factor reduction.
- Laboratory Tests: Blood tests, urine analysis, or other diagnostic tests might be ordered based on your health history and examination findings.
Duration
Typically takes 30-60 minutes.
Setting
Performed in a primary care physician's office, outpatient clinic, or healthcare center.
Personnel
- Primary care physician (MD/DO)
- Nurses or medical assistants for initial assessments and blood draws
Risks and Complications
- Minimal risk; slight discomfort from physical examination or blood draws.
- Rarely, side effects from laboratory tests or screenings.
Benefits
- Early detection of potential health problems.
- Personalized health advice and management plan.
- Better management of existing chronic conditions.
Recovery
- No significant recovery time is needed.
- Follow-up appointments may be scheduled based on findings.
Alternatives
- Telehealth consultations for general health advice and preliminary assessments.
Specialist visits for addressing specific health concerns.
Pros: Convenient and can address specific health issues. Cons: May not provide a comprehensive overview of general health.
Patient Experience
- Generally painless and non-invasive.
- Slight discomfort may be felt during physical exam or blood draw.
- Comfort and privacy are prioritized, and patients are encouraged to discuss any concerns openly with their provider.