Periodic comprehensive preventive medicine reevaluation 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/diag
CPT4 code
Name of the Procedure:
Periodic Comprehensive Preventive Medicine Reevaluation and Management (Annual Physical Exam, Wellness Visit)
Summary
This procedure involves a thorough check-up where a healthcare provider evaluates your overall health. It includes taking your medical history, conducting a physical examination, counseling you on healthy lifestyle choices, and ordering any necessary laboratory tests.
Purpose
Addressed Issues: The procedure is designed to catch potential health problems early, keep track of chronic conditions, and promote a healthy lifestyle. Goals: Early detection of diseases, risk factor management, preventive care, and health education.
Indications
- Annual or periodic health maintenance
- Management of chronic diseases
- Screening for potential health problems
- Individuals with risk factors for certain diseases based on age, gender, or family history
Preparation
- Fasting may be required if blood tests are to be taken
- Bring a list of current medications
- Note any recent health changes or concerns
Procedure Description
- Medical History: Review of personal and family medical history, lifestyle habits, and current health concerns.
- Physical Examination: Vital signs check (blood pressure, heart rate, temperature), examination of different body systems (heart, lungs, abdomen, skin, etc.), and a focused physical exam based on patient’s age and gender.
- Counseling: Discussion on diet, exercise, mental health, smoking cessation, and other lifestyle factors.
- Interventions: Guidance on risk factor reduction and anticipatory guidance for disease prevention.
- Laboratory/Diagnostic Orders: Blood tests, imaging studies, or other diagnostic tests as needed.
Duration
Typically takes 30 to 60 minutes, depending on the complexity of the patient's health status.
Setting
Performed in an outpatient clinic or a doctor's office.
Personnel
Doctors (Primary Care Physicians), Nurse Practitioners, Physician Assistants, Nurses, Medical Assistants
Risks and Complications
- Minimal risks associated with the physical examination itself
- Potential discomfort from blood draws or diagnostic tests
- Uncommon but possible risk of inaccurate results or overdiagnosis
Benefits
- Early detection of health issues
- Tailored advice for healthy living
- Improved management of chronic conditions
- Reduced risk of future health problems
Recovery
- No significant recovery period required
- Immediate return to daily activities
- Follow-up depends on test results and identified health issues
Alternatives
- More frequent but less comprehensive check-ups
- Specialist visits for specific health concerns
- Home-based health monitoring (limited compared to professional evaluation)
Patient Experience
- Typically well-tolerated with minimal discomfort
- May feel anxious about test results or physical exam
- Health education and personalized advice can be empowering and reassuring
Pain management and comfort measures are usually unnecessary, but apprehensive patients should communicate their concerns to the healthcare team.