It's my understanding that the provider can use his/her discretion. Some influential factors will be age, past medical history, family history, etc. CPT states that "the comprehensive nature of the preventive medicine services (99381-99397) reflects an age/gender appropriate history/exam and is not synonymous w/ the "comprehensive" exam required in E/M mgmt codes 99201-99350. The distinction between an office visit (new v/s established, 99201-99215) versus a preventive exam is that the office visit codes are motivated by a problem oriented complaint. As a result, the preventive exam isn't driven by the E/M guidelines; however, they are a good guide (i.e. the genitourinary exam). Medicare, on the other hand, does provide a layout of what is expected for the "Welcome to Medicare" exam.
Obtain the following:
•Height, weight, and blood pressure
•Visual acuity screen
•Measurement of body mass index (required effective January 1, 2009)
•Other factors deemed appropriate based on the individual’s medical and social history and current clinical standards
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