Examination of participant in clinical trial

This code signifies a medical encounter where an individual is being assessed or monitored as part of their involvement in a clinical research study. It specifically captures the physician's examination component of a participant's visit within a trial protocol.

Apply this code for routine or scheduled physical examinations performed on healthy volunteers or patients enrolled in a clinical trial. It is appropriate for visits where the primary purpose is to follow the study protocol's examination requirements, rather than to diagnose or treat an acute illness unrelated to the trial.

• Ensure the documentation clearly indicates the patient's participation in a clinical trial and that the service rendered is an examination related to that trial.
• Do not use this code for examinations performed to diagnose or treat a new, unrelated medical condition that arises during the trial; those conditions should be coded separately.
• This code is for the examination itself; any specific tests or procedures performed during the visit should be coded with their respective CPT codes.