A congestive heart failure patient is discharged from the hospital and has a follow up appointment with his primary care physician five days after discharge. The primary care physician’s office calls him within 36 hours after discharge to follow up by phone to see how he is doing. Because he has had weight gain since leaving the hospital, the primary care office requests to see him that same day to see if this gain is from fluid retention and related to his congestive heart failure. He is seen in their office and the medical decision making is considered moderate complexity. What is the correct evaluation and management code for this patient?
