An established patient at an assisted living facility develops a cough that is diagnosed as pneumonia after radiology was performed. The physician was called in to assess her and ordered the x-ray as an outpatient. Because of her history of congestive heart failure, this acute diagnosis is more complex. The physician does a detailed interval history, a detailed examination and considers his medical decision making to be of moderate complexity because he has spent 40 minutes with the patient, at the assisted living facility and talking with the patient’s family when they come for a visit. What is the correct evaluation and management CPT code for this patient?
