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?

Question

Quizplus · Accepted Answer

99336 is the correct code for an established patient at an assisted living facility who requires a detailed interval history, a detailed examination and moderate-complexity medical decision making.
Code 99334 is incorrect because this code is for an encounter that is problem focused and involves straightforward medical decision making. Code 99335 is incorrect because this code is for an expanded problem-focused history and examination as well as low-complexity medical decision making. Code 99337 is incorrect because this code is for a comprehensive history and examination and moderate-to-high-complexity medical decision making.

An Established Patient at an Assisted Living Facility Develops a Cough