A 65-year-old was admitted in the hospital two days ago and is being examined today by his primary care physician, who has been seeing him since he has been admitted. Primary care physician is checking for any improvements or if the condition is worsening.
CHIEF COMPLAINT: CHF
INTERVAL HISTORY: CHF symptoms worsened since yesterday.
Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I'm concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome.
REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins.
PHYSICAL EXAMINATION:
GENERAL: Mild respiratory distress at rest
VITAL SIGNS: BP 168/84, HR 58, temperature 98.1.
LUNGS: Worsening bibasilar crackles
CARDIOVASCULAR: RRR, no MRGs.
EXTREMITIES: Show worsening lower extremity edema.
LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12.
IMPRESSION:
1. Severe exacerbation of CHF
2. Poorly controlled HTN
3. Worsening ARF due to cardio-renal syndrome
PLAN:
1. Increase BUMEX to 2 mg IV Q6.
2. Give 500 mg IV DIURIL times one.
3. Re-check usual labs in a.m.
Total time: 20 minutes.
What E/M category is used for this visit?

a. Inpatient Consultation (99251-99255)
b. Initial Hospital Visit (99221-99223)
c. Established Patient Office/Outpatient Visit (99211-99215)
d. Subsequent Hospital Visit (99231-99233)