A 6-year-old with cystic fibrosis is admitted with fever and shortness of breath. At the request of the attending physician, the infectious disease specialist sees the patient. A comprehensive history and physical examination are performed. A diagnosis of acute pneumonia is made, antibiotic treatment and respiratory therapy are recommended, and medical decision making is moderate. The consulting infectious disease specialist spends 115 minutes on the floor seeing the patient, talking with the family, reviewing data, charting, and discussing the case with the attending physician. The medical record reflects the time and coordination of care efforts. How should the infectious disease specialist’s services be reported?

The appropriate code, based on the required 3 key components (history, physical examination, and medical decision making), would be 99255, initial inpatient consultation. The medical record reflects that there was a request made by the attending physician for the infectious disease specialist’s opinion or advice...

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