What CPT codes are used for inpatient ID consultations?

Initial inpatient consultations use 99252-99255 based on MDM complexity. Most ID consults involve moderate (99254) or high (99255) complexity due to extensive data review and high-risk antimicrobial decisions. Follow-up visits use 99231-99233. Document the requesting provider and specific clinical question. If consultations aren't recognized by the payer, use appropriate inpatient E/M codes.

How do I document antimicrobial stewardship decisions?

Document: culture and sensitivity results reviewed, current antimicrobial regimen, rationale for antibiotic choice (spectrum, penetration, drug interactions, renal/hepatic function), de-escalation plan when cultures finalize, duration of therapy with specific end date, and monitoring plan (drug levels, renal function, repeat cultures). This supports medical necessity and demonstrates stewardship.

What documentation supports prolonged IV antibiotic therapy?

Document: specific diagnosis requiring prolonged therapy (endocarditis, osteomyelitis, prosthetic joint infection), culture data supporting organism identification, why oral therapy is inadequate (bioavailability, bone penetration, no oral option), planned duration with clinical endpoint, and OPAT (outpatient parenteral antimicrobial therapy) plan if applicable.

How do I document source control recommendations?

Document: identified or suspected source of infection, imaging findings (abscess, collection, hardware), recommendation for intervention (drainage, debridement, device removal), urgency of source control, surgical consultation if needed, and follow-up plan to confirm source control adequacy. Inadequate source control is a common reason for treatment failure.

What elements support billing for daily ID follow-up visits?

Daily follow-up visits (99231-99233) are appropriate when managing active infections requiring ongoing assessment. Document: culture results, antibiotic response (fever curve, WBC trend, clinical improvement), antibiotic adjustments, new complications or concerns, and ongoing recommendations. Avoid seeing patients daily once stable on effective therapy with no active management decisions.

Infectious Disease Consultation Template - ID Consult

Visit Information

Date: [Date]
Visit type: Inpatient Consult / Outpatient Consult
Referring provider: [Name]
Reason for Consult: [e.g., Bacteremia, Osteomyelitis, FUO]

History of Present Illness

Onset and course: [Timeline of symptoms, fevers, chills] Localizing symptoms: [Cough, dysuria, wound drainage, headache, diarrhea] Prior treatments: [Antibiotics used, duration, response]

Infectious History

Exposures: [Sick contacts, animals, occupational]
Travel History: [Domestic/International, dates, prophylaxis]
Sexual History: [Partners, protection, prior STIs]
Procedures: [Recent surgeries, lines/catheters, dental work]
Implants: [Joints, valves, pacemakers, mesh]

Medical History

Immunocompromise: HIV, Diabetes, Steroids, Chemotherapy, Transplant
Prior Infections: MRSA, VRE, C. diff, ESBL
Allergies: [Specific antibiotic allergies - Reaction type]

Review of Systems (Infectious Focus)

Constitutional: Fevers, chills, night sweats, weight loss
HEENT: Sinus pain, sore throat
Resp: Cough, sputum
GI: Diarrhea, abdominal pain
GU: Dysuria, frequency
Skin: Rashes, wounds, ulcers
MSK: Joint pain, swelling

Physical Examination

Vitals: Tmax [Value], HR [Value], BP [Value] General: Toxic / Non-toxic / Cachectic Skin: [Rashes, wounds - describe size, depth, drainage, erythema] Lines/Devices: [IJs, PICCs, Ports - site assessment] Lymph Nodes: [Adenopathy location] Chest: [Lung sounds] Heart: [Murmurs - new vs old] Abdomen: [Tenderness, organomegaly] MSK: [Effusions, range of motion]

Data Review

Microbiology:

Blood Cultures: [Date/Result]
Urine Cultures: [Date/Result]
Wound Cultures: [Date/Result]
Serologies: [HIV, Hep B/C, Syphilis, etc.]

Imaging:

CXR: [Findings]
CT/MRI: [Findings - abscess, collections, osteo]
Echo: [Vegetations?]

Labs:

WBC: [Value] (Diff: Neutrophils/Bands)
CRP/ESR: [Values]
Procalcitonin: [Value]
Renal/Liver: [Cr, LFTs]

Assessment

1) [Primary Infection - e.g., MSSA Bacteremia]

Source: [Suspected/Confirmed]
Complications: [Endocarditis, metastatic seeding]

2) [Antibiotic Plan]

Plan

Antimicrobials:

Drug: [Name, Dose, Frequency, Route]
Duration: [Start date] to [End date] (Total: X days/weeks)
Stewardship: De-escalation planned? Yes / No

Source Control:

Abscess drainage: Done / Needed
Line removal: Done / Needed
Debridement: Consult Surgery

Monitoring:

Repeat cultures: [Frequency] until negative
Labs: [CBC, CRP weekly, Drug levels]

Follow-up:

Daily hospital rounds / 1 week clinic / IV antibiotic management

Infectious Disease — New Patient Consultation Template

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