Although CPT 99211 can be reported for limited assessments performed by nonphysician staff members, the vaccine and allergy history intake is considered vaccine related and not separately reportable. CPT 90460 is reported when a physician provides counseling about the benefits and risks associated with the vaccine and signs and symptoms that would indicate an adverse reaction.
Because the physician did not document seeing the patient at this encounter, report CPT 90471 for the administration of the immunization.

Regarding Z08, ICD-IO-CM guidelines state: "The follow-up codes are used to explain continuing surveillance following completed treatment of a disease. They imply that the condition has been fully treated and no longer exists." When using a follow-up code as the primary reason for an encounter, a history code indicating what condition the patient originally had should be assigned as secondary. Aftercare codes are used to describe the continued treatment of a disease. In this case, the malignancy has been eradicated, the disease no longer exists, and aspirin is being used merely as a preventative measure. History codes can never be reported as first listed; rather, a follow-up code or other current disease and/or condition should precede it.

An open appendectomy procedure is reported with CPT 44950. A metastatic colon malignancy is a cancer that began in the colon but has spread to other areas. In this scenario, that means that the primary malignancy is the colon, and the secondary malignancy is the appendix.
Additionally, ICD-IO-CM guidelines state that when "treatment is directed toward the metastatic site only, the metastatic site is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code." The malignancy codes do not specifically state
"appendix," but the ICD-IO-CM coding crosswalk in the neoplasm table assigns this diagnosis as C78.5 secondary malignant neoplasm of large intestine and rectum.

To calculate the total number of units, it is important to understand that anesthesia time is measured in 15-minute intervals (or in fractions thereof). In this scenario, take the total number of minutes spent on the procedure (105) and divide it by 15. The total number of time units is 7. The time units are then added to the base unit (10) for a total of 17 units.

Catheter access, standard supplies such as a flush solution, and the flush at the end of the infusion are all considered necessary to facilitate the infusion and are inclusive to CPT codes
96360-96361. Declotting a catheter involves the injection of a thrombolytic agent to dissolve the clot and is separately reportable with CPT 36593.