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.

If 99402 is part of a more complex service, it would not be separately identifiable, thus eliminating answer A Because 99385 includes counseling/anticipatory guidance/risk factor reduction interventions, the additional 30 minutes that the provider spent discussing contraceptives would not be considered a significant, separately identifiable E/M service, eliminating answer B. Last, because time is not a factor when selecting a preventative service,
99417 reflected in answer C, indicating a prolonged outpatient E/M service totaling 30 minutes would not apply.

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.

When a hematologr procedure that could be billed alone is encompassed in another code, only the most complex of the tvo should be reported. Because CPT 85046 includes the reticulocyte count billing CPT 85044 as secondary despite using a different method would be considered an unbundling of services. Per ICD-IO-CM guidelines, an organ or tissue transplant status code is for use "only if there are no complications or malfunctions of the organ or tissue replaced." As the testing is to determine whether the engraftment was successful, a bone marrow transplant status code would not be appropriate until deemed by the provider.

Tuberculosis (TB) can usually spread from the lungs to another site via the bloodstream.
Because the documentation does not specify whether the TB is primary or secondary, the coder would default to A15.9, as TB unspecified. A cough and fever are symptoms of an underlying illness and would not be coded because a definitive diagnosis of TB is present. Because TB is an HIV- related illness, B20 would be the first listed code.