Oncology & Hematology Coding Alert

Question: How should I report the following case? A patient presented for chemotherapy to treat a primary malignant neoplasm of the nasopharyngeal floor. The patient complained of new onset of extreme fatigue, and the oncologist performed a level-3 office visit to evaluate her. The patient then received a 30-minute gemcitabine infusion followed by a 60-minute cisplatin infusion. We did not supply the drugs.

Montana Subscriber

Answer: For the diagnoses indicated, you should report V58.11 (Encounter for antineoplastic chemotherapy), 147.3 (Malignant neoplasm of nasopharynx; anterior wall), and 780.79 (Other malaise and fatigue).

The procedure codes and modifiers you should use include:

• 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the gemcitabine infusion
• +96417 (Chemotherapy administration, intravenous infusion technique; each additional sequential infusion [different substance/drug], up to 1 hour [List separately in addition to code for primary procedure]) for the cisplatin infusion
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the E/M service
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99213 to show that the E/M service was distinct from the chemotherapy administration.

Tip: Although your practice did not supply the drugs and therefore should not report them on your claim, you still need to understand the drugs used so you can choose the appropriate administration codes. In other words, you need to know whether to use a chemotherapy administration code or a different therapeutic administration code. Individual payers define which drugs qualify for the higher paying chemotherapy administration codes, but gemcitabine and cisplatin would both qualify.

ICD-9-CM link: On your claim, you should link V58.11 and 147.3 to both 96413 and +96417. You should link 780.79 to 99213-25.