You Be the Coder: Knock Out This Nasopharyngeal Case

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.

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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, [...]
  
  - Published on 2011-11-09