Dermatology Coding Alert

Question: A mother brought her 5-year-old son in to our office with blisters on his shoulders from sunburn. The dermatologist cleaned the area and applied ointment and a dressing. Should I report the treatment with an E/M code?


California Subscriber 
 

Answer: No. Because the dermatologist provided initial treatment of a burn, you should instead assign a burn treatment code. Select the appropriate code based on the burn's degree and treatment.

Because the deep sunburn required a dressing, you should assign 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small [less than 5 percent total body surface area]). Physicians consider blistering from prolonged sun exposure a second-degree burn.

For a first-degree burn with minimal treatment, you would report 16000 (Initial treatment, first-degree burn, when no more than local treatment is required). Link the burn code to the sunburn diagnosis (692.71).

If the dermatologist provided a significant and separate E/M service, you should also report the office visit (such as 99212-99213, Office visit for the evaluation and management of an established patient ...) appended with modifier 25 (Significant, separately identifiable E/M  service by the same physician on the same day of the procedure or other service). The office visit could even include counseling on proper safe sun habits and advice on using sunscreen.

Remember: You should also code any subsequent burn treatment. For instance, if the dermatologist has the child return for debridement or a dressing change without anesthesia, you may report 16020 again. Code 16020 has zero global days.