Dermatology Coding Alert

Question: A physician diagnoses a patient with a second-degree burn on her right palm (944.25). The treatment plan calls for the patient to apply ice or run cold water over the area two or three times a day, and to apply Silvadene cream twice a day. The physician notes that blisters had formed over the base of the right thumb and palm that measured about 6 cm in diameter. Should I use a burn code for the physician's service?


Colorado Subscriber

Answer: No. You should reserve a burn code, such as 16000 (Initial treatment, first-degree burn, when no more than local treatment is required) or 16010 (Dressings and/or debridement, initial or subsequent; under anesthesia, small), for when the physician provides actual treatment.

In your example, the physician only evaluates the patient's problem and provides a treatment plan the patient could perform herself. Therefore, you should instead report the appropriate E/M code (99201-99215).

Choose the level based on the documentation's history, exam and medical decision-making components and the patient's status as new or established.

For example, if the patient is established and the physician documents expanded problem-focused history and low-complexity medical decision-making, you could assign 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).