ED Coding and Reimbursement Alert

Accurate codes tell exact location and severity

When a patient with a burn shows up in the emergency department, coding can get heated right away - mainly because the first step is so difficult to report.

Burn diagnosis coding, which the physician must perform before reporting any other service, can include multiple five-digit codes. Documentation must reflect severity and burn location, and the patient may have more than one burn area to report.

Step 1: Code for the Burn Location

Before you do anything else in burn diagnosis coding, you must select a code from the 940-947 ICD-9 group to explain the injury's anatomic location. Codes from this group are always at least four digits. In burn cases, you may need two or more different codes from the 940-947 group for a single patient. 
   
"The first code is for the injured part of the body, the part that's been burned: the foot, the head, the chest, etc.," says Patricia Sylvia, RN, CPC, of Outer Banks Emergency Physicians in Nags Head, N.C. "These ICD-9 codes are for different (anatomic) areas."

"When coding for burns, make sure that you use separate codes for each burn site on the body," says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC, in Deer Park, Ill. This means that multiple diagnosis codes are allowable when you report the condition of one burn patient, so don't be afraid to use more than one code from the 940-947 series if the situation calls for it.
 
Example: A patient presents to the emergency department with burns on her right thigh, right foot, and the right side of her trunk. To describe her injuries, you would report a code from the 942.xx series (Burn of trunk) and a code from the 945.xx series (Burn of lower limb[s]) to account for the entirety of the burn area.

Warning: These diagnosis codes don't include all types of burns, however - so make sure the burn you are reporting is indeed part of the 940-947 code group.

"These codes (940-947) don't include friction burn and sunburn. Those need to be excluded right off the bat" when reporting burns, Gilhooly says.

If your patient has sunburn, choose the proper code from the 692.7x group (Contact dermatitis and other eczema; due to solar radiation). Diagnosis codes for friction burns are chosen from the "Superficial Injury" group (910-919).

Step 2: Determine the Appropriate Fourth Digit

The 941-947 burn diagnosis codes must extend at least to the fourth digit, which reflects burn severity. When considering the burn's seriousness, use these fourth-digit codes:

0 - Unspecified degree

1 - Erythema (first-degree)

2 - Blisters, epidermal loss (second-degree)

3 - Full-thickness skin loss (third-degree NOS)

4 - Deep necrosis of underlying tissues (deep third-degree) without mention of loss of a body part

5 - Deep necrosis of underlying tissues (deep third-degree) with loss of a body part. 
 
If a patient presents with second-degree burns to his face, you would report 941.20 (Burn of face, head and neck; blisters, epidermal loss [second degree]; face and head, unspecified site). 

When a patient has multiple burns of varying degrees in the same anatomic area, code only for the highest-level burn. For example, if a patient presents with a second-degree burn on her left wrist and a deep third-degree burn on her left hand, report 944.48 (Burn of wrist[s] and hand[s]; deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part; multiple sites of wrist[s] and hand[s]).

Step 3: Carefully Consider Fifth Digit

When you add a fifth digit, you're telling payers more precisely the location of the burn within a given anatomic area. While the fourth-digit codes are the same regardless of the anatomic location of the burn, each code from 941-945 has a separate fifth-digit subset.
 
For example, code 943.x (Burn of upper limb, except wrist and hand) has eight fifth-digit subclassifications to choose from to make the coding more exact. The fifth digit shows the specific part of the body surface area that's been diagnosed, Gilhooly says.

Consider this: A patient with first-degree burns to his neck presents to the ED. The proper ICD-9 code for this session is 941.18 (Burn of face, head and neck; erythema [first degree]; neck), because it appropriately describes the burn's general anatomic area (face, head and neck), severity (first degree), and the specific anatomic site (neck). 

Remember that the meaning of the fifth digit depends on the original three-digit code. For example, a fifth digit of 3 applied to 941.xx signifies a burned lip(s); a fifth digit of 3 applied to 945.xx signifies a burn to the ankle.

As with the fourth digit, higher-degree burns take precedence over lesser-degree ones in the same anatomic area. For instance, when a patient has third- and first-degree burns on her abdominal wall, you should report only 942.33 (Burn of trunk; full-thickness skin loss [third degree NOS]; abdominal wall) because both burns are on the trunk.

Remember: Reporting a burn code does not prevent you from assigning an E/M code as well, says Michael Granovsky, MD, CPC, FACEP, vice president of MRSI in Stoneham, Mass. "These patients may have severe injuries that are often multi-system," he says. "The treatment of the burn may only represent one aspect of the patient's care, and a separately identifiable E/M code will likely apply as well."