ED Coding and Reimbursement Alert

Don't send off that claim until you've checked for billable ancillary services

Once you've figured out the proper primary burn diagnosis code(s), it's time to begin looking at the secondary diagnosis, which informs payers of the amount of the body burned, as well as the percentage of third-degree burns on a patient.
 
"We use secondary codes when it's an extensive burn," says Patricia Sylvia, CPC, RN, of Outer Banks Emergency Physicians in Nags Head, N.C. "Otherwise, we just report an injury code and a burn code."

What is an extensive burn? "If third-degree burns have affected more than 20 percent of the body, I use (secondary codes)," says Joan Gilhooly, CHCC, CPC, President of Medical Business Resources LLC, in Deer Park, Ill.
 
This criterion is not hard and fast, however. Some offices are even using the 948 series with less extensive burns than that, because you don't have much to lose with further diagnoses.
 
Experts recommend that you formulate a definition of an "extensive" burn for your office, rather than leaving the definition up to the individual physician, nurse, coder or billing supervisor. Try to organize a "sit down" with your doctors and billing department to decide what will constitute an "extensive burn" in your ED.
 
When reporting a secondary code, choose from the 948.xx group (Burns classified according to extent of body surface involved). Just as with the primary diagnosis codes, secondary codes often carry to the fifth digit. The first three numbers are always 948; use the fourth and fifth digits to describe the percentage of the body burned and percentage of the body with third-degree burns, respectively. Keep in mind that this will vary by case.
 
To report a secondary burn code, you should first determine whether the burn is small, medium or large. Secondary diagnosis coding is based on the "Rule of Nines," which divides the body into increments of 9 percent in order to make total burn-affected body surface easier to determine. (For a visual explanation of the "Rule of Nines," see page 271 in ICD-9 2004.)
 
For example, with code 948.32, the fourth digit (3) indicates that 30-39 percent of the body surface has been burned. The fifth digit (2) signifies that 20-29 percent of the body has third-degree burns. (For more information on the "Rule of Nines" and burn coding in general, see "Are You Billing for Burns Correctly? Not if You're Overlooking the 16000 Series" in the August 2003 edition of ED Coding Alert.)

Use E Codes When Applicable

In many burn cases, an E code is required to explain the exact cause of the burn. Payers use E codes to help determine whether a third party may be partially responsible for the patient's treatment. For example, if a patient was burned while working in a coal mine, you would bill workers' compensation for the treatment.
 
If a patient presents with burns sustained while handling hydrochloric acid, assign E924.1 (Accident caused by hot substance or object, caustic or corrosive material, and steam; caustic and corrosive substances). Before submitting your first claim with an E code, make sure the payer will accept it.
 
"Some insurance carriers don't recognize E codes, so we check first," Gilhooly says. "It can even vary state-to-state with Medicare, but we report them in Illinois."

Locate Any Separate E/M Codes

In addition to secondary diagnosis coding and possible E codes, doctors often perform separately billable E/M services when treating some burn victims. If a man twists his ankle and burns his hand breaking his fall on a stove burner, for instance, the ED physician would treat the burn and evaluate the patient's ankle for injury.

 When a separate E/M service is performed in addition to a burn diagnosis, report the appropriate E/M code and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).