ED Coding and Reimbursement Alert

Chart documentation guides the proper code choice to describe your burn care.

Summer is here, school is out and the heat is on. Burn presentations in the ED run from red and sore sunburns to serious third degree destruction from campfires or fireworks, so you have to know the whole spectrum of burn coding options, including when to report E/M codes.

Follow these four steps when coding your ED physician’s burn treatment services to ensure accuracy and appropriate pay.

Step 1: Does the Chart Documentation Support a Burn Code?

Not every burn presentation in the ED will require treatment that qualifies for 16000-16030 service. If the burn was minor enough that no real treatment was provided, such as very minor sunburn that required no dressing, debridement, or local treatment, you could include burn treatment in the ED E/M code, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance for Zotec Partners in Durham, NC.

Coding scenario: A patient reports to the ED with her shoulders painfully burned after spending a day at the pool. The emergency physician examines the area, notes redness with some blister formation and diagnoses a mild burn requiring no further treatment. She tells the patient to take ibuprofen over the counter for the pain. Chart documentation supports a level-two service.

In this instance, the physician examined the burn but did not provide any local treatment above and beyond the evaluation and management service, Norris says. On the claim, you’d report only a 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity …) for the encounter.

However, most burns seen in the ED are severe enough to require some sort of treatment and coders should keep an eye for these opportunities to capture these services, says Norris.

Step 2: Search for Key Phrases That Support Reporting Code 16000.

Review the chart documentation to identify terms that align with the CPT^® descriptors for the burn codes to identify the correct service to report.

If the physician provides local treatment of a first-degree burn, such as cleansing and ointment, then you’d report CPT^® 16000. A first-degree burn affects the epidermis only. Usually these types of burns just involve erythema, but may also exhibit some swelling and/or minor pain. The most likely treatment in 16000 (Initial treatment, first degree burn, when no more than local treatment is required) scenarios is cool towels, soothing balms, and topical medication application; substances such as Silvadene or triple antibiotic ointment, says Norris. Dressings are possible but unlikely for most first-degree burns; they rarely require any treatment except application of moisturizer to soothe the skin. In some cases, the physician might apply a topical anesthetic, she adds.

Example: A patient reports to the ED with a burn on the top of his left hand and forearm from a grease fire in a restaurant. The physician examines the patient’s wound and the surrounding area. The first layer of skin is burned, but there are no blisters, particulate matter, or signs of further injury. The physician applies Silvadene and instructs the patient on how to care for the burn. Notes indicate a level three E/M service accompanied the burn treatment.

What to code: You could report both the ED E/M code 99283 and the burn treatment code 16000, says Norris. Don’t forget to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99283 to show that the E/M and burn treatment were separate services, she explains.

Step 3: Does the Chart Mentions Debridement? Then Consider Partial-Thickness Codes.

For more serious burns with partial-thickness burns or 2^nd degree burns, you would code with 16020-16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent...)

Tip: Look for mention in the chart of a burn that involves blistering. It may be either superficial, involving only the epidermis and superficial layers of the dermis or deep, involving the deep layers of the dermis. Depending on the extent of the partial thickness burn, the ED physician may have to debride the burn or for those partial-thickness burns covering a larger body area, a specialist may have to be called to determine if surgical treatment is needed to prevent scarring.

Partial-thickness burns can be fairly minor if the burned area is small and the patient is otherwise healthy and not elderly or very young, or they can likewise be quite serious and even necessitate transfer to a burn unit, says Norris.

When the physician performs partial-thickness burn treatment, they might use Silvadene following the procedure, but would most likely use some type of non-adherent dressing and additional antibiotic ointment depending on the location and the patient’s skin pigmentation. If you see documentation that contains some of the above elements, consider codes 16020-16030. Keep in mind these codes are applied for dressings and/or debridement of partial thickness burns and are delineated based on the percentage of total body surface area, Norris adds.

Keep in mind: CPT^® ranks the codes by size based on the percentage of total body surface area involved in the burn. These include:

• 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small [less than 5% total body surface area]),
• 16025 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium [e.g., whole face or whole extremity, or 5% to 10% total body surface area]) and
• 16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; large [e.g., more than 1 extremity, or greater than 10% total body surface area])

TBSA Can Change Over Time Depending on Patient Age or Size

Body areas changes as the patient ages and the proportions of a body area, such as the head, alters. The Lund- Brower Classification Method Table from the CPT^® book can help illustrate this point, says Norris.

Step 4: Is A Separate E/M Service Warranted?

Patients reporting to the ED for burn treatment almost always require a separate E/M service in addition to the treatment. Many of these patients will receive a low-level E/M service along with a 160xx service. There are certain situations, however, in which the physician might provide a high-level E/M in addition to burn treatment, Norris warns.

In addition to 16000-16030, these encounters might also include 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity …) or 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) service.

Consider Internal Burn Damage: These higher E/M levels may be appropriate if the patient suffers from chemical poisoning, smoke inhalation, etc. In addition to the burn, he may need extensive management and monitoring beyond the external injuries, or if the burn itself is extensive. Burns can be very serious injuries that can have a myriad of complications including life-threatening infections, shock and pneumonia, says Norris

Example: A patient suffers an electrical burn that causes an arrhythmia and requires aggressive rehydration and replacement of electrolytes. The E/M for this encounter might be high, even up to 99285 or 99291, depending on the patient’s condition. Another example of a potential high level E/M service (99285 or critical care 99291) would be a patient with second degree burns over 15 percent of his body who requires aggressive fluid resuscitation for hypotension, indicating possible shock, multiple consults including a burn specialist, aggressive pain management and immediate dressing of burns and treating with topical and IV antibiotics to prevent infection, Norris adds.