ED Coding and Reimbursement Alert

Look for Total Body Surface Area (TBSA) documentation in notes.

Look for three things in the documentation to accurately report burn presentations diagnosis codes. The guidelines in both ICD-9-CM and ICD-10-CM direct you to consider the anatomical location of the burn, the severity of the burn, and the cause of the burn.

Guidelines for Classifying Burns vs. Corrosions

Unlike the ICD-9-CM code set, ICD-10-CM differentiates between burns and corrosions. ICD-10-CM burn codes describe thermal burns caused by a heat source, such as a fire, and burns resulting from electricity or radiation. ICD-10-CM corrosion codes describe burns caused by chemicals, such as battery acid. The ICD-10-CM guidelines are the same for both burns and corrosions, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, Chief Executive Officer, Edelberg + Associates.

Burn severity is classified based on the depth of the burn, such as first degree characterized by erythema, second degree noted by the presence of blistering or third degree, which involves the full-thickness (epidermis and dermis).

However, often ED patients suffer from multiple classifications of burns in multiple anatomical locations. When coding these cases, assign a separate code for each location with a burn. If a patient has multiple burns on the same anatomical site identified by a code, select the code that reflects the most severe burn for that location.

Sequencing tip: List the codes in order of severity, with the most severe burn first, Edelberg explains.

Example: A patient presents to the emergency department after tripping and falling into a camp fire. The emergency physician’s documentation indicates the patient has first, second, and third-degree burns on his upper back, first and second-degree burns on his left palm, and second and third-degree burns on his left upper arm.

In ICD-10-CM, list the following codes for this scenario:

• T21.33XA (Burn of third degree of upper back, initial encounter);
• T22.332A (Burn of third degree of left upper arm, initial encounter); and
• T23.252A (Burn of second degree of left palm, initial encounter)

ICD-10 Expands Reporting Concepts of Cause, Laterality, and Encounter

Diagnosis coding for burns was complex under ICD-9, but ICD-10 takes it to another level. Under ICD-9, burn codes were reported by body site, depth, extent and an additional code to identify the external cause, when applicable. Those requirements continue under ICD-10 but with a few additional concepts.

In ICD-10, you’ll also report the agent or cause of the corrosion, laterality, and encounter. Plus, ICD-10 makes a distinction between burns and corrosions. Burn codes apply to thermal burns (except sunburns) that come from a heat source, such as fire, hot appliance, electricity and radiation. Corrosions are burns due to chemicals, says Edelberg.

In addition to this distinction, there are coding conventions that are essential in attaining the correct code assignment. These sequencing conventions include:

• When more than one burn or corrosion is present, sequence the code that reflects the highest degree first.
• When the reason for the admission or encounter is for treatment of external burns or corrosions, sequence the code that reflects the highest degree first.
• When a patient has both internal and external burns or corrosions, the circumstances of admission govern the selection of the principal diagnosis (or first-listed diagnosis).
• When a patient is admitted for burn injuries and other related conditions such as smoke inhalation or respiratory failure, the circumstances of admission govern the selection of the principal diagnosis

Burns Classified According to Extent

Whenever you can determine the total body surface area (TBSA) on a patient who suffers burns, you should include a secondary diagnosis code to capture that information, Edelberg warns.

Both ICD-9-CM and ICD-10-CM guidelines address coding burns classified according to the extent of body surface involved. In ICD-9-CM, the codes under 948 (Burns classified according to extent of body surface involved) provide these details. In ICD-10-CM, you’ll turn to the codes under T31 (Burns classified according to extent of body surface involved) or T32 (Corrosions classified according to extent of body surface involved).

Report these base codes when the provider doesn’t specify the site of the patient’s burns in the medical record, or when there is a need for additional data. Burn units often capture and track this data to evaluate burn mortality. The guidelines also suggest using these codes when there is mention in the documentation of a third-degree burn involving 20 percent or more of the total body surface area. These codes are based on the classic “rule of nines” in estimating body surface involved. Body areas are measured in increments of 9 percent, says Edelberg.

According to the guidelines for burn coding in ICD-10:

• head and neck, the right arm, and the left arm each equal 9 percent
• the back trunk, front trunk, left leg, and right leg each equal 18 percent (the front and back trunk are divided into upper and lower segments, and each leg is divided into back and front segments, each equaling 9 percent)
• genitalia equal 1 percent.

In ICD-9-CM, the fourth code digit identified the percentage of total body surface with all degrees of burns. The fifth digit identified the percentage of the patient’s body surface with third-degree burns. Although ICD-10-CM doesn’t include a table of fifth character options, the codes follow the same general pattern as ICD-9-CM, Edelberg explains.

Example: A patient has burns on 60 percent of his body surface. Approximately 1/3 (33 percent) of his body surface has third-degree burns. 

In ICD-9-CM, appropriate coding was:

948.63 (Burn [any degree] involving 60-69 percent of body surface with third degree burn 30-39%)

In ICD-10-CM, appropriate coding is:

T31.63 (Burns involving 60-69% of body surface with 30-39% third-degree burns)

External Cause Codes

Both ICD-9-CM and ICD-10-CM guidelines recommend reporting appropriate external cause codes for burn patients. Not all payers accept these codes but they are helpful for research purposes.

Example: A volunteer firefighter who was severely burned during an extensive, uncontrolled forest fire in his rural community is seen at the emergency room for evaluation. Investigators are unable to determine the cause of the fire.

Appropriate ICD-10-CM codes are:

X01.0XXA (Exposure to flames in uncontrolled fire not in building or structure, initial encounter);
Y26.XXXA (Exposure to smoke, fire and flames, undetermined intent, initial encounter);
Y92.821 (Forest as the place of occurrence of the external cause); and
Y99.2 (Volunteer activity).

With the high volume of burns presenting to the ED each year, it’s important to understand the guidelines for coding these injuries. The ICD-10 “grace period” for the highest degree of specificity will likely be ending in October, so if the chart documentation lacks the details necessary for you to code with the utmost specificity, ask for clarification from the provider, Edelberg says.