ED Coding and Reimbursement Alert

Also, carriers like 2 diagnosis codes on all 16000 claims

When a patient reports to the ED for burn treatment, coders must first determine the size of the burn. Then, they can start looking for the right CPT Code.

Why? The burn treatment code set in CPT 2006 includes three burn categories---small,- -medium- and -large---and coding for the wrong-size burn could result in claim denials.

-It [burn size] will be the key issue. Coders need to determine a small, medium or large burn before they can choose the code,- says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.

Burn Size Is 1 of 4 Decisions You-ll Make on Claims

But choosing the burn size is only the beginning; you-ve also got to:

- assign the appropriate ICD-9 codes
- hunt for the proper burn treatment code
- look for additional services the physician may have provided.

After you observe these steps, your burn care coding claims should stand up to even the most spurious scrutiny. Read on for inside tips to prevent you from getting singed by your burn care coding.

Choose Dx First When Coding Burns

On claims with burn treatment codes, you must include at least two diagnosis codes, Thomas says. The first code, which represents the location of the patient's burn, should come from the 940.x-947.x series.
 
For example, if a patient has a first-degree burn on her third, fourth and fifth knuckles, the proper diagnosis code would be 944.13 (Burn of wrist[s] and hand[s]; erythema [first degree], two or more digits, not including thumb).

The second diagnosis code you-ll need comes from the 948.xx series. This code represents the total body surface area (TBSA) and severity of the burn, says M. Tray Dunaway, MD, FACS, CSP, CHCO, of Healthcare Value Inc. in Camden, S.C.

While some of the 947.x codes are only four digits, you must carry all 948.xx codes out to the fifth digit,  Dunaway says. To code the appropriate fourth and fifth digits, you must know:

- Fourth digit--Percent of total body surface area affected by the burn of any degree.
- Fifth digit--Percent of body surface with third-degree burns.
 
Example: If a patient's diagnosis is 948.11 (Burns classified according to extent of body surface involved;  burn involving 10-19 percent of body surface; 10-19 percent of body surface third degree), the fourth digit indicates that 10 to 19 percent of TBSA was burned. The fifth digit indicates that between 10 and 19 percent of the TBSA contained third-degree burns.

(For more information on calculating TBSA for burn patients, see -Heed -Rule of Nines- When Calculating Burn Area- later in this issue.)

Choose Burn Treatment Code Next

After assigning the proper ICD-9 codes, you should choose the appropriate burn treatment code, Thomas says. On burn care claims, you should report:

- 16000 (Initial treatment, first-degree burn, when no more than local treatment is required) for first-degree burns (i.e., a burn that only affected the epidermis).

- 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small [less than 5 percent total body surface area]) for small burns.

- 16025 (... medium [e.g., whole face, or whole extremity, or 5 percent to 10 percent total body surface area]) for medium burns.

- 16030 (... large [e.g., more than 1 extremity, or greater than 10 percent total body surface area]) for large burns.

Take the earlier example of a patient with a 948.11 burn diagnosis. Since the fourth digit indicates that the patient suffered burns on 10 to 19 percent of TBSA, you would report 16030 for the procedure.

Caveat: If the physician assesses the burn and then instructs the nurse to simply dress the wound--a common ED scenario--you cannot report a burn care code, Thomas says.

When you use codes from the 16000 series, the physician must provide the services. Ideal documentation for a 16000 claim would include a procedure note of some sort, since these codes are from the surgery section of CPT 2006.

If the nurse cares for the burn, choose the appropriate E/M code. For example, a patient reports with a first-degree burn she incurred while handling a curling iron. The physician looks at the burn, then the nurse cleans and dresses the injury. On the claim, you should report an appropriate low-level E/M code.

Remember: There is new language in the CPT book for 2006 specifying that codes 16020-16030 include the application of materials (e.g., Biobrane, among other burn dressings). Do not report these materials, or their application, as a separate service.

Look for Separate E/M Services

When you use a code from the 16000 series, make sure you-re reporting all ancillary services, too.
 
Why? If the physician treats a burn, odds are she-ll have to provide an E/M service as well, experts say.

-The patient is going to have to be evaluated [by the physician] to determine the extent of the burn and what needs to be done, treatment-wise,- Thomas says.

There is no typical level of service for these E/M services; it all depends on the type and severity of the burn, Thomas says. For example, a patient who burned himself on a hot pan will need a lower E/M level than a patient who was burned internally by a faulty electrical wire.

Do this: No matter what level of service you are coding for a burn patient, make sure you attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show that it was a separate service from the burn care.
 
So if you are reporting treatment of a small burn and a level-two E/M service, you would:

- report 16020 for the burn care.

- report 99282 (... an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M service.

- attach modifier 25 to 99282 to show that the E/M and burn care were separate procedures.