ED Coding and Reimbursement Alert

Coding for burn evaluation and treatment in the emergency department (ED) can be difficult because the degree and mechanism of injury vary so greatly from patient to patient. The evaluation and management (E/M) level varies depending on the degree of burn and what the treatment is. Treatment may vary based on the location, the degree of the burn, the patients history, etc. notes Chris Morey, chart abstractor in the emergency department at Ball Memorial Hospital in Muncie, Ind. If you have three different physicians, they may each do something completely different.

The key to correct coding is choosing the appropriate E/M code (99281-99285) and accompanying burn treatment code (16000-16035) for first-degree and superficial second-degree thermal burns in a typically healthy patient.

Determining Level of Medical Decision-making

The most challenging aspect of assigning the overall E/M level for the visit is determining the level of medical decision-making used by the physician. CPT offers no guidelines correlating the degree of injury with the level of medical decision-making (MDM), and physician documentation is difficult to gauge in these types of injuries, says Morey.

Tip: Coders using the Health Care Financing Administrations score sheet for Medicare auditors may find it useful to use the bullets under the Number of Diagnoses and Management Options and the Risk Table in the MDM section of the score sheet. (See insert Emergency Department Coding Table.)

There are no hard and fast rules, and coders must evaluate each chart individually when coding burn treatment, advises Stephen Holbrook, MD, FACEP, an emergency physician and clinical operations director in the emergency department at DeKalb Medical Center in Decatur, Ga. That is a really tough problem because, if it is a typical healthy person that has a thermal burn, the difference in evaluation between a first degree and superficial second degree is about the same, he says. For most of those, the superficial seconds and the first degrees, pretty much no matter what you do with them, the patient is going to get better. Your evaluation needs to be whether there is any other comorbidity associated with this patient.

According to the CPT documentation guidelines for assigning an E/M level, there are three components to each E/M servicethe level of history taken, the level of examination performed and the level of medical decision-making used by the physician.

When determining a level of MDM (minimal, low, moderate or high complexity) three elements must be consideredthe number of possible diagnoses and management options, the amount and/or complexity of data reviewed, and the risk of morbidity or mortality to the patient. Most practices use a point system recognized by Medicare carriers to calculate the level of MDM.

Note: For detailed information about calculating evaluation and management levels, see the series of articles in the August, September, October and November 1999 issues of ED Coding Alert.

Evaluate Possible Comorbidity

In Holbrooks experience, most patients presenting in the ED for treatment of first- and second-degree burns have little medical history or co-existing problems, he says. Therefore, there will not be a high level of history or a comprehensive medical examination for the coder to evaluate.

Establishing the degree of the thermal burn itself is relatively obvious. What the coders and the documentation need to go into is thisis there any chance the thermal burn has presented any complications? he says. Is there respiratory involvement? The coder would see a chest examination by the physician. Is there any evidence of cardiovascular instability? Is there anything with this burn at all that has any abdominal involvement?

Documentation of cardiac or respiratory involvement can shift the categorization under diagnoses or treatment options from just a self-limited or minor problem to a new problem with additional work-up planned, which can mean a higher overall level of MDM.

As a rule of thumb, coders may start out assuming MDM of low complexity for first- and second-degree burns and look to the treatment performed and the signs of comorbidity for raising the level, advises Randy Thompson, CPC, coding consultant with Health Care Consultants of America Inc., a physician reimbursement consulting firm based in Augusta, Ga.

I would say for the first-degree burn that required just cream or a bandage, it would be an acute, uncomplicated illness, that would remain low complexity, Thompson says. For anything other than that, it usually would be moderate complexity.

Templates Aid Documentation

To improve documentation of complex E/M services like burn treatments and evaluations, many EDs now use templating systems that prompt the physicians for documentation instead of relying on the physician to dictate his or her evaluation and management process, says Holbrook.

The burn template prompts the physician to record when the burn occurred, where it is, what is the mechanismflame, chemical, electrical, etc., he says. It talks about the burn itself, then it goes through a review of systemsdo you have any lung issues before, eye problems before, chest pain, nausea, vomiting, a quick social history. There is a very large physical exam section that shows where the burn is, what the severity is and a big section on the treatment. Coders would need the documentation on what we do for pain control and pain relief and then any debridement performed and wound coveragethat would be where we would either do well or poorly in terms of assigning the E/M level.

However, use of just a template may not be enough, says Morey. Her department also uses a templated documentation system, yet she still has difficulty assigning E/M codes for burn injuries.

Burn Treatment Codes in Addition to E/M Level

In addition to reporting an E/M code for the overall evaluation of the burn injury or injuries, coders can also assign a code from the Burns, Local Treatment section of CPT (16000-16035) for any dressings or debridement performed.

For first-degree burns requiring cream or a bandage, use code 16000 (initial treatment, first-degree burn, when no more than local treatment is required). For superficial second-degree burns requiring dressing, codes 16020* (without anesthesia, office or hospital, small) or 16025* (without anesthesia, medium [e.g., whole face or whole extremity]) or 16030 (without anesthesia, large [e.g., more than one extremity]) could be used depending on the total size of the burn area treated.

According to CPT, these codes are used for the local treatment of the burned surface only, with the necessary related medical services reported separately with the appropriate E/M codes, says Thompson.

To the best of my knowledge, these codes are reported separately and would not require the application of a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in the ED, he says.

Note: Some burn treatment codes are starred (*) procedures, which would affect use of the -25 modifier. Medicare policy differs from CPT policy for starred codes. If you use a starred burn treatment code, check the individual payer policy on reporting starred surgical procedures and E/M codes at the same visit.

According to CPT Assistant, the publication issued by the American Medical Association to explain CPT policy, the burn treatment codes do not include the evaluation and management services involved in the history, exam and medical decision-making for concurrent systemic problems experienced by the patient. But, the usual pre- and post-procedural services directly related to the burn (e.g., explaining procedures to the patient or family, supervising the positioning and prepping of the patient, monitoring the patients stability, and providing aftercare instruction) are included in the procedure code and not reported separately.

For example, says Thompson, if a patient presented with a small, uncomplicated first-degree burn and the physicians only evaluation and management service was directed at treating the wound as opposed to evaluating the patients overall condition, a separate E/M code would not be reportable.