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 [...]