ED Coding and Reimbursement Alert

ED coders must rely on specific physician documentation of medical history, physical examination of the burn and level of medical decision-making to assign the appropriate evaluation and management (E/M) code (99281-99285). Then, they must use the documentation of the physical examination and treatment to choose a burn treatment code (16000-16035, burns, local treatment) if applicable. Patients with larger second- and third-degree burns are more likely to require a higher level of care and additional procedures, which can increase the level of E/M code or even require critical care.

If a burn is associated with a potential for respiratory injury, the physician will evaluate the respiratory and cardiovascular systems (in addition to the actual burn injury), explains John Stimler, DO, FACEP, a practicing emergency physician in Jacksonville, Fla., and past president of the Florida chapter of the American College of Emergency Physicians. Inhalation injuries will lead to the patients admission, and the visit would usually be coded at the 99285 (emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patients clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) level. If the patient requires intubation or is being observed very carefully for impending respiratory failure, the critical care codes (99291-99292) may be used, provided the physician attended to the patient exclusively for 30 minutes or more.

BSA and Location May Matter More Than Degree of Burn

Treatment of small, localized burns, even if they are second- or third-degree, may be handled on an outpatient basis and not require a significant level of service.

A localized burnif not in areas such as the face, the perineum, etc.can often be managed as an outpatient, says Dennis Beck, MD, an emergency physician with Beacon Medical Services in Aurora, Colo. When dealing with localized burns, the physician is mainly determining at the outset whether the patient can be managed as an outpatient or needs to be admitted. Most departments have specific thresholds for the amount of body surface area (BSA) burned that requires the patients admission. Anything below that you could probably treat as an outpatient, Beck adds.

Emergency physicians usually will provide local treatment (i.e., debridement, dressing, ointment) for localized first-degree and second-degree burns, says Stimler. Typically, burn treatment procedures performed in the ED are reported with codes 16000 (initial treatment, first-degree burn, when no more than local treatment is required), 16020 (dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small), 16025 (without anesthesia, medium [e.g., whole face or whole extremity]) or 16030 (without anesthesia, large [e.g., more than one extremity]), depending on the size or percentage of body area of the second- or third-degree burn. Most third-degree burns are treated by the plastic surgeon because they will require grafting, Stimler says. In that case, the emergency doctor does an initial workup and refers the case to the surgeon.

For E/M coding for burn patients, Beck recommends using the chief complaint as an initial guide and examining the chart to see that the documented evaluation and management is consistent with the severity of injury.

We often look at what the medical necessity would be, based on the chief complaint, he explains. If someone comes in with a localized burn and is a young, healthy adult with a small burn, the physician may not need a comprehensive history and physical. The level of E/M should still be commensurate with the chief complaint. A small, isolated burn might just be an expanded, problem-focused history and exam, or a detailed history and physical. For the most part, these are going to be about a 99283 (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 moderate complexity). But when someone is brought in by 911 after being in a burning house, there is consideration for carbon monoxide and additional physical trauma, and there probably needs to be at least a detailed or even comprehensive history and physical, and that would most likely be a 99284 or 99285.

Treating Severely Burned Patients

Often, patients injured in fires who sustain burns over a large area of the body will have complications in addition to burn injuries to the skin and tissue, say Stimler and Beck. These complications may require additional management and procedures by the emergency physician.

In the face of an extensive burnover 10 percent of the body sustaining third-degree burns or more than 30 percent of the body with second-degree burnsfluid resuscitation must be provided to the patient. These patients tend to lose a large amount of fluid through the burn tissue and may have respiratory burns that could lead to future breathing compromise, notes Stimler. In these types of cases, critical care services may be provided to the patient to establish or maintain an airway, along with appropriate fluid resuscitation.

It has become easier to report critical care codes in these situations, says Beck. The CPT definition of critical care has been changed to include patients who are potentially unstable rather than just unstable and that would certainly include these patients, he says.

The emergency physician may perform an intubation and central line placement (for fluid resuscitation) on these patients. Beck says, This is the kind of intervention that we would often have on a seriously injured burn patient, and it would not be uncommon to spend 30 minutes or more (the minimum time for coding critical care) with the patient.

Lack of Documentation Still Biggest Obstacle

Even taking the above tips and guidelines into consideration, assigning the appropriate codes is not possible without clear physician documentation, says Beck. The lack of documentation is a problem, he admits. I frequently hear physicians say, But, I always do that. As in, I always ask the patient how long they were in the burning house and whether there was any risk of carbon monoxide exposure or risk of burn injury to the lungs. But, if they dont include this information in their documentation, you cant include it in determining the level of service.

Some physicians always may perform a complete exam, including a brief mental-status check, for all burn patients, he says. But, again, if that information is not documented, the coder has no idea the physician performed that level of examination. If you dont document it, you cant get the credit, Beck states.

Note: See Correct Coding Is Crucial to Reimbursement for First- and Second-degree Thermal Burns on page 27 of the April 2000 ED Coding Alert for guidelines for coding treatment of first-degree and superficial second-degree thermal burns.