ED Coding and Reimbursement Alert

-Rule of Nines- is not just for ICD-9 coding

Your physician will certainly treat her share of first- and second-degree burn patients. So you should focus on the ins and outs of coding these burn encounters.

Why? ED physicians rarely treat more-severe burns. When a patient reports with third- or fourth-degree burn, your physician will most likely examine the patient and call in a specialist to handle treatment.
 
Check for E/M on Burn Encounters
 
Burn patients who present to the ED almost universally receive a separate E/M service before burn treatment, says Maria Narvaez, RHIT, CCS-P, manager of coding operations at LifePoint Hospitals Inc. in Brentwood, Tenn.

-The E/M is necessary to assess patient condition prior to treatment,- Narvaez says. This E/M can include:

- determining the cause of the trauma,
- searching for any conditions that a patient might have that could interfere with treatment, or
- examination of the affected part necessary to determine the extent of burns and the degree of the burns.

Best bet: Look for evidence of a separate E/M on each of your burn code claims. If you decide to file a separate E/M, be sure to 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 code to show that the E/M and burn treatment were separate services.

Example: A patient with burns on her lower left leg reports to the ED. The physician performs a level-two E/M and discovers first-degree burns on the leg, which he treats with cool towels, gauze and an application of topical antibiotics.

On this claim, you should report the following:

- 16000 (Initial treatment, first degree burn, when no more than local treatment is required) for the burn treatment
- 99282 (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 low complexity) for the E/M
- modifier 25 linked to 99282 to show that the E/M and burn treatment were separate services.
 
Exception: In rare instances, a patient might report to the ED for follow-up burn care (this may occur if the patient has no primary-care physician, for example). In these cases, the physician might perform burn treatment without documenting a separate E/M.

Size Drives 2nd-Degree Burn Treatment Choice

While you-ll report 16000 for all of the first-degree burns that the physician treats, selection of second-degree treatment codes is more involved. Characteristics: -Second-degree burns involve damage to the epidermis and the dermis (the second layer of skin, located beneath the epidermis), characterized by blistering, with red, moist skin,- says Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla.

If the physician treats a patient's second-degree burns, Narvaez says, you should choose from these codes, depending on the situation:

- 16020--Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)
- 16025--- medium (e.g., whole face or whole extremity, or 5% to 10% total body surface area)
- 16030--- large (e.g., more than one extremity, or greater than 10% total body surface area).
 
Remember -Rule of Nines- When Assigning TBSA

Because the second-degree burn codes are listed according to total body surface area (TBSA) burned, coders must decide how much of a patient's body was burned before choosing a code.

For CPT coding, the Rule of Nines defines severity by body area:

- Head and neck: 9 percent TBSA
- Each total arm: 9 percent
- Chest: 18 percent
- Back:  18 percent
- Genitalia: 1 percent
- Lower extremities: 18 percent each

Example: A 72-year-old patient presents to the ED with a burn to her right hand and forearm from the stove. The physician examines the patient and determines that she is an insulin-dependent diabetic. Due to blistering and skin loss on the palm, the physician characterizes the burn as second-degree with 3 percent total BSA involved.

There is no involvement of any finger joints, and the hand and fingers have good sensation and blood flow.

The ED physician debrides the wound's loose skin, applies silvadene, covers the wound and wraps the hand.

Due to her insulin dependence, the patient is to be seen in follow-up by her primary physician to be sure that the wound does not develop infection.

On the claim, Edelberg says, you should report the following:

- 16020 for the burn treatment
- 99283 (- an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M
- modifier 25 linked to 99283 to show that the burn treatment and E/M were separate services.

Explanation: The patient suffered burns to her hand and forearm totaling 3 percent; therefore, you should choose the small second-degree burn treatment code (16020 for second-degree burns totaling less than 5 percent TBSA).

(Note: Choosing the right CPT code is only half the task when it comes to burn treatment coding. Accurate ICD-9 coding is absolutely vital to the health of your burn treatment claims. For more information on diagnosis coding, see -Report Burn Location Diagnosis to at Least the Fourth Digit- in the January/February 2007 issue of ED Coding Alert.)