ED Coding and Reimbursement Alert

Hint: Treatment calls for more than the 16000 codes

The treatment your physician provides to most burn victims in the emergency department (ED) qualifies for both evaluation and management (E/M) codes as well as codes from the 16000 series. Don't sell your practice short -- follow this guide to smart burn coding and score the reimbursement you deserve.

The overall evaluation of the patient -- including history, exam, medical decision-making, and assessment of other areas -- corresponds to the E/M service. You should describe the care of the burn itself, often involving procedures, by using codes from the 16000 series, says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems in Stoneham, Mass.

Though most burn treatments in the ED qualify for both codes, you can't report them both unless your physician personally performs an assessment (E/M) that's appropriate to the patient's problem. In these cases, append 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.

When reporting the E/M part of the service, make sure the level you choose matches the patient's complaint.

Real-World Example: A young, healthy female has a small, localized burn. She probably won't need a comprehensive history and physical. An expanded, problem-focused history and exam or a detailed history and physical are generally more realistic choices in this scenario. However, an elderly patient involved in a house fire with facial burns and potential smoke inhalation would likely warrant a comprehensive history and exam to investigate this high-risk presentation.

Exception: For most small burns (usually first- and second-degree), unless the injury is on the patient's face or perineum, the ED physician will provide local treatment, such as debridement, dressings, and ointment. If the patient has more extensive burns, such as extensive second-degree burns or even small third-degree burns, the ED physician will handle the initial workup and then transfer care to a specialist. In these cases, you might only report an E/M code (99281-99285) depending on the documentation provided.

Select 16000 when the physician tends to a first-degree burn only (burns affecting only the epidermis), says Stephanie Collins, CPC, healthcare consultant with Gates, Moore & Company in Atlanta.

For more extensive burns, you must choose among codes 16020-16030. You do not determine the appropriate code by debridement depth or type of tissue involved, as is usually the case, Collins says. Instead, select codes based on the size of the affected area and the severity of the burn.

These are the burn codes you'll use most in the ED:

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)

16030 -- ... without anesthesia, large (e.g., more than one extremity).

Suppose a patient presents to the ED with small second-degree burns on her hands. The physician cleans the wound, applies moist towels, debrides a small amount of nonviable tissue, and applies the initial dressing with Silvadene. The physician also updates the patient's tetanus vaccine, gives her a prescription for pain medication, and evaluates her for other potential injuries.

For this service, you would report 16020 and the appropriate E/M from the 9928x series -- possibly a level three (99283), depending on the specific presentation and the documentation provided, Granovsky says.