ED Coding and Reimbursement Alert

Question: A patient reported to the ED with her shoulders painfully burned after spending a day at the beach. The emergency physician examined the area, noted redness with some blister formation, and diagnosed a mild burn requiring no further treatment. She told the patient to take ibuprofen over the counter for the pain. The chart documentation supports a level-two service but the physician wants us to report a burn code. Can you advise?

Codify Subscriber

Answer: Not every burn presentation in the ED will require treatment that qualifies for 16000-16030 service. If the burn was minor enough that no real treatment was provided, such as very minor sunburn that required no dressing, debridement, or local treatment, you could include burn treatment in the ED E/M code.

In this instance, the physician examined the burn but did not provide any local treatment above and beyond the evaluation and management service. On the claim, you'd report only a 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 encounter.

However, many burns seen in the ED are severe enough to require some sort of treatment and coders should keep an eye for these opportunities to capture these services.