ED Coding and Reimbursement Alert

Question: A patient presented to the ED with a burn to his left eyelid after a spark from his fireplace burned him. Documentation only supports a level-two evaluation and management service, but I’ve never reported eye burn treatment before. Which E/M code should I report for this visit?

Codify Subscriber

Answer: Report 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 eye burn treatment.

Unfortunately, your doctor’s documentation may have limited the E/M in this case. While some minor burns are low-complexity, more extensive burns, including those involving critical structures such as the eye, may often qualify for moderate medical decision-making.

A well-documented record for a second degree burn from a small grease fire on the stove would likely support moderate medical decision making. Consider the example below: A 19-year-old male is frying hamburgers after working a night shift and falls asleep. He awakens to a grease fire on the stove and tries to quickly put it out with water, burning both forearms with splattering grease and sustaining scattered second-degree burns. A detailed history and physical exam are performed, his Tetanus is updated and he requires an IM injection for pain.

Patients with eye burns from fire or sparks (a common occurrence this time of year) are typically treated with a topical antibiotic and possible pain medication, given an eye patch and sent home. As in this example, the documentation only supports a low-level E/M code.

Only consider adding a burn treatment code such as 16000 (Initial treatment, first degree burn, when no more than local treatment is required) if the chart documentation demonstrates a separately identifiable procedure to justify that code.

Don’t forget ICD-10 codes. Choosing the right burn diagnosis code is important to this claim’s success. If the burn is confined to the eye, consider T26.02XA (Burn of left eyelid and periocular area, initial encounter). In addition, you should consider adding an external cause code if one suits the patient’s situation, such as Y26.XXXA (Exposure to smoke, fire and flames, undetermined intent, initial encounter).