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ED Coding and Reimbursement Alert

You be the coder:

High-Level E/Ms and Burn Patients

Published on Wed Jan 27, 2010

Question: A 42-year-old female is brought to the ED by ambulance after being rescued from a house fire. She has suffered burns to 60 percent total body surface area (TBSA), with 10 percent full-thickness and 50 percent partial-thickness burns, primarily on her hands, arms, legs, and feet with a few severe burns on her face and scalp. The emergency medical technicians started intravenous fluids in the ambulance and there is significant swelling. The patient also had severe smoke inhalation and is struggling to breathe.

The ED physician spends 79 minutes stabilizing the patient and treating her burns. Escharotomies are needed on both legs due to swelling (two incisions per leg). The physician fully evaluates the patient; current concerns, other than the actual burns, are impending respiratory failure, possible carbon monoxide poisoning (labs are drawn), and tachycardia. Upper airway swelling causes the ED physician to order a tracheotomy, and the patient is also placed on a ventilator. Examination reveals significant foreign bodies in the partial-thickness burns on the hands and small areas, totaling 3 percent TBSA, which the physician debrides. The physician orders consultations from cardiology and respiratory medicine, and then decides the patient is stable enough to transfer to the ICU. How should I code this scenario?

Wisconsin Subscriber

Answer: The ED physician most likely provided critical care for this patient in addition to the burn care and debridement because the patient presented in a life-threatening situation and required immediate stabilization.

Best bet: You indicate that the entire encounter took 79 minutes; go back and check the notes, and talk to your physician, to see how long he spent on each procedure separate from critical care. So let's say that the total procedure time was 24 minutes (for the debridement, escharotomies, and tracheostomy) and the E/M service was 55 minutes.

You'd report the following:

• 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small [less than 5% total body surface area]) for the debridement;

• 16035 (Escharotomy; initial incision) for the first escharotomy;

• +16036 (... each additional incision [Lest separately in addition to code for primary procedure]) x 3 for the next three escharotomies;

• 31603 (Tracheostomy, emergency procedure; transtrachael) for the tracheostomy;

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care; and

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99291 to show that the E/M and burn treatment were separate services, if the payer requires it.

Be sure: You don't want to overcode this one. Make absolutely sure that the physician's actions and patient's condition warrant 99291; otherwise, you might have to opt for 99285 (Emergency department visit for the evaluation and management of a patient ...).

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