General Surgery Coding Alert

Select 16000 when the surgeon 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 16010-16030. You do not determine the appropriate code by debridement depth, as is usually the case, Collins says. Instead, select codes depending on if the surgeon anesthetizes the patient, as well as the size of the affected area.
 
For example, Collins says, if the surgeon treats more than one extremity with the patient under anesthesia, you should use 16015; if the surgeon does not anesthetize the patient, you should report 16030. Similarly, for treatment of an entire extremity (or the face), use 16025 if the surgeon does not use anesthetic, or 16015 if the surgeon does sedate the patient. For small debridements under anesthesia, select 16010; if the patient did not received anesthesia, use 16020.
 
The surgeon must determine whether the affected area qualifies as small, medium or large, using the CPT descriptors as a guideline. The surgeon should clearly state the size of the affected area in his or her documentation to support any code selection.

2. Claim Skin Grafts, When Applicable

Because codes 16000-16030 describe immediate local treatment of the burn surface only, you may report skin grafts separately if the surgeon performs them, Collins says. You should select the appropriate skin graft code(s) from the 15100-15650 portion of CTP.
 
For example, the surgeon treats a patient with third-degree burn on the left arm, using anesthesia. In addition, he uses a free, full-thickness graft measuring 40 square cm to close the wound. In this case, you should report 16010 for the initial burn treatment and 15220 (Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less), +15221 (... each additional 20 sq cm [list separately in addition to code for primary procedure]) for placement of the skin graft.
 
Note: See next month's General Surgery Coding Alert for complete information on reporting skin grafts.

3. Report Escharotomy Separately

As with skin grafts, you should report escharotomy separately, if the surgeon performs it. This procedure involves incising the eschar (the leathery slough formed by a third-degree burn) to expose the subcutaneous tissue beneath, says Tray Dunaway, MD, a practicing general surgeon in Camden, S.C. The surgeon then debrides and
dresses the affected area, and may subsequently perform a skin graft.
 
Report the first escharotomy using 16035 (Escharotomy; initial incision) and any initial incision beyond the first with (+16036, ... each additional incision [list separately in addition to code for primary procedure]). For example, a patient with full-thickness burns on the trunk, back and both legs undergoes escharotomies on all four sites. In this case, you would use 16035 to describe the first escharotomy and 16036 x 3 for the three subsequent escharotomies.
 
You may claim initial debridement following escharotomy by appending modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the appropriate debridement code (16010-16030), Dunaway says. Although the escharotomy includes a 90-day global period, the surgeon plans the debridement at the time of the escharotomy, and therefore the debridement qualifies as a staged procedure. And, because skin may continue to burn even after it is removed from the initial source of heat, the patient might need to return as additional tissue dies. You may report these debridements with modifier -58, also.
 
For example, following escharotomy, the surgeon provides initial debridement for a small third-degree burn on the lower left leg. Claim 16035 for the escharotomy and, at the later date when the surgeon performs debridement, 16010-58.

4. Treat Infections as Staged Procedures

For follow-up procedures, you may have to append modifiers to receive appropriate payment. For instance, if the surgeon must treat an infection on the burned skin surface, you may report the appropriate procedure code, such as additional debridements, with modifier -58 appended. This is because the burned area may be contaminated from the onset, and any infection requiring surgical attention is not a complication of the original procedure but of the burn itself, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill.
 
Payers would consider an infection from any indwelling catheter or venous line placed during the first escharotomy to be a surgical complication, however. Therefore, Medicare insurers will pay for the procedure only if the patient had to return to the operating room and you append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate procedure code, Mueller says.