General Surgery Coding Alert

Don't double up on wound care.

When your general surgeon treats serious burns, you'll need to know how to deploy CPT 16035 (Escharotomy; initial incision) and +16036 (... each additional incision [List separately in addition to code for primary procedure]) as your best coding tools. Learn the clinical conditions that warrant reporting 16035-+16036 and additional codes with the following expert tips.

Tip 1: Zero in on Keywords

If you see the terms "escharotomy," "faciotomy," or simply "incision" in the surgical report for treatment of a patient with third-degree burns, you're dealing with 16035-+16036. "Eschar is typically a full thickness injury where the burned skin becomes leathery and delineates from viable tissue underneath," says M. Tray Dunaway, MD, FACS, CSP, a surgeon, author, speaker, and coding educator with Healthcare Value Inc. in Camden, S.C. An escharotomy involves the physician creating surgical incision(s) through the burned area. The procedure releases pressure from swollen tissue that could otherwise hamper circulation. The incisions often spread open due to swelling and require coverage with a sterile bandage.

Watch Dx: Your surgeon will assess burn severity as first, second, or third degree, and an ICD-9 code from the range 940.x-947.x (Burn ...) will account for the burn's severity and body site.

First-degree burns usually only redden the skin, while second-degree (partial thickness) burns affect both the outer and underlying skin layers, causing pain, redness, swelling, and extensive blistering. Third-degree (full thickness) burns extend into deeper tissues and cause white or blackened, charred skin that may be numb because the burn trauma has destroyed the nerve endings.

"The diagnosis code is crucial to show medical necessity for escharotomy, since the procedure is for third-degree burns," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

Tip 2: Know What's Included

When your surgeon performs escharotomy, you'll need to use both 16305 and +16306 if the procedure involves more than one incision. Do this: Report 16305 for the first incision, and +16306 for each additional incision. The length of the incision is not relevant to the code selection.

For instance: The surgeon treats a patient with third-degree burns on the left arm by creating a 40 cm incision down through to the level of the subcutaneous fat along each side of the arm. You should code 16305 and +16306.

Dressing included: Because escharotomy includes applying dressing, you shouldn't additionally report one of the other burn treatment codes (16020-16030, Dressing and/or debridement of partial-thickness burns, initial or subsequent ...) with 16305 for the same site.

Separate wound care is off limits, too: Even if your surgeon performs services at the escharotomy site that qualify as active wound management, you can't separately report the service. Correct Coding Initiative (CCI) edits bundle 97602 (Removal of devitalized tissue from wound[s], non-selective debridement, without anesthesia, including topical application[s], wound assessment and instruction[s] for ongoing care, per session) and 97605-97606 (Negative-pressure wound therapy ...) as components of 16305.

Tip 3: Watch for Later Debridement

Third-degree burn treatment often involves services beyond the initial escharotomy procedure. "The surgeon often needs to go back at a later date to perform a debridement and prep the field for a graft," Dunaway says.

Code subsequent treatment: For deeper debridements following escharotomy, "use the standard debridement codes 11042-11048 [Debridement ...] according to size and depth," says Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS, President of Askmueller Consulting, LLC in Lenzburg, Ill.

Skip 58: Escharotomy codes no longer have an assigned global period, although they used to have a 90-day global, Mueller says. That means you no longer need to use modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) with the code for related debridement following initial escharotomy.

Tip 4: Capture Separate E/M

Your surgeon may perform a separately identifiable E/M service in addition to the escharotomy, such as evaluating the patient for dehydration and heart problems, according to Dunaway. In that case, you could additionally report an E/M code such as 99222 (Initial hospital care, per day, for the evaluation and management of a patient ...). There is no typical level of service for burn E/M encounters; it all depends on the type and severity of the burn and what systems the physician examines.

Don't miss: If you're reporting the escharotomy with an E/M procedure, you'll need to 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 to show that it was a separate service from the burn care.

Tip 5: Bill Separately for Graft Services

Skin grafts are common following escharotomy, according to Dunaway. But codes 16035-+16036 describe only the immediate burn treatment, not the subsequent grafts. "Grafts are separately reportable according to location and size, which has to be recorded by the surgeon at the time of the procedure," Mueller says.

Do this: Select the appropriate code from the CPT graft section (15040-+15431) using the surgeon's documentation.

For example: The surgeon treats a patient with a third-degree burn on the left arm, creating a single incision through the eschar. In addition, the surgeon uses a free, full-thickness graft measuring 40 square cm to close the wound. In this case, you should report 16035 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), plus +15221 (... each additional 20 sq. cm [list separately in addition to code for primary procedure]) for placing the skin graft.