General Surgery Coding Alert

Capture debridement pay with proper documentation.

Whether from a sunburn in this new spring season, or a damaging fire, burn presentation to your surgeon may run from red and sore to serious third degree damage. That means you should know the spectrum of burn coding options, including when to report E/M codes.

Let our experts lead you through a decision-making process to make sure you choose the right codes and capture the pay you deserve.

Be Ready to Default to E/M

Not every burn presentation will require treatment that qualifies for one of the CPT^® burn treatment codes (16000-16030). For minor burns without any directed treatment, you should bundle the surgeon’s burn assessment in the E/M code, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance for Zotec Partners in Durham, N.C.

Coding scenario: A new patient reports with her right calf painfully burned after backing into a space heater in the garage. The surgeon examines the area, notes redness but no blisters or broken skin, and diagnoses a mild burn requiring no further treatment. She tells the patient to take ibuprofen over the counter for the pain. Chart documentation supports a level-two service.

In this instance, the surgeon examines the burn but does not provide any local treatment beyond the evaluation and management service, Norris says. On the claim, you’d report only a 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making …) for the encounter.

But some burns are severe enough to require some sort of treatment, and coders should keep an eye for these opportunities to capture these services, says Norris.

Focus Diagnosis Coding

To select a burn treatment code, you first need to look for information in the surgeon’s note that indicates the diagnosis based on burn classification, site, and surface area.

Burns are classified as first, second, or third degree. A first-degree burn affects the epidermis only and typically involves erythema and possibly some swelling and/or minor pain. In contrast, second-degree (partial thickness) burns affect both the outer and underlying skin layers. They cause 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.

You’ll select an ICD-10 code for the type of burn based on body site such as T20 (Burn and corrosion of head, face, and neck). The fourth digit specifies burn type, while the fifth digit gives more specific information about the site, such as T20.12-- (Burn of first degree of lip[s]…). You’ll also need a seventh digit to indicate the encounter, such as T20.12XA (… initial encounter)

There’s more: You also need to know how much body surface area the burn covers. When you find surface area documentation in the surgeon’s note, you should list a code from category T31 (Burns classified according to extent of body surface involved) as a second diagnosis following the body site code (or alone if you don’t know the body site). For instance, you might list T31.10 (Burns involving 10-19% of body surface with 0% to 9% third degree burns).

Search for Key Phrases That Support Burn Codes

In addition to the diagnosis code information regarding type, location, and extent of the burn, you should search your surgeon’s note for a description of treatment actions, such as application of topical medication, debridement, and/or use of wound dressing. Taken together, that information should be sufficient for you to select one of the following burn treatment codes:

• 16000 — Initial treatment, first degree burn, when no more than local treatment is required
• 16020 — Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)
• 16025 — … medium (e.g., whole face or whole extremity, or 5% to 10% total body surface area)
• 16030 — … large (e.g., more than 1 extremity, or greater than 10% total body surface area)

Example: A patient reports with a burn on the top of his left arm and shoulder area from falling against a metal barrel containing a fire for burning trash. The physician examines the patient’s wound and the surrounding area. The first layer of skin is burned in the left chest area, but there are no blisters, particulate matter, or signs of further injury. The physician applies Silvadene and instructs the patient on how to care for the burn. Notes indicate a level one E/M service.

What to code: You should report the burn treatment code 16000, but you should not list a separate E/M code, because the visit was directed at the burn treatment.

More extensive: In a different case, your surgeon documents debridement and dressing of a second degree burn covering 8 percent of total body surface area. He also documents a level two new-patient E/M, including evaluating the patient for dehydration and shallow respirations.

Do this: Report the service as 16025 plus 99202-25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service). You can list both the burn treatment and the E/M together because the surgeon evaluated conditions distinct from the burn itself during the patient encounter.