General Surgery Coding Alert

To establish medical necessity for burn treatments, surgeons must supply the correct diagnoses codes. This can be confusing because codes from two different ICD-9 series must be used in tandem. In addition, both the site of the treatment and the size of the affected area must be documented clearly.

Select ICD-9 by Location and Severity

Burn diagnosis codes fall within ICD-9 range 940-949. Selecting the correct diagnoses for burns can be difficult because:

The physician may not have clearly or accurately described the location or extent of the burn

More than one ICD-9 code may be necessary to indicate the location, extent and severity of the burn(s)

If the same area has multiple burns of differing degrees, only the highest-level burn should be noted.

The ICD-9 manual includes two types of codes that, when used correctly, provide information on the location, extent and severity of the burn(s). These diagnoses justify the treatments provided, explains Marcella Bucknam, CPC, billing and compliance manager with the department of surgery at the University of Nebraska Medical Center in Omaha. If the patients chart (and the ICD-9 codes) indicates only second-degree burns, for example, the carrier may want to know why an escharotomy was performed.

The first set of codes (941-945) indicates the location and severity of the burn(s). The initial three digits describe the general location. For example, codes beginning with 941 describe burns to the face, head and neck. The 942 series is used for burns to the trunk. Codes 943, 944 and 945 describe burns to the arms, hands and legs, respectively.

The fourth digit in this code series describes the severity of the burn, from least to most severe, as follows:

0 unspecified degree
1 erythema (first-degree)
2 blisters, epidermal loss (second-degree)
3 full-thickness skin loss (third-degree NOS)
4 deep necrosis of underlying tissues (deep third-degree) without mention of loss of a body part.
5 with loss of a body part.

The fifth digit describes the specific location of the burn within a body area. Unlike the categories for the fourth digit which are the same regardless of body area the fifth-digit categories are specific to the affected area. For instance, the following fifth-digit classifications apply only to the trunk (942):

0 unspecified site
1 breast
2 chest wall
3 abdominal wall
4 back (any part)
5 genitalia
9 other and multiple sites of trunk.

Higher-degree burns in the same area take precedence over lesser burns, Bucknam notes. For example, if the patient has a third-degree burn on the chest and a second-degree burn on the stomach, only 942.32 is coded because both burns are located on the trunk. An additional second-degree burn on the upper arm, however, should be coded separately (943.23) because the arm is part of a different body area.

Detail Extent of Burn

The fourth and fifth digits of ICD-9 948.xx detail the percentage of the body burned and the percentage of the body affected by third-degree burns, respectively.

For example, if 948.31 is listed, the patient has burns over 30-39 percent of the body, with third-degree burns covering 10-19 percent of the body (refer to the ICD-9 manual for a complete list of fourth- and fifth-digit categories).

The percentage of the body that has been burned can be calculated using the information in the first set of ICD-9 codes described above (940.xx-945.xx), and then applying the rule of nines, which assigns specific percentages to sections of the body, as follows:

9 percent head and neck
18 percent back
18 percent front
9 percent left arm
9 percent right arm
18 percent left leg
18 percent right leg
1 percent perineum

Note: The trunk and back are further divided into upper and lower sections. Therefore, if a portion of the lower trunk is affected, only 9 percent is affected, not the entire 18 percent.

Even if the entire body area is not affected, the total percentage of that area should be claimed. In other words, even if only a portion of the left arm or right leg is burned, the full 9 percent for that area is claimed. Therefore, the actual total body surface area burned may be different from the coded percentage. This differs from the fluid resuscitation parameters which are calculated using only the actual percentage that was burned also used by surgeons to treat burns.

Note: The percentages are slightly different for babies, due to the relative large size of their heads (18 percent). While back and front remain at 18 percent and arms remain at 9 percent, the legs have been trimmed to 14 percent each to account for the increased size of the head and face.

Apply CPT Codes Accurately

When treating a small, localized third-degree (or full-thickness) burn (e.g., a burn the size of a silver dollar on the leg), an escharotomy will likely be performed, says Tray Dunaway, MD, a practicing general surgeon in Camden, S.C. Escharotomy involves incising the eschar (the leathery slough formed by a third-degree burn) to expose the subcutaneous tissue beneath. The affected area is debrided and dressed. Subsequently, a skin graft may also be performed.

Debridement may also be necessary to remove dead skin from partial-thickness (second-degree) burns. In many cases, however even for large second-degree burns only an E/M service (e.g., an office visit or admit to observation if the patient is too uncomfortable to be sent home) is provided. Frequently, Dunaway notes, the patient is first seen in the emergency department and may return to see the surgeon in the office.

New Escharotomy Code Available

Patients with third-degree burns on more than one site may require additional escharotomies. Until this year, only 16035 (escharotomy; initial incision) could be billed, regardless of the number of escharotomies performed. CPT 2001 has introduced a second code (+16036, each additional incision [list separately in addition to code for primary procedure]) to report each additional incision.

Note: Code +16036 (2.32 relative value units [RVUs]) is an add-on code and may be used only with 16035 (5.81 RVUs in a nonfacility setting, 3.11 in a facility setting).

For example, a patient with full-thickness burns on the trunk, back and both legs undergoes escharotomies on all four sites. According to Bucknam, the session should be coded as follows:

16035
16036 x 3.

Note: Modifier -76 (repeat procedure) should not be attached to the second and third escharotomies because it implies that an identical procedure was repeated at a different time. In this case, the procedure is performed at a separate site and is therefore not identical.

Debridement and Dressing

CPT includes the following debridement codes specific to burn treatments:

16010 dressings and/or debridement, initial or subsequent; under anesthesia, small

16015 under anesthesia, medium or large, or with major debridement

16020 without anesthesia, office or hospital, small

16025 without anesthesia, medium (e.g., whole face or whole extremity)

16030 without anesthesia, large (e.g., more than one extremity)

These codes describe immediate and palliative procedures that require local treatment of the burn surface only, Bucknam says.

The correct code is not determined by the depth of the debridement, as is usually the case. Instead, whether the patient was anesthetized and the size of the affected area drive the selection. If more than one extremity is affected and if the patient is debrided under anesthesia, 16015 should be used; if the patient is not anesthetized, 16030 is appropriate. Similarly, if an entire extremity (or the face) is affected, use 16025 if anesthetic is not administered or 16015 if the patient is sedated. For small debridements under anesthesia, 16010 is correct; if the patient did not received anesthesia, use 16020.

Note: Nonautologous skin grafts may be used as living (or, if bilaminate skin substitute is used, nonliving) bandages, followed by an autologous skin graft after the dead tissue has been debrided. Look for further coverage of this issue in an upcoming General Surgery Coding Alert.

Although nonphysician practitioners (NPPs) such as nurse practitioners or physician assistants would not likely perform the initial debridement/dressing following an escharotomy, they may perform subsequent debridements if state scope-of-practice laws or regulations permit.

When NPPs perform such debridements, the burn debridement/dressing codes should not be used. Instead, 97601 (removal of devitalized tissue from wound; selective debridement, without anesthesia [e.g., high pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session) should be coded if the debridement is selective (i.e., involves cutting or removing tissue). If the procedure does not involve removing tissue, use 97602 ( non-selective debridement, without anesthesia [e.g., wet-to-moist dressings, enzymatic, abrasion], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session).

Note: According to CPT Changes 2001: An Insiders View, published by the AMA, 97601 and 97602 are to be reported by nonphysician professionals (e.g., physician assistants, nurse practitioners, enterostomal therapy nurses, wound care nurses, physical therapists) licensed to perform these procedures, and are not reported in addition to other debridement codes.

Select the Appropriate Modifier

Escharotomies include a 90-day global surgical package, meaning that most related services or procedures performed within 90 days of the original procedure cannot be separately billed. But because the initial debridement performed after the escharotomy was planned at the time of the original procedure, it is considered a staged procedure and is separately payable as long as modifier -58 (staged or related procedure or service by the same physician during the postoperative period) is appended, Bucknam says.

In addition, Bucknam notes, 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. These debridements should also be billed with modifier -58 appended.

Because the burned area is considered contaminated from the onset, any infection of the skin surface requiring surgical attention is not a complication of the original procedure, but rather a staged procedure. Therefore modifier -58 would again apply, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill.

Mueller notes, however, that an infection arising from any indwelling catheter or venous line placed at the time of the first escharotomy would be considered a surgical complication and would be payable only if the patient had to return to the OR and modifier -78 (return to the operating room for a related procedure during the post-operative period) is appended.