General Surgery Coding Alert

Question: Our surgeon treated a patient at a subsequent visit for a second degree burn of the left foot from bath water that was too hot. What is the correct ICD-10 code for the case?

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Answer: The correct code is T25.222D (Burn of second degree of left foot, subsequent encounter) with an additional code to report percent of total body surface area (TBSA) that is burned, and a third code for cause of injury.

Note seventh character: When it comes to injuries, you’ll always need to list the appropriate seventh character to describe the treatment encounter: “A” for initial encounter, “D” to indicate a subsequent encounter, or “S” to indicate sequela.

Report the TBSA: The next step in coding burns is to report the portion of the body affected by the burn and the portion affected by third degree burns.

In the scenario described above, suppose the surgeon documents that the patient’s burn covers 2 percent of his body. You should report T31.0 (Burns involving less than 10% of body surface). You should always select a code from category T31 (Burns classified according to extent of body surface involved) as a supplementary code with categories T20-T25 when the site is specified. Otherwise, you can use category T31 as the primary code only when the site of the burn is unspecified.

Report the cause of the burn: If known, you should always add an external cause code to describe how the burn happened. In this case, you should list X11.0xxD (Contact with hot water in bath or tub, subsequent encounter). Note that if the burn came from contact with running hot water in the bath or tub, then the diagnosis code would be X11.1xxD (Contact with running hot water, subsequent encounter).

To find the right external cause code for this patient, you’ll look in the Index to External Causes of Injuries in your ICD-10 coding manual. Look under “contact,” “hot,” “tap-water,” “in bathtub” or “running” to find your code (X11.0 or X11.1, respectively). Then turn to the tabular list to see if you have a match and if there are any other requirements for the code.

In this case, you’ll see that you need to report seven characters, but the listed code is only four characters long. In situations like this, you should report “x” as a placeholder for the fifth and sixth characters so that you can list the required seventh character.