General Surgery Coding Alert

Question: I know that it's important to know a burn's severity when assigning a diagnosis code, but how should  we determine this information?

Massachusetts Subscriber

Answer: When dealing with burns, physicians and coders have to work especially closely to ensure that the selected diagnosis accurately reflects the patient's condition.

Above all, this means that physicians must thoroughly document the burn's location(s), extent and severity. All the information you need should be included in the operative report. If it's not, you should ask the documenting physician for additional details, informing him of the importance of complete documentation when assigning burn diagnoses.

Code series 941-946 requires a fourth digit to describe burn severity, 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.

First-degree burns affect only the outer skin layer (epidermis). They cause pain, redness and swelling. 

Second-degree (partial thickness) burns affect both the skin's outer and underlying (dermis) layer. They cause pain, redness, swelling and blistering.

Third-degree (full thickness) burns extend into deeper tissues. They cause white or blackened, charred skin that may be insensate because of the destruction of nerve endings by the burn trauma.

Only if the documentation does not indicate burn degree, and you cannot acquire the information from the physician, should you assign -0- as a fourth digit, and you should be aware that this unspecified diagnosis could affect your ability to obtain reimbursement for any treatment the physician provides.

The 941-945 series also requires a fifth digit to describe the burn's exact location within a specified body area (for instance, you can further identify a -burn of trunk,- series 942, as -breast- using a fifth digit of -1- or -back- using a fifth digit of -4,- and so on).

Additionally, you should also select a code from the 948.xx series as a secondary diagnoses with 940-947. These codes likewise require a fourth and fifth digit, which describe the percentage of the body surface burned and the percentage of the body surface affected by third-degree burns, respectively.

Example: A patient presents with second- and third-degree burns over 30 percent of his body with the third-degree burns taking up 20 percent. In this instance, you would report 948.32 (30-39 percent of body surface; 20-29 percent third degree). Once again, the physician's documentation must support the code selection by noting the percentage of body burned, the body parts affected and burn severity.