General Surgery Coding Alert

Question: How should I choose codes from the 940-947 series if a patient has both first- and second-degree burns of the face? Should I code each level of burn separately or combine them?


Arizona Subscriber


Answer: When assigning diagnoses for burns in the same anatomical location, you should report only the more severe (in this case, second-degree) burns using the appropriate location code.

For instance, codes beginning with 941 describe face, head and neck burns. Use the 942 series for burns to the trunk. Codes 943, 944 and 945 describe burns to the arms, hands and legs, respectively.

In addition, you must indicate the severity of a burn by assigning a fourth digit attached to the appropriate 941-946 code(s), 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.

In this case, therefore, you would report 941 (for face) with a fourth digit of 2 (for second-degree burns).

Finally, when reporting the 941-946, you must assign a fifth digit to describe the burn's specific location within a body area. For example, a fifth digit of 1 when applied to 941.xx describes -ear [any part].-

Again, higher-degree burns take precedence over lesser-degree burns in the same general anatomic area. For example, for a third-degree burn on the chest and a first-degree burn on the stomach, report only 942.32 because both burns are on the trunk. But you may code an additional second-degree burn on the arm separately (943.23) because the arm is part of a different body area.

A final tip: You should never report first-degree burns separately with the 941-946 series when there are more severe burns on any other part of the body -- unless treatment is specifically directed at the first-degree burn.

For example, if the patient has a second-degree burn on the shoulder and a first-degree burn on the chest, you would only report the second-degree burn on the shoulder (943.25).