General Surgery Coding Alert

Question: Our surgeon saw a patient for two burns: a second-degree burn on her right wrist and a separate first-degree burn at the same location. How many diagnosis codes should I report?

Michigan Subscriber

Answer: Because the burns were in the same anatomic location, you should report the burns to the highest degree of severity using a single code, and leave the burn of lesser severity off the claim. For this encounter, therefore, you would report 944.27 (Burn of wrist[s] and hand[s]; blisters, epidermal loss [second degree]; wrist) to represent both burns.

If the burns were instead in separate anatomic areas, you would report a diagnosis code for each injury. Therefore, if the surgeon treats a first-degree burn on a patient's right elbow and a second-degree burn on the patient's wrist, you-d list 943.12 (Burn of upper limb, except wrist and hand; erythema [first degree]; elbow) for the elbow burn and 944.27 for the wrist burn.

Don't forget: When choosing diagnosis codes for your burn treatment claims, you must also include a code from the 948.xx set (Burns classified according to extent of body surface involved) to represent the total body surface area (TBSA) of the burn.

For instance, if a patient had burns to 8 percent of TBSA, with no mention of third-degree burns, you would include 948.00 (Burn [any degree] involving less than 10 percent of body surface; less than 10 percent or unspecified) on the claim.