Internists treating patients with first- or second-degree burns often report E/M codes 99201 (office or other outpatient visit; new patient) or 99212 (... established patient), but using the correct burn treatment code (16000 series) would result in greater reimbursement.
"Revenue is being lost, and inaccuracies in coding and billing are apparent," says Kathy Pride, CPC, coding supervisor for the Martin Memorial Group, a 57-physician group practice in Stuart, Fla. For instance, reimbursement for an E/M office visit (e.g., 99212) in Florida is $37, compared to $71 for burn treatment (16000, initial treatment, first-degree burn, when no more than local treatment is required).
Many internists now have an expanded role in treatment services because so many function as primary care physicians (PCPs). In the past, a patient who presented with minor burns would have been referred to a dermatologist, says Sherry Straub, RHIT, CCS, manager of coding and compliance for Esse Health in St. Louis.
Understand Burn Coding Criteria
Selecting the appropriate CPT burn code for dressing changes depends on the size of the affected area and whether the patient requires anesthesia. Because patients treated for burns at an internal medicine office would not be anesthetized, the applicable CPT codes include 16000 for the initial treatment; 16020* (dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small) for a small burn that comprises less than 4 percent of a body segment; 16025* (... without anesthesia, medium [e.g., whole face or whole extremity]) for a medium burn that comprises 4-9 percent of a body segment; and 16030 (... without anesthesia, large [e.g., more than one extremity]) for a large burn that comprises more than 9 percent or a whole segment. These codes describe immediate and palliative procedures that require local treatment of the burn surface only.
Applying the "Rule of Nines"
The size of the burn (small, medium or large) depends on the percentage of total body surface area (TBSA) affected and is determined by applying the "Rule of Nines."
This rule is used to calculate the percentage of the body burned by dividing the TBSA into 9 percent segments: 9 percent head and neck, 18 percent trunk (back), 18 percent trunk (front), 9 percent left arm, 9 percent right arm, 18 percent left leg, 18 percent right leg, 1 percent perineum.
The front and back of the torso are further divided into upper and lower sections. Therefore, if a patient presents with burns on the lower part of the torso, only 9 percent should be recorded.
An involved case recently seen by an internist was a patient who presented to the emergency room with a third-degree burn he received from splattering grease on his hand. The burn area was relatively small, so the ED physician referred the patient to the internist to handle the follow-up care. The internist billed the appropriate burn codes for each dressing treatment and more than doubled reimbursement from what an E/M code would have paid. In this case, the internist reported 16020 because the burn covered less than half of the patient's arm. (According to the Rule of Nines, the arm makes up 9 percent of the total body area.)
Criteria for Choosing Diagnosis Codes
Internal medicine coders must apply not only the appropriate CPT burn code but also two ICD-9 codes -- and, in some cases, a corresponding E code. While the ICD-9 code determines which CPT code to choose, the E code lets the carrier know the exact cause of the burn.
The diagnosis codes for burns are 940-949 (burns from electrical heating appliance, electricity, flame, hot object, lightning, radiation and internal and external chemical burns). The first diagnosis code is selected by location and severity of the burn. The second diagnosis code details the extent of the burn. Coders depend on physicians' precise documentation to bill correctly for burn treatment. The physician must accurately describe the location and/or extent of the burn and if the same area has multiple burns. Only the highest-level burn should be reported from the patient's chart.
Choosing the First Diagnosis Code
Codes 941-945 describe both the location and severity of the burn(s). The first three digits of the code indicate the location of the burn on the body. For instance, 941 is used for burns of the face, head and neck. The trunk of the body is coded with 942; upper limbs require 943; the wrists and hands are coded with 944; and burns of the lower limbs require 945.
The fourth digit in the burn diagnosis code series includes five levels that describe the burn from least to most severe. For example, the fourth-digit code for blisters, epidermal loss (second degree) would be "2." A complete list of fourth digits can be found after each diagnosis code listing in the ICD-9 manual.
Coders should choose the fourth digit based on the highest degree of burn on the patient's body. In other words, if a patient has a combination of second- and third-degree burns on the arm, the fourth digit would be "3," because third degree is more severe.
The fifth digit describes the specific location of the burn on the body and is unique to each body area. For example, for the patient with the grease burn on the wrist(s) and hand(s) a fifth digit of "6" would identify the burn as being on the back of the hand. A shaded box located below the base diagnosis code in the ICD-9 manual lists the digits available.
In the splattered-grease case, the first diagnosis code would be 944.30. Code 944 is for a burn on the wrists and hands, a fourth digit of "3" identifies a third-degree burn, and a fifth digit of "0" defines an unspecified site.
If multiple burns appear on the same body area, the burn of higher severity takes precedence when coding. An example would be a second-degree burn on the chest and a less severe burn on the abdominal wall. The coder should use 942.22 because both burns appear on the trunk of the body, but the burn on the chest, being more severe, would take precedence in the diagnosis.
The appropriate ICD-9 code for the patient presenting with sunburn would be 946.2 because it is a burn of multiple specified sites (946) with second-degree status (fourth code of "2"). There is no fifth digit with code 946.
Using 948 as the Second ICD-9 Code
The second diagnosis code required is always 948.xx (burns classified according to extent of body surface involved). Code 948 classifies burns according to the extent of the body surface involved. The fourth and fifth digits indicate the diagnosis. The fourth digit details the total percentage of the body burned, and the fifth digit accounts for the percentage of third-degree burns to the body.
Note: Code 948 is used when the site of the burn is unspecified, or with categories 940-947 when the site is specified. Detailed fourth and fifth digits are located below each base diagnosis code in the ICD-9 manual.
The fifth digit is for use with category 948 to indicate the percent of body surface with third-degree burn. Therefore, 948.32 would mean 30-39 percent (fourth digit) of the body has burns with third-degree burns covering 20 percent (fifth digit) of the body.
The 948 code for the patient burned by splattered grease would be 948.00. The 948 indicates the extent of body surface burned. The fourth digit "0" accounts for less than 10 percent of the total body burned, and the fifth digit "0" means less than 10 percent of the burns are third degree. The sunburn would be coded 948.00 for the same reasons described in the splattered-grease burn example.
E Codes Determine Exact Cause of Burn
E codes are secondary codes that indicate precisely the cause of the burn. The E codes help the insurer determine whether a third-party carrier may be liable. If, for instance, the burn happened at a patient's work site, the E code informs the insurer that perhaps a workers' compensation claim should be filed.
E926.2 (exposure to radiation; visible and ultraviolet light sources; sun rays) should be used for the sunburn to indicate the burn was caused from overexposure to visible and ultraviolet light sources. The E code for the splattered-grease care should be E924.0 (accident caused by hot substance or object, caustic or corrosive material, and steam; hot liquids and vapors, including steam; burning or scalding by hot or boiling liquids not primarily caustic or corrosive). If the patient had burned his hand from working over a fryer at a restaurant, for example, then the E code would indicate that the employer is responsible.
Pride says E codes generally are not required by carriers and rarely affect reimbursement for burn treatments. However, she adds, it is proper coding to add the E codes when appropriate as it assists the insurance company in determining the cause of an accident.
