Internal Medicine Coding Alert

Question: The physician diagnosed a patient with a second-degree burn on her right palm (944.25). He advised the patient to apply ice or run cold water over the area two or three times a day, and to apply Silvadene cream twice a day. In the documentation, the physician noted that blisters had formed over the base of the right thumb and palm that measured about 6 cm in diameter. How should I report this visit?

Arkansas Subscriber

Answer: Because the physician only evaluated the patient's problem and provided a treatment plan the patient could perform herself, you should report the appropriate E/M code (99201-99215).
 
The extent of the documentation that meets the three components - history, exam and medical decision-making - and whether the patient is new or established will determine the code you choose.
 
For example, if the patient is established and the physician documents expanded problem-focused history and low-complexity medical decision-making, you could assign 99213 (Office or other outpatient visit ...).
 
In this instance, you may be tempted to report burn code 16000 (Initial treatment, first-degree burn, when no more than local treatment is required) or 16010 (Dressings and/or debridement, initial or subsequent; under anesthesia, small), but don't give in.
 
These codes represent actual treatment the physician provides, not simply evaluation and planning.