Internal Medicine Coding Alert

Question: A patient with blisters on his shoulders from sunburn came into our office. The internist cleaned the area and applied ointment and a dressing. Should I report the burn treatment with an E/M code?


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Answer: No. Because the internist provides initial treatment of a burn, you should instead assign a burn treatment code. Select the appropriate code based on the burn's degree and treatment.

Because the deep sunburn requires a dressing, you should assign 16020 (Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small). Physicians consider blistering from prolonged sun exposure a second-degree burn. For a first-degree burn with minimal treatment, you would report 16000 (Initial treatment, first-degree burn, when no more than local treatment is required). Link the burn code to the sunburn diagnosis (692.71).

If the internist provides a significant and separate E/M service, you should also report the office visit (such as 99212-99213, Office visit for the evaluation and management of an established patient ...) appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The office visit could even include counseling on proper safe sun habits and advice on using sunscreen.