Internal Medicine Coding Alert

Question: An established patient reports to our physician with firstand second-degree burns to his abdominal wall from a steam burn. During an E/M service, the physician uses gauze and topical ointment to treat the patient's burn. Notes indicate that the anterior trunk is "18% burned." How many diagnosis codes should I include on the claim?

Georgia Subscriber

Answer: You'll report two diagnosis codes; one for the burn and one for the total body surface area (TBSA) burned. On your claim, report the following:

• The appropriate burn treatment code. Since the patient suffered both first and second degree burns on 18% of the body, consider 16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area). Had the burns been first-degree only, the alternative code would be 16000 (Initial treatment, first degree burn, when no more than local treatment is required).

• The appropriate E/M code for an established patient (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) based on the physician's notes; append modifier 25 to indicate that the E/M service was significant and separately identifiable from the burn treatment, assuming the documentation supports that assessment.

• 942.23 (Burn of trunk; blisters, epidermal loss [second degree]; abdominal wall) appended to 16030 and the E/M code to represent the burn.

• 948.10 (Burns classified according to extend of body surface involved; 10-19 percent of body surface; less than 10 percent or unspecified [with third degree burns]) appended to 16030 and the E/M code to represent the total body surface area (TBSA) burned.

Why no 1st-degree? When the patient suffers from burns of varying degrees in the same area, you'll choose a diagnosis code that represents the highest-degree burn in the area.