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Part B Insider (Multispecialty) Coding Alert

Part B Coding Coach:

Don't Let Burn Coding Singe Your Reimbursement

Published on Sat Sep 25, 2004

Keep your burn coding cool with these 7 expert steps

Confused by the number of burn coding options? You're not alone.

With some diagnoses there is clearly one code series to choose from - but that's not the case with burns. ICD-9-CM lists codes for both burn location (940-947) and percentage of body burned (948). And unlike some simpler diagnoses, burn codes require fourth and fifth digits to specify the degree and exact location of a patient's burn.

Even though codes exist for both burn location and percentage of body burned, you don't necessarily have to "report codes from both the 940-947 and 948" series, says Linda Martien, CPC, CPC-H, coding consultant with National Healthcare Review Inc in Woodland Hills, CA. Follow these seven expert steps for success to ensure your burn coding doesn't end up burning you:
 
1. Review documentation for all burn-related information. To report the most specific code, you'll need to know the burn location, burn degree and the percentage of body surfaced burned (this percentage is especially important for third degree burns).
 
2. Determine burn location. You should use codes 940-947 "to code the burn by body location," says Lisa Center, CPC, quality coordinator with Freeman Health System in Joplin, MO. ICD-9-CM divides codes 940-947 by the following locations:

  • 940 - Burn confined to eye and adnexa

  • 941 - Burn of face, head, and neck
  • 942 - Burn of trunk

  • 943 - Burn of upper limb, except wrist and hand

  • 944 - Burn of wrist(s) and hand(s)

  • 945 - Burn of lower limb(s)

  • 946 - Burns of multiple specified sites

  • 947 - Burn of internal organs

    Start your coding by choosing the appropriate code based on location. For example, if a patient has a burn on her hand, you know to begin your coding with the 944 series.

    3. Select a fourth digit based on degree of burn. If you are reporting 941-946, make sure to select a fourth digit, Center says. Codes 941-946 each list six fourth-digit options to indicate the degree of the patient's burn:

  • 0 - Unspecified degree
  • 1 - Erythema [first degree]

  • 2 - Blisters, epidermal loss  [second]

  • 3 - Full-thickness skin loss  [third degree NOS]

  • 4 - Deep necrosis of underly ing tissues [deep third degree] without mention of loss of a body part

  • 5 - Deep necrosis of underlying tissues [deep third degree] with loss of a body part

    Exception: Codes 940 and 947 are different: 940 (Burn confined to eye and adnexa) lists fourth digits to indicate both precise location and type of burn (regular, chemical or unspecified); 947 (Burn of internal organs) lists fourth digits to specify precise location.

    Examples: For a patient with an acid chemical burn of the cornea and conjunctival sac, you would report 940.3. You only need the fourth digit to report the appropriate code. Likewise, for a patient with a burn in his esophagus, you would report 947.2. No fifth digit is necessary.

    4. Select a fifth digit based on precise location. Codes 941-945 also require a fifth digit to indicate the precise location of the patient's burn. You must assign a fifth digit if you are reporting any burns of the face, head, neck, trunk, upper limb, wrist, hand or lower limb.

    Example: A patient presents for treatment of a second-degree burn on his ankle. You would report 945.23 (Burn of lower limb[s]; blisters, epidermal loss [second degree]; ankle).

    5. Choose 948 or 949 if no specified burn location. If the physician's documentation does not specify the location of the patient's burn, but does indicate the extent of body surface burned, you should select the appropriate 948 code (Burns classified according to extent of body surface involved).

    The basics: To report the correct 948 code, you must first select a fourth digit to indicate the percentage of total body surface burned, Center says. Then use a ifth digit to indicate what percentage of the total burned area is a third-degree burn, Martien adds.

    Avoid this common mistake: Coders often stumble over the fifth digit for 948 because they mistakenly think the fifth digit indicates the percentage of total body surface with third degree burns. In fact, you should select the fifth digit that indicates the percentage of the total burned area only that is a third-degree burn, Martien says.

    Example: The physician's documentation does not note the location of a burn but does state the patient has burns on 20 percent of his total body surface. The documentation also states that 50 percent of the burned area is third degree burns. You would report 948.25 (Burns classified according to extent of body surface involved; 20-29 percent of body surface; 50-59%).

    Note: If you are using 948 because the physician did not specify location, but the patient has no third-degree burns, report 948.x0 (...less than 10 percent or unspecified) to indicate there are no third-degree burns.

    Last resort: If documentation doesn't specify a burn location or the extent of body surface burned, you have no choice but to report 949 (Burn, unspecified) with the appropriate fourth digit to indicate the degree of the burn.

    6. Report 948 in addition to burn location code if patient has third-degree burn. Not only can you use 948 when the physician doesn't specify burn location, but you should also use 948 in addition to a burn location code (941-947) when the patient has a third-degree burn.

    Avoid extra work: Remember, if a patient has no third-degree burns, there is no need to report a 948 code in addition to the burn location code, Martien says.

    Sequence matters: "In the case of multiple burns, sequence first the code that reflects the highest degree of burn," Center says.

    What about 946? According to CPT, you can use 946 (Burns of multiple specified sites) to report "burns of sites classifiable to more than one three-digit category in 940-945," Martien says. CPT also states that 946 excludes "multiple burns NOS" (949.0-949.5). Even though 946 is appropriate for multiple burn sites, most coding experts recommend this code as a last resort. Don't use 946 if you can code burns by specific area, Martien advises.

    Example: Suppose a patient presents with a small second-degree burn on her back and a burn covering most of her upper arm, 30 percent of which is a third-degree burn. You would first report 943.33 (Burn of upper limb, except wrist and hand; full-thickness skin loss [third degree NOS]; upper arm) and then report 942.24 (Burn of trunk; blisters, epidermal loss [second degree]; back [any part]). You should then also report 948.03 (Burns classified according to extent of body surface involved; burn [any degree] involving less than 10 percent of body surface; 30-39%) to indicate the percent of total burn area that is third-degree burn.

    7. Use the Rule of Nines to help determine burn size. ICD-9-CM and CPT provide the Rule of Nines to help physicians and coders figure out the percentage of total body surface burned by dividing the areas of the body into percentage groups:

  • The head and neck, the right arm, and the left arm each equal nine percent.

  • The back trunk, front trunk, left leg, and right leg each equal 18 percent (the front and back trunk and each leg are divided into upper and lower segments, each equaling nine percent).

  • The genitalia equal one percent.

    When to use it: You only need to use the Rule of Nines "when burns are extensive over a body area," Martien says. If a patient has a small first-degree burn on her forearm, for example, you would simply report 943.11 (Burn of upper limb, except wrist and hand; erythema [first degree]; forearm), she notes.

    However, if a patient has extensive burns covering his upper and lower back, the Rule of Nines tells you that each back segment is worth nine percent. Therefore, the total body area burned equals 18 percent - meaning you would report 948.1x to indicate the patient has burns on 10-19 percent of his body.

    Editor's note: You can find the Rule of Nines section on page 61 of your 2004 CPT manual and on page 271 of the Tabular List in your 2004 ICD-9-CM manual.

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