Part B Insider (Multispecialty) Coding Alert

Fourth, fifth digits are vital to these ICD-9 codes

To accurately code diagnoses for patients with burn injuries, coders must know whether the patient had any third-degree burns. They also need to know when to combine multiple burns into one ICD-9 code and when to submit a separate code for each burn.

Check out this expert advice on burn diagnosis coding, and follow these three steps each time you are coding for a burn victim.

1. Select Burn Location

The first diagnosis code you-ll select for burn victims represents the location of the burn (or burns) and also the severity. You-ll find these codes in the 940-947 ICD-9 set, says Debra Williams, CPC, coding supervisor at Horizon Billing Specialists in Grand Rapids, Mich.

All the codes in the 940-947 set require at least a fourth digit, and some require five, says Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla. These codes -break down the classification first by anatomic site and then by degree of burn,- she says.

Example: The physician's notes indicate that a patient suffered a first-degree burn to his chest wall. Based on this description, 942.12 (Burn of trunk; erythema [first de-gree]; chest wall, excluding breast and nipple) is the correct diagnosis.

Exception: The codes that ex-tend only to the fourth digit (940.X, 946.X, 947.X) do not describe both burn severity and burn location. In these cases, just code based on what ICD-9 requires for the burn. For instance, take a look at 940.3 (Burn confined to eye and adnexa; acid chemical burn of cornea and conjunctival sac), which does not require a fifth digit. This diagnosis is first defined as a burn confined to eye and adnexa (940.x), and the -3- further defines the injury, de-scribing an acid chemical burn of the eye's cornea and conjunctival area.

2. Check That You-ve Coded Each Burn

Patients who present for burn care will often have more than one burn. Check out this quick Q&A, which describes how to code for several multiple-burn scenarios:

Question: What if the patient has burns in different anatomical locations?

Answer: Code separately for each burn. So if the patient has first-degree neck burns and second-degree shoulder burns, report the following:

- 943.25 (Burn of upper limb, except wrist and hand; blisters, epidermal loss [second de-gree]; shoulder) for the second-degree burn

- 941.18 (Burn of face, head, and neck; erythema [first degree]; neck) for the first-degree burn.

On all multiple-burn claims, you should code the burn of the highest severity first, Williams says.

Question: What if the burns are of the same severity and in the same anatomic location?

Answer: You should be able to represent them with a single diagnosis code. Just be sure to use the proper fifth digit to indicate that the burns are in the same area. For example, if a patient has second-degree burns to her left forearm and elbow, you would code 943.29 (Burn of upper limb, except wrist and hand; blisters, epidermal loss [second degree]; multiple sites of upper limb, except wrist and hand).

Question: What if the patient has burns of varying degrees in the same body area?

Answer: In these scenarios, you will submit a code for each burn. -This is the only way to give the full picture as to the extent of the injury,- Martien says. So if a patient has first- and second-degree burns on her lower leg, you should report the following:

- 945.24 (Burn of lower limb[s]; blisters, epidermal loss [second degree]; lower leg) for the second-degree burn

- 945.14 (Burn of lower limb[s]; erythema [first degree]; lower leg) for the first-degree burn.

3. Heed -Rule of Nines- for TBSA Diagnosis

Once you have selected a code (or codes) to represent the patient's injuries, you-re ready to choose a code from the 948.XX group--if the patient has suffered any third-degree burns.

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

Explanation: Use the 948.XX codes to identify the percent of the body burned. Select the fourth digit according to the percentage of total body surface area (TBSA) burned. Then, use the fifth digit to specify the percentage of body surface that has third-degree burns.

To arrive at the TBSA burned, use the -Rule of Nines,- which breaks body areas down by percentage of the whole body. The breakdown differs slightly for children, whose anatomies are different from adults-.

-For instance, in an adult, the head is 9 percent of the TBSA. In an infant or small child, it counts for 18 percent due to the disproportionate size of their heads,- Martien says. CPT breaks down TBSA percentages as follows:

Example: 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.

Step 1: 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]) to account for both of the patient's burns.

Step 2: Report 948.00 (Burns classified according to extent of body surface involved; burn [any degree] involving less than 10 percent of body surface; less than 10 percent or unspecified) to indicate the percent of body surface that constitutes the third-degree burn.

Use 949 as a Last Resort

Although you-ll typically use the 948.XX codes as secondary diagnoses, there are situations when they would be the primary, and only, diagnosis.

If the physician does not specify the burn site in the documentation, you should include a 948.XX code in lieu of a 940-947 diagnosis, Williams says.

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