Part B Insider (Multispecialty) Coding Alert

Watch out: Not all burn care is created equal -- you may need to code some as E/M.

Your practice probably sees patients with painful sunburns requiring treatment--but can you report anything beyond an E/M code for your services? Check out this expert guidance covering various types of burns to be sure.

While someone might technically be "burned," you cannot automatically choose a burn treatment code for each patient. If a burn does not require any local treatment, then you should typically report the service with an E/M code.

Check Notes for 16000 Clues

Example: An established patient reports to the dermatologist concerned about his sunburned back. The physician examines the patient's injury, and decides that it is superficial and will heal on its own. The doctor tells the patient to avoid lying on his back and to wear his shirt in the sun, and that the burn should fade in a day or two. This scenario would result in a low-level E/M such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...).

This does not mean that all sunburns will be E/M services. Caring for these injuries might result in a procedure code -- if the burn is serious enough, and you can find evidence of treatment in the encounter notes.

Confirm Local Treatment

Turn to the procedure code set when the provider evaluates and treats the patient's burn. If local treatment occurs, choose 16000 (Initial treatment, first degree burn, when no more than local treatment is required) for the encounter.

Definition: Treatment of a 16000 burn would probably include use of topical medication. A first-degree burn usually only reddens the skin. There may be some swelling and mild blistering, but this is nominal and usually resolves quickly.

In some 16000 encounters, the physician will use a topical anesthetic. Bandages are possible, but unlikely, for most first-degree burns, which rarely require any treatment beyond application of moisturizer to soothe the skin, she explains.

Payout: You'll lose almost $26 in deserved payment if you fail to use 16000 when justified. The 16000 code pays about $68 (2.02 transitioned non-facility relative value units multiplied by the 2012 Medicare conversion factor of $34.0376), while a low-level E/M such as 99212 is worth about $42 (1.25 RVUs x $34.0376) using the 2012 Medicare Physician Fee Schedule.

Know When 16000-E/M Claims Are Appropriate

Your doctor may provide both an E/M and local treatment for a patient's burns during the same encounter, which can push payment up near $100. A patient who is presenting for initial treatment and has not been evaluated may need an E/M prior to treatment. For initial-treatment burn patients, the doctor needs to take a history, examine the burn site, and perform medical decision making (MDM) to determine how to treat the injury.

Example: An established patient reports to the physician with an oven burn on his right hand. The injury is red, swollen, and non-blistering. Patient reports redness worsened overnight.

The doctor performs a problem focused exam and finds the palm of the hand is erythemous, swollen, and hot. The physician applies sterile gauze over the burn and surrounding nonburned tissue, and uses tape to secure the wrap. He advises the patient to continue covering the burn with gauze and to avoid applying tape to any burned areas.

Before sending the patient home, the doctor tells him to keep the burn away from oils, ice, and cold water (straightforward MDM).

In this instance, you can include an E/M and a burn treatment code. On the claim, report the following: 99212 for the E/M modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99212 to show that the E/M and treatment were separate services 16000 for the treatment.

You can append modifier 25 to the procedure code whenever a surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with 0-day, 10-day or "XXX" global periods, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

Payout: This encounter would net the practice about $110 ($68 for 16000 and $42 for 99212).