Part B Insider (Multispecialty) Coding Alert

Question: We are providing physical therapy for gait training for a patient who also has a pair of burns. She has a second-degree burn on her right wrist and a first-degree burn on the back of her right hand. How many diagnosis codes should I report to account for these burns?

Nebraska Subscriber

Answer: You'll need to list two codes for this patient's burns, plus another code to indicate the total body surface area (TBSA) of the burn. It's true that you should code for burns of the same local site with the code for the highest degree burn. But your patient's burns involve two local sites -- the wrist and back of hand.

Code for the burn on the wrist with 944.27 (Burn of wrist[s] and hand[s]; blisters, epidermal loss [second degree]; wrist). For the burn on the back of the hand, you'll report 944.16 (...erythema [first degree]; back of hand).

No matter what: When choosing diagnosis codes for burns, you should also consider a code from the 948.xx set (Burns classified according to extent of body surface involved) to represent TBSA of the burn. So if a patient had burns to 8 percent of TBSA, with no mention of third-degree burns, you would include 948.00 (Burn [any degree] involving less than 10 percent of body surface; with third degree burn of less than 10 percent or unspecified amount). Including a 948.xx code is especially important when coding third-degree burns that cover 20% or more other of the body.