Pediatric Coding Alert

Don't let your practice pay the price for children who took in some rays over spring break. Instead, add a cool $23 per visit with 16000 rather than 99213.

Some pediatric practices may not realize that unless a burn visit qualifies for CPT 99214 , they can receive more reimbursement with the code for first-degree burn initial treatment (16000), says Sherry Wilkerson (Straub), RHIT, CCS, CCS-P, coding and compliance manager for Esse Health in St. Louis. Knowing which codes to use, whether an E/M is also justified and the diagnoses to assign will peel away old methods and rejuvenate your practice's bottom line.

Many pediatricians are unaware that the burn codes exist, says Kay Faught, coding consultant for CPT Coding and Clinic Management in Jacksonville, Ore. "Consequently, the physicians report an office visit code only, which undervalues their services," she says.

Because treatment codes generally pay more than E/M codes, practices that fail to use the burn codes suffer financially. "With increasing capital costs and shrinking reimbursement, pediatricians cannot afford to sacrifice codes that they are entitled to bill," Wilkerson stresses.

The burn codes that pediatricians use in the office usually pay more than office visit codes. For instance, after vacationing in Florida, a parent brings in a child whose pale midwestern skin could not tolerate the sunshine. The patient's back is red from a first-degree burn. The pediatrician performs a simple cleaning of the sunburned area and applies an ointment. Because the physician in this example provided initial treatment of a first-degree burn, you should report 16000 (Initial treatment, first-degree burn, when no more than local treatment is required), which carries 2.02 relative value units (RVUs) and reimburses at an unadjusted rate of $74.32, based on the Medicare Physician Fee Schedule (MPFS). (Although pediatricians usually do not have patients on Medicare, the MPFS gives the Medicare allowance, which can be used as a benchmark to which you can compare other insurers. Private payers may reimburse more.)

To reach this same reimbursement level, the visit would have to qualify for a level-four established patient office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient physicians typically spend 25 minutes face-to-face with the patient), which has 2.17 RVUs and pays $79.83, according to MPFS. "Most pediatricians, however, code minor sunburn with 99213 or less, which results in less reimbursement than if the doctors billed 16000 for these services," Wilkerson says. If the visit meets the criteria for a level-three office visit, reporting 99213 (Office or other outpatient visit for the evaluation and management of an established patient physicians typically spend 15 minutes face-to-face with the patient) instead of 16000 would sacrifice $23.18 (99213 has 1.39 RVUs x $36.79 conversion factor = $51.14 -$74.32 [16000 reimbursement rate] = -$23.18).

After getting the lowdown on payment rates, you should heat up your burn code knowledge. While a little too much fun in the sun might land you with a first-degree burn and 16000, deep sunburns may require more extensive treatment, such as dressings and/or debridement, and therefore different codes. Although CPT assigns 16010 (Dressings and/or debridement, initial or subsequent; under anesthesia, small) and 16015 ( under anesthesia, medium or large, or with major debridement) for burn care with anesthesia, these codes refer to general anesthesia, which most pediatric practices do not offer. In addition, many pediatricians treat nothing more than small burns. Therefore, you will probably encounter only one additional burn code in the office setting, Faught says.

Regardless of what your pediatrician's office treats, CPT designates three codes for second-degree burn treatment without anesthesia. Your pediatrician will usually perform 16020* (Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small) at the highest and refer patients who have larger burns, such as 16025* ( without anesthesia, medium [e.g., whole face or whole extremity]) and 16030 ( without anesthesia, large [e.g., more than one extremity]), to the emergency room for treatment, Faught says. If your pediatrician treats a small second-degree burn, you should report 16020, which involves dressing and/or debridement of the area including cleansing the wound and applying a new or initial dressing, Wilkerson says.

Because 16020 involves treating a more severe burn, you would think that it would contain more RVUs than 16000. But because 16020 is a starred procedure, which by definition includes the surgical procedure only, the second-degree burn code contains slightly fewer RVUs (1.99) than the initial burn treatment code. Consequently, if the pediatrician documents a history, examination and the medical decision-making that led to treating the burn, you should report an E/M for his or her services in addition to the burn code. In this case, most carriers will require 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 the E/M code, Faught says. Therefore, if the physician documents his or her services, you will assign 9921x-25 in addition to 16020, which pays $73.21.

Depending on the severity of the burn, your pediatrician may request that the patient return for follow-up care. If the doctor changes the dressing or excises skin, you should report 16020-16025. On the other hand, if the physician simply checks the wound, assign the appropriate-level E/M code, such as 99212 ( physicians typically spend 10 minutes face-to-face with the patient and/or family), rather than a treatment code.

Because of 16020's starred status, you can report an additional E/M visit. But 16000 does not carry the same designation. Despite this difference, based on the pediatrician's documentation, the situation and the payer, you may separately report an office visit appended with modifier -25 in addition to the initial burn treatment code.

Most insurers may bundle a minor E/M with 16000, which has a 0-day global period, and require the physician to perform an additional evaluation to justify billing 9921x-25, Wilkerson adds. So, make sure to ask payers for their modifier -25 guidelines. Although CPT does not require different diagnoses to bill a significant, separately identifiable E/M service, separate ICD-9 codes clearly indicate the medical necessity for 9921x-25. If your documentation supports a significant, separately identifiable E/M service in addition to the burn care, you should report both 16000 and 9921x-25.

For instance, after returning from a Caribbean hiatus, a mother brings in her 8-year-old daughter, who has minor sunburn on her back and complains of ear pain. In addition to treating the burn, the pediatrician examines the child's ear and diagnoses swimmers'ear (380.12). Because the doctor performed a significant, separately identifiable E/M service from the burn treatment, you should report both the E/M service (9921x-25) appended with modifier -25 and the procedure (16000). Make sure to link the correct diagnosis codes to each procedural code. Link 380.12 to 9921x-25, and link the ICD-9 code for the sunburn (692.71, Sunburn) to 16000, Faught says. For second-degree sunburn, assign 692.76 (Sunburn of second degree).

Note: Although sunburn diagnostic coding requires only one code from the 692.7x series, "Other inflammatory conditions of skin and subcutaneous tissue due to solar radiation," other types of burns require multiple diagnoses from the 940-949 series (Burns) that indicate the burn's location and severity as well as a possible E code explaining the burn's cause. Coders should note that 940-949 exclude sunburn, Faught stresses.