Pediatric Coding Alert

Add almost $65 to the bank when you meet this simple criterion.

Sunburns can possibly qualify for burn care instead of an  E/M service if you meet certain guidelines. Answer the "local treatment" question to potentially add $65 to your bottom line.

No Extra Care Means No Extra Pay

Red skin -- even an area that might technically be "burned" -- doesn't automatically lead to reporting a burn treatment code.

Clue: If your staff doesn't administer treatment specifically for the sunburn, you may only report an E/M code for the check. The correct code depends on the situation, but you would most likely report 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Example: A mother brings her son to your office because of his sunburned shoulders and back. After examination, the pediatrician determines the burn is superficial and will heal on its own in a few days. He instructs the mother to have her son wear his shirt while outdoors. You'll report the appropriate E/M code such as 99212 for an established patient or 99201 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient.

Topical Medication Hints to 16000

If the child in the example above has a more severe burn, his care might qualify for code 16000 (Initial treatment, first degree burn, when no more than local treatment is required).

Clue: Check whether your staff treats the burn with topical medication (anesthetic) or other options.

"A first-degree burn usually only reddens the skin," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P,  COBGC, CCC, manager of compliance education for the University of Washington Physicians. "Any swelling or mild blistering usually is nominal and resolves quickly."

"I've taught for years that besides diagnosing the sunburn -- which is a first degree burn -- and using 99212, the physician should treat it with a cold, wet compress on the area and report 16000," says Richard Lander, MD, FAAP, a pediatrician and clinical assistant professor of pediatrics at University of Medicine and Dentistry of New Jersey.

The pediatrician will discuss several factors with the parent (the sunburn, expected progression, proper treatment, pain management, prevention). Even if the parent has already "diagnosed" her child's sunburn before coming to your office, the visit still merits 99212.

Pay change: Legitimately claiming 16000 will add almost $65 to your bottom line, according to the 2010 Medicare Physician Fee Schedule (1.78 total non-facility relative value units multiplied by the current 2010 Medicare conversion factor of 36.0846). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99212, and you should expect full pay for both the E/M service and sunburn care.