Pediatric Coding Alert

Question: A mother presents with her son whose back is red from what I diagnose as a first-degree burn. I perform a simple cleaning of the sunburned area and apply an ointment. Should I use an E/M code for the burn treatment?

Ohio Subscriber

Answer: No. You should instead report the cleaning and ointment application with a sunburn code.
 
Because you 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). This code more accurately describes the furnished services than an E/M code (99201-99215, Office or other outpatient visit ...).
 
Bonus: The burn codes that pediatricians use in the office usually pay more than office visit codes.
 
For instance, the National Physician Fee Schedule that Medicare uses assigns 1.83 total nonfacility relative value units (RVUs) to code 16000 and reimburses it at an unadjusted rate of $69.35. (Although pediatricians usually do not have patients on Medicare, the NPFS 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 as a level-three new patient office visit (99203, Office or other outpatient visit for the evaluation and management of a new patient ...) or a level-four established patient office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient ...).
 
These codes contain 2.56 RVUs (99203) and 2.18 RVUs (99214), which equates to a national payment of $97.02 and $82.62 respectively using the 2006 conversion factor of 37.8975.
 
Most pediatricians, however, report minor sunburn with CPT 99213 or a lower-level code, which results in less reimbursement than if the doctors billed 16000 for these services.
 
Don't lose out: 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 cut $16.67 from the claim. (Code 99213 has 1.39 RVUs x 37.8975 conversion factor = $52.68. Subtract that from $69.35 [the 16000 reimbursement rate] = $16.67.)