Primary Care Coding Alert

And don’t forget this acronym to assign Dx

A male patient spills hot water from a pan on a stove on his right thigh, resulting in a first-degree burn. A female patient receives a second-degree burn to the palm of her left hand when she accidentally places it around a hot curling iron. Neither incident warrants a trip to the emergency room, but two days later, both patients come to see your provider and have their painful burns treated.

S/S.E.E. Your Way to ICD-10 Accuracy

The first thing to remember in both these scenarios is that you will need multiple ICD-10 codes to report them accurately. Fortunately, there’s an acronym you can use to “remember what details you need, the minimum number of codes you need, and the order in which to report them,” according to Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer.

For the first listed code, you’ll need to report site and severity from the Burns and corrosions (T20-T30) section of Chapter 19 in the ICD-10 manual. Next, you’ll stay in that chapter and provide a second code to document the extent of the burn using a code from section T31 when the primary code is from T20-T25. And finally, you’ll use an external cause code, most likely from the Contact with heat and hot substances (X10-X19) section of Chapter 20, giving you the acronym S/S.E.E. (Source: blr.hcpro.com/content.cfm?content_id=314407).

Assess Severity and Extent

Burns that are treated in the primary care setting are usually either first degree (producing erythema, or reddening, of the epidural, or surface, layer of the skin) or second degree (producing both erythema and blisters filled with fluid), which will limit your choices for the first code needed to code both scenarios.

As for extent, “the provider should document the TBSA, or total body surface area, of the burn,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “In the absence of that documentation, coders may estimate the percentage of the burn area using the ‘Rule of Nines,’” Bucknam goes on. This rule divides the body into twelve sections and assigns each one a value of 9 percent (except the genitalia, which are assigned 1 percent).

So, your provider would assess the burn on the right thigh of the male patient at 9 percent, and the burn to the female patient’s hand at less than 4.5 percent, which is the total body surface area of the front of the left arm according to the Rule of Nines. (Another classification method, Lund-Browder, would assess it at 2.5 percent.)

Coding tip: The sections of the body that you use to determine extent are not the same sections of the body you would use to determine site. Make sure you consult a Rule of Nines diagram, such as the one that accompanies section T31 in your ICD-10 or the Lund-Browder diagram in CPT® before assessing extent.

Look to Local Treatment Codes

Again, in the primary care setting, your code choices will be limited, as treatments for both first- and second-degree burns are usually local in nature. “For very minor burns that really require no treatment, like the first-degree burn from spilled hot water, many providers might decide to only bill an evaluation and management (E/M) code as there is little actual treatment provided for a first-degree burn,” says Bucknam.

For cases that are slightly more complex, “there could be local treatment,” which you would document with a code such as 16000 (Initial treatment, first degree burn, when no more than local treatment is required), according to Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

For example, “if the patient had diabetes, which has a negative impact on wound healing, the provider might decide to cleanse and bandage the burn and perhaps apply an antibiotic prophylactically,” Bucknam adds.

As second-degree burns go below the dermis and produce blisters, they require debridement and dressing, which means you will choose a code from 16020-16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent ...). Unlike 16000, code choices in this group are determined by size, so “if the burn is less than 5 percent of the total body surface area, which is likely the case, use the code 16020 [... small (less than 5% total body surface area)],” Holle recommends, though you will obviously defer to your provider’s notes for the precise code choice.

Coding note: Second-degree burns are deep and often require several visits during the healing phase for additional debridement and dressing changes. Rather than code this visit with an evaluation and management (E/M) service, use 16020-16030 each time, as these codes have zero global days.

Putting It All Together

For your male patient, you can now go ahead and code 16000 (Initial treatment, first degree burn, when no more than local treatment is required) with the accompanying ICD-10 codes in the following sequence:

• T24.111A — Burn of first degree of right thigh, initial encounter
• T31.0 — Burns involving less than 10% of body surface
• X12.XXXA — Contact with other hot fluids, initial encounter.

You would code the female patient in a slightly different way, however, using 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) to describe your provider’s service, along with:

• T23.252A — Burn of second degree of left palm, initial encounter
• T31.0 — Burns involving less than 10% of body surface
• X15.8XXA — Contact with other hot household appliances, initial encounter.

One final note: For ICD-10 sequencing purposes with both patients, you will need observe the note to T31 which states that, when the site of the burn is specified, this code “should be used as a supplementary code.”