Primary Care Coding Alert

When a patient seeks treatment from the family physician for a minor burn, many offices code the encounter as an E/M visit. However, in most cases, the office can secure higher reimbursement by using the appropriate burn code (16000 series).

"Generally speaking, treatment codes pay better than E/M codes," says Emily Hill, PAC, president of Hill & Associates, a consulting firm in Wilmington, N.C., who works with physician practices on issues related to coding and compliance.

Burn Codes Pay More

Burn codes will typically result in higher payment than E/M codes for the type of burn injuries family physicians see in their offices, Hill says. For example, a patient seeks treatment for a first-degree burn from a hot-water spill. The coder should use 16000 (Initial treatment, first-degree burn, when no more than local treatment is required). This code has a relative value unit (RVU) of 1.79, for a (national, not adjusted for region) Medicare allowance of $68.48.

To reach that same payment level with an established patient using E/M coding, the coder would have to assign the higher-level 99214 (Office or outpatient visit, established patient), which has an RVU of 2.06 and a resulting Medicare allowance of $78.81. A minor hot-water burn would not usually require that level of examination, Hill notes, making reimbursement difficult.

Payment for burn treatment codes is higher because, in addition to the physician's time, the RVUs take into account the practice expenses associated with treating the burn, such as nurses' time, dressings and other supplies, Hill says.

When to Apply the Different Codes

While 16000 is the correct code for initial treatment of a first-degree burn, several other codes apply for more extensive burns requiring dressings and/or debridement, Hill says. Because the size of the burn is key in determining which code to use, be sure the physician provides that information.

For instance, a patient comes to the office with a second-degree leg burn from a motorcycle exhaust pipe. The proper code is 16020* (Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small), Hill says. With an RVU of 1.77, this code is comparable in reimbursement to the example above.

For larger wounds, the code is 16025* ( without anesthesia, medium [e.g., whole face or whole extremity]), with an RVU of 3.44, or 16030 ( without anesthesia, large [e.g., more than one extremity]), with an RVU of 4.64. Codes 16010 ( under anesthesia, small) and 16015 ( under anesthesia, medium or large, or with major debridement) aren't typically used in a family physician's office, Hill says, because they apply to procedures done under anesthesia, and a local anesthetic does not meet the criteria.

Follow-up visits should be coded using the 16000 series if the doctor changes the dressing or excises skin. However, if the physician simply checks the wound, a burn code cannot be used. Instead, use an E/M code such as the low-level 99212.

One question that comes up is how to code two or three small second- or third-degree burns, Hill adds. Rather than billing 16020* two or three times, the office should combine the size of the burns, assigning 16025* or 16030, she says.

When to Use Both E/M and Burn Codes

Occasionally, coders can assign both E/M and burn codes. For example, a diabetic who missed her last regular diabetic checkup seeks treatment of a second-degree burn she suffered after touching a hot stove. Code for the burn treatment (16020*), Hill says, then also assign the appropriate E/M code for the patient's diabetic checkup, being careful to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

"The key when billing is to make sure to link the burn diagnosis [e.g., 944.25] to the burn treatment code [e.g., 16020*] and to link the diabetes diagnosis [e.g., 250.00] to the appropriate E/M code," Hill says.

Joan Peters, CPC, CHCC, director of business operations for Bassett Health Care, a hospital and multispecialty practice with 250 providers in Cooperstown, N.Y., gives another example: A patient suffers a burn after touching a hot stove in an unexplained fall after a bout of dizziness. The physician could probably justify performing an E/M service to look for problems associated with dizziness and the fall, in addition to providing burn treatment.

These cases are not typical, though, Peters says. "Overall, billing both an E/M and a burn code would be pretty risky," she says. "Generally you would go with one or the other."

Use Two or Three Diagnosis Codes

Most coders make mistakes in burns (940-949), Peters says, because many are unaware that they should use at least two and possibly three diagnosis codes. Both the primary and secondary diagnosis codes require fourth and fifth digits, she notes.

Peters gives the following example of how to code a second-degree burn when a patient has touched a hot stove with the palm of the hand.

Primary Code First

The first three digits in the primary diagnosis code indicate the general location of the burn on the body. The fourth digit denotes the degree of the burn, ranging from unspecified (0) to deep third-degree burn (5). The fifth digit pinpoints the exact location of the burn. In the example, the code is 944.25 (Burn of wrist[s] and hand[s], blisters, epidermal loss [second degree], palm).

Secondary Code Follows

The secondary diagnosis code describes the extent of body surface burned and uses the "Rule of Nines" to determine the percentage. This rule divides the body into sections of 9 percent and multiples of nine, with the head/neck nine and each arm representing 9 percent; the back 18, the front chest/abdomen and each leg constituting 18 percent and the perineum making up the remaining 1 percent of body surface. Hill notes that the "Rule of Nines" is different for children than for adults. (See introductory section in CPT on "Burns, local treatment" [16000 series] for more information on the "Rule of Nines.") Hill also says coders should urge physicians to indicate the burn size on discharge forms. Even though the "Rule of Nines" says a leg is 18 percent of adult body area, a small leg burn would not represent 18 percent, Hill notes.

In the palm-burn example, the secondary diagnosis code is 948.00 (Burn [any degree] involving less than 10 percent of body surface). The fourth digit notes the percent of body surface burned. The fifth digit is required, Hill says, to indicate the amount of the body with third-degree burns. Using 0 (... less than 10 percent or unspecified) as the fifth digit may seem misleading when the patient has no third-degree burns, Peters says, but the number should be used because carriers require a fifth digit to process the claim.

If the patient has several burns of varying degrees (e.g., a hot-water spill caused second-degree burns on the palm and several small first-degree burns on a leg), Peters says to code the primary diagnoses for both burns as above. For example, code 944.25 for the palm burn and 945.14 (Burn of lower limb[s], erythema [first degree], lower leg) for the splatter burns on the leg. Next, add together the size of the burns to arrive at the appropriate secondary diagnosis code (e.g., 948.00), Peters says.

E Code Sometimes Necessary

Peters also recommends using an E code to establish the burn's cause. In the palm-burn example above, the code is E924.8 (Accident caused by hot substance or object, caustic or corrosive material, and steam; other), which includes burning by heat from electric heating appliance.

However, Hill recommends using an E code only when necessary, such as in workers' compensation claims. "Most carriers don't even process the E codes," Hill says. While agreeing that some carriers don't look at the E codes, Peters says they can help claims go through more quickly. If the cause is not specified, third-party payers sometimes question the provider and delay payment, Peters said.

"The more information you give them, the less chance they're going to have questions later," Peters says.