Primary Care Coding Alert

Burn treatment and level of care streamlines your coding options.

Just because a patient diagnoses himself as "burned" after being in the sun too long doesn't mean you automatically choose a burn treatment code for the encounter. Here's how to know when you can legitimately submit a burn code versus an E/M service.

Plan for E/M Code Up Front

Most -- but not all -- sunburn cases merit E/M codes.

Example: An established patient visits the office because he's concerned about his sunburned back. The physician examines the patient's back and decides the burn is superficial and will heal on its own in a few days. The physician advises the patient to avoid lying on his back and to wear his shirt while in the sun. She recommends using a topical aloe gel to help relieve pain.

Code it: The physician didn't spend a lengthy amount of time examining or counseling the patient, and didn't administer any treatment. Therefore, the visit leads to a low-level E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Switch to 16000 for More Extensive Care

Caring for sunburn injuries can result in a procedure code instead of E/M. The seriousness of the burn and evidence of documented treatment will be your clues to consider different codes.

Top option: If the physician provides local treatment to the patient's sunburn, choose 16000 (Initial treatment, first degree burn, when no more than local treatment is required) for the encounter.

Watch for: A first-degree burn usually only reddens the skin. The patient might have some swelling and mild blistering, but this is normal and usually resolves quickly. Treatment of a burn categorized by 16000 would probably include use of topical medication, such as a topical anesthetic. The physician might also apply bandages to the burned area, but first-degree burns rarely require more than an application of moisturizer to soothe the skin.

Reporting 16000 will add approximately $26 more to your bottom line than a low-level E/M code such as 99212. Code 16000 pays about $68 (2.02 transitioned non-facility relative value units multiplied by the 2012 Medicare conversion factor of $34.0376), while 99212 is worth about $42 (1.25 RVUs x $34.0376) using the 2012 Medicare Physician Fee Schedule.

Watch for E/M Plus 16000 Opportunities

In some situations, the physician might provide both an E/M service and local treatment of the patient's burn during the same encounter. That combination can bump your payment up near $100.

Example: An established patient visits your office with an oven burn on her right hand. The injury is red, swollen, and non-blistering. The patient says the redness worsened overnight. The physician performs a problem-focused exam and finds that the palm is erythemous, swollen, and hot. He applies sterile gauze over the burn and surrounding non-burned tissue, using tape to secure the bandage. He advises the patient to continue covering the burn with gauze, but to keep the tape off any burned areas. He also tells the patient to keep the burn away from oils, ice, and cold water. The physician's exam qualifies as moderate medical decision making.

In this instance, you can report both an E/M and a burn treatment code. On the claim, report 99212 for the E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to show that the E/M and treatment were separate services. Also include 16000 for the treatment.

Remember: You can append modifier 25 to the E/M code whenever a physician provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with 0-day, 10-day or "XXX" global periods, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

Payout: This encounter would net the practice about $110 ($68 for 16000 and $42 for 99212).