Wiki Coding third-degree burns

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Magapo

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Hi, everyone: Scenario: Patient with 10% third-degree burn, right foot and ankle. Agent: boiling oil. She requieres 3 debridements before full thickness graft (including muscles), always under anesthesia. Actually, patient needs to stay at hospital for antibiotic and pain management. CPT 16025 seems like a poor description for the patient condition. Which CPT will fit better this case? I appreciate your help.
 
A CPT code is a description of a procedure or service, not of a patient's condition. In order to recommend a CPT code, it's really necessary to see the provider documentation of what services were performed at these encounters.
 
Thank you, Thomas. The physician documents "debridement of muscle and fascia of right foot and ankle of 7% of total body surface area", where 71% of the lesion is necrotic.
 
Magapo said:
Thank you, Thomas. The physician documents "debridement of muscle and fascia of right foot and ankle of 7% of total body surface area", where 71% of the lesion is necrotic.
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This documentation doesn't give you much to work with. 'Debridement' by itself isn't very specific and could be a procedure as simple as using a gauze pad to remove debris from the wound. Ideally, the provider should also document the method used for the debridement (i.e. type of instrument), the depth of the tissue removed, and the size of the area debrided.

16025, per the CPT description, would be used for treatment of partial thickness, or 2nd degree burns, which are limited to skin layers, so that code wouldn't apply here. Since this involves debridement of muscle and fascia, CPT codes 11043 and 11046 are more appropriate codes, however you will need the provider to document for you the measurement of the area debrided in sq cm in order to be able to code this.
 
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