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Account for Percentage and Depth when Coding Burns

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  • December 1, 2011
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Get the proper reimbursement for burn treatment in the physician’s office.

By Charlene Endre-Burgett, MS-HCM, CMA, CPC, CPM-MCS, CMSCS
How often does your practice see a patient with the common sunburn? Or, someone whose burn resulted in a blister? Burn coding is often forgotten in the physician practice setting, which leaves money on the table. A review of types of burns commonly seen in a physician practice, and some quick tips, will help you reclaim your rightful reimbursement.

Degrees of Burns (Depth of Burn)

There are six degrees of burns. We’ll focus on first- and second-degree burns and coding for a physician practice setting.
A first-degree burn is a superficial burn of the outermost layer of skin, or epidermis. Examples include sunburn or being scalded with hot water from the sink. The skin turns red and there is no blistering. Although painful, the function of the skin is not compromised.
A second-degree burn damages the second layer of skin, the dermis. These are “partial-thickness burns.” Typical causes include contact with a hot iron, chemicals, or boiling liquids. An initial sign of second-degree burn is blistering. Second-degree burns are the most painful, and there is an increased risk of infection compared to a first-degree burn. If the second-degree burn covers a large percentage of body area, emergency care may be needed due to the patient’s risk of going into shock and need for fluids.
Third- through sixth-degree burns are typically addressed in the hospital setting, and require fluids and extensive debridement, skin grafting or amputation; the latter two burn degrees are usually fatal, and are determined by autopsy.

Rule of Nines (Body Surface Area)

Burns are categorized by percentage of body area. For example, “he has a second-degree burn over 30 percent of his body” is a common way to describe a burn. Percentages are determined using “The Rule of Nines,” and knowing this rule is essential for CPT® and ICD-9-CM coding of second-degree and higher burns.
A baby’s body area is measured differently than an adult because its head and torso have more skin area than their appendages. A second-degree burn, even at a lower percentage of skin area, presents a greater risk and requires more emergent care than for an adult with the same type of burn. Each area of the body has a percentage amount assigned, and all the percentage amounts added together equal 100 percent (see Rule of Nines illustrations for percentage breakdown).

CPT® Coding for First- and Second-degree Burns

To determine a CPT® code for burn treatment, the medical record must document the degree of the burn and the percentage of body area affected. For second-degree burns, it’s important to document information on what is done during the visit because burn coding can be used for a dressing change or debridement.
Typical procedure codes include:
16000                  Initial treatment, first degree burn, when no more than local treatment is required
16020                  Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)
16025                  Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% of total body surface area)
16030                  Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% of total body surface area)
CPT® code 16000 is for initial treatment only, whereas codes 16020, 16025, and 16030 are for initial and subsequent visits. CPT® does not specify a maximum number of subsequent visits; however, a specific health plan may have a maximum number.
Note that 16020, 16025, and 16030 state “dressing and/or debridement.” It is appropriate to report these codes when patients are coming in specifically for dressing changes and the application of a burn product, such as Silvadene cream (silver sulfadiazine).
Burn treatment codes can be used in addition to an office visit; however, the office visit must be medically necessary and modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service must be appended to the office visit. A separate, medically necessary office visit might occur, for instance, to prescribe medications such as antibiotics and pain medication.
Coding example: A wheelchair-bound patient presents to the office after dropping a pot of boiling water onto her lap. Exam reveals second-degree burns on both upper legs—anterior and posterior—and on the genital area. Areas are dressed with Silvadene cream and bandages. Patient is told to return in three days for possible debridement, along with dressing change. Patient is prescribed medication for pain management.
To calculate the percentage of area burned, total both upper legs for 18 percent (9 percent for the upper portion of each leg) and add an additional 1 percent for the genital area. A total of 19 percent of body area is affected.
CPT® code 16030 is appropriate in this example because these are partial thickness burns covering more than one extremity or 10 percent of body area. Depending on the provider’s documentation, an evaluation and management (E/M) code in the 9920x-9921x series is also appropriate when appended with modifier 25.

CPT® does not specify a maximum level of subsequent visits; however, a specific health plan may have a maximum level.

Diagnosis Coding for Burns

ICD-9-CM codes for burns can be found in the “Injury and Poisoning” section, specifically in the 940-949 range (except for sunburn: see the “Code Sunburns with Accuracy” infobox). Burn codes from 940-946 involve specific body areas, including multiple sites.
For code 948 Burns classified according to extent of body surface involved, the ICD-9-CM codebook instructs, “This category is to be used when the site of the burn is unspecified, or with categories 940-947 when the site is specified.” The code requires a fifth digit if the burn is third degree; otherwise, use the appropriate four-digit code based on the percentage of burned body surface.
The appropriate diagnosis codes for our example above, for instance, would be:
946.2                  Blisters, epidermal loss [second degree]
948.1                  Burns classified according to extent of body surface involved; 10-19 percent of body surface [a fifth digit is not appropriate in this case because this is not a third-degree burn]

E Codes Add Precision

In addition to the codes describing the type of burn and body area, a variety of E-codes may be called upon to describe how the injury occurred. For example, E958.1, E968.0, and E988.1 are burns due to fire. A burn caused by a hot liquid in an assault is coded to E968.3 Assault by hot liquid. Or, an accidental burn by hot liquid (as in our example) would be identified with E924.0 Accident caused by hot substance or object, caustic or corrosive material, and steam; hot liquids and vapors, including steam.
Charlene Endre-Burgett, MS-HCM, CMA, CPC, CPM-MCS, CMSCS, has 26 years of health care office management experience, as well as 15 years of coding experience. She is the administrator for North Scottsdale Family Medicine in Scottsdale, Ariz.

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