Dermatology Coding Alert

Published on Thu Dec 17, 2015 PDF

Tip: Check documentation for mention of debridement and capture deserved reimbursement.

As the weather grows colder and a nice fire or a space heater is used to warm a home, burns can become more prevalent. Burn presentations run from red and sore to serious third degree destruction, so you have to know the whole spectrum of burn coding options, including when to report E/M codes.

Follow these three steps when coding your dermatologist’s burn treatment services to ensure accuracy and appropriate pay.

Tip 1: Does the Chart Documentation Support a Burn Code

Not every burn presentation will require treatment that qualifies for CPT® 16000-16030 service. If the burn was minor enough that no real treatment was provided, such as minor sunburn that required no dressing, debridement, or local treatment, you should include burn treatment in the E/M code, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance for Zotec Partners in Durham, N.C.

Coding scenario: A new patient reports with her right calf painfully burned after backing into a space heater in the garage. The dermatologist examines the area, notes redness but no blisters or broken skin, and diagnoses a mild burn requiring no further treatment. She tells the patient to take ibuprofen over the counter for the pain. Chart documentation supports a level-two service.

In this instance, the physician examined the burn but did not provide any local treatment above and beyond the evaluation and management service, Norris says. On the claim, you’d report only a 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making …) for the encounter.

However, some are severe enough to require some sort of treatment and coders should keep an eye for these opportunities to capture these services, says Norris.

Tip 2: Search for Key Phrases That Support Reporting Code 16000

Review the chart documentation to identify terms that align with the CPT® descriptors for the burn codes to identify the correct service to report.

If local treatment of a first-degree burn occurs, such as cleansing and ointment, then you’d report CPT® 16000. A first-degree burn affects the epidermis only. Usually these types of burns just involve erythema, but may also exhibit some swelling and/or minor pain. The most likely treatment in 16000 (Initial treatment, first degree burn, when no more than local treatment is required) scenarios is cool towels, soothing balms, and topical medication application; substances such as Silvadene or triple antibiotic ointment, says Norris. Dressings are possible but unlikely for most first-degree burns; they rarely require any treatment except application of moisturizer to soothe the skin. In some cases, a topical anesthetic might be applied, she adds. .

Example: A patient reports with a burn on the top of his left arm and shoulder area from falling against a metal barrel containing a fire for burning trash. The physician examines the patient’s wound and the surrounding area. The first layer of skin is burned in the left chest area, but there are no blisters, particulate matter, or signs of further injury. The physician applies Silvadene and instructs the patient on how to care for the burn. Notes indicate a level three E/M service accompanied the burn treatment.

What to code: You could report both the E/M code 99203 and the burn treatment code 16000, says Norris. Don’t forget to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to 99203 to show that the E/M and burn treatment were separate services, she explains.

Step 3: Does the Chart Mentions Debridement? Then Consider Partial-Thickness Codes

For more serious burns with partial-thickness burns or second-degree burns, you would code with 16020-16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent...)

Tip: Look for mention in the chart of a burn that involves blistering. It may be either superficial, involving only the epidermis and superficial layers of the dermis or deep, involving the deep layers of the dermis. Depending on the extent of the partial thickness burn, the physician may have to debride the burn or for those partial-thickness burns covering a larger body area, a specialist may have to be called to determine if surgical treatment is needed to prevent scarring.

Partial-thickness burns can be fairly minor if the burned area is small and the patient is otherwise healthy and not elderly or very young, or they can likewise be quite serious and even necessitate transfer to a burn unit, says Norris.

When the physician performs partial-thickness burn treatment, he might use Silvadene following the procedure, but would most likely use some type of non-adherent dressing and additional antibiotic ointment depending on the location and the patient’s skin pigmentation. If you see documentation notes that contain some of the above elements, consider codes 16020-16030. Keep in mind these codes are applied for dressings and/or debridement of partial thickness burns and are delineated based on the percentage of total body surface area, Norris adds.

Keep in mind: CPT® ranks the codes by size based on the percentage of total body surface area involved in the burn. These include:

• 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small [less than 5% total body surface area]),
• 16025 (… medium [e.g., whole face or whole extremity, or 5% to 10% total body surface area]) and
• 16030 (… large [e.g., more than 1 extremity, or greater than 10% total body surface area])