ED Coding and Reimbursement Alert

You may mistakenly believe you should report an E/M code (99281-99285) only for emergency department (ED) burn visits, but you are losing out on valuable reimbursement by forgetting about the 16000 series.

Suppose a patient comes into the ED with a first-degree burn from a kitchen fire. Code 99282 has a relative value unit (RVU) of 0.73, while code 16000 has an RVU of 2.02, more than twice the value paid for the E/M. The appropriate code from the burn series could raise your reimbursement substantially. You will usually see cases that warrant reporting both the E/M and burn code. Remember, though, that you should report burn treatment codes only when the physician personally provides the service, not when he or she only assesses and dresses the burn. For burn assessments without physician involvement in the dressing application, you would report only the appropriate E/M code.
 There are several common burn codes you will see in the ED:

 16000 Initial treatment, first-degree burn, when no more than local treatment is required

 16020* Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small

 16025* and 16030 without anesthesia, medium or large.

To report a burn code, you must determine whether the burn is small, medium or large. You should apply the Rule of Nines described for an adult and child in the CPT and ICD-9 manuals. Category 948.x (Burns classified according to extent of body surface involved) for diagnostic coding is based on the Rule of Nines to estimate the amount of body surface burned, says Katie Cianciolo, RHIA, CCS, CCS-P, a coding consultant.

This rule divides the body into 9 percent increments to make it easier for you to calculate the total body surface area affected by the burn, Cianciolo says:
 

 The head and neck, the right arm, and the left arm each equal 9 percent.
 

 The back trunk, front trunk, left leg, and right leg each equal 18 percent (the front and back trunk and each leg can be divided into upper and lower segments, each equaling 9 percent).
 

 The genitalia equal 1 percent.

Based on these rules, the physician can calculate the total percentage of the body that was burned, she says. Cianciolo gives an example of a patient who has 10 percent first-degree, 15 percent second-degree, and 30 percent third-degree burns of the trunk. This corresponds to the diagnosis code 948.53 (50-59 percent of body surface; 30-39 percent third degree).

Most ED visits will encompass both an E/M service and a burn treatment service. The 16000-16036 series is for local treatment of burned surfaces only, and the physician must still perform an assessment (E/M) that is appropriate to the presentation, says Marty Herman, MD, FAAP, FACEP, associate professor of pediatrics at UT College of Medicine, Memphis, Tenn. In most cases, he recommends reporting the E/M code for the initial assessment, along with the burn treatment code. The only time he might report a burn treatment code alone would be if the patient returned for follow-up burn care. In most well-documented initial presentations, you should report both the E/M (i.e., 99284) and burn treatment code (i.e., 16020) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code. 

Suppose a patient was cooking over a campfire. He complained of chest pains, passed out over the fire and hit his head in the process. He received burns over 9 percent of his trunk and arms. The ED physician will not only treat the burns but also evaluate the patient for cardiac problems and a head injury. This level of service would constitute an E/M service and a burn treatment.

For most small burns presenting in the ED, not involving the face or the perineum, the ED physician will frequently manage the injury independently. Most ED physicians will provide local treatment (debridement, dressing, ointment) for localized first- or second-degree burns. You will use the above-mentioned codes. Plastic surgeons treat most third-degree burns because they require grafting. The ED physician will do the initial workup and refer the patient to the specialist. In this case, you would code for the appropriate level of E/M care.

In coding for the E/M portion of the service, you should determine the medical necessity based on the chief complaint. The level of E/M should correlate with the complaint. A young, healthy male with a small burn will not need a comprehensive history and physical. A small, isolated burn will usually need an expanded, problem-focused history and exam, or a detailed history and physical.
 
Use 99291 for Critical Burns

Although most of your burn patients will require only low- to medium-level E/M codes, some of your cases will be severe. For instance, emergency medical services (EMS) brings in a patient who was caught in a burning house. In addition to severe burns, there are the issues of carbon monoxide poisoning, smoke inhalation, and traumatic injuries. Cases like this may constitute a detailed or even comprehensive history and physical, such as in codes 99284 (Emergency department visit for the evaluation and management of a patient, which requires a detailed history, detailed examination and medical decision-making of moderate complexity) or 99285 (... comprehensive history, comprehensive examination and medical decision making of high complexity).

Some cases will even require critical care codes. For example, if a child receives burns and presents in critical condition, such as with respiratory compromise or shock from the burns or other trauma, the child may require critical care, Herman says. When the patient has extensive burns (more than 10 percent of the body with third-degree burns or over 30 percent of the body with second-degree burns), the physician must provide fluid resuscitation.

Some burns may cause critical conditions, such as a chemical burn from hydrofluoric acid causing cardiac arrest, Herman says. Sometimes, the ED physician must provide critical care to establish or maintain an airway, along with the fluid resuscitation. If the physician debrides the burn or otherwise renders care to the burn consistent with the 16000 series, you should report these codes, Herman recommends. Neither CPT nor the Correct Coding Initiative bundles the 16000-series codes with critical care, and you may report these with modifier -25 on the E/M code. As with all nonbundled critical care procedures, remember to deduct this time from your critical care time.