ED Coding and Reimbursement Alert

Question: A patient presents to the emergency department (ED) with second-degree burns to their head and neck; they got too close to a bonfire and sustained the injuries. After performing an ED evaluation and management (E/M) service, the physician debrides the burns, snips away ragged tissue around the edges of the burn, and applies bandages. Total body surface area (TBSA) of the burns is 8 percent. Encounter notes indicate that the physician performed moderate medical decision making (MDM) during the E/M service. How should I report this encounter?

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Answer: You’ll need a pair of CPT^® codes, a modifier, and a trio of ICD-10-CM codes to report this encounter correctly. On the claim, report the following:

• 16025 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area)) for the debridement and dressing

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for the E/M service

• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99284 to show that the ED E/M and the debridement were significant, separately identifiable services

• T20.29XA (Burn of second degree of multiple sites of head, face, and neck, initial encounter) appended to 16025 and 99284 to represent the patient’s burns

• T31.0 (Burns involving less than 10% of body surface) appended to 16025 and 99284 to represent the TBSA burned

• X03.0XXA (Exposure to flames in controlled fire, not in building or structure, initial encounter) appended to 16025 and 99284 to represent the cause of the patient’s burns.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC