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Question: A patient presented to the emergency department (ED) for a painful and blistered right palm. The patient had been cooking and scalded their palm with boiling water while straining pasta. The site appears uninfected; but the burn site is moist, and the patient complains that it is difficult to complete tasks with the hand due to the pain and location of the burns. The provider prescribes Silvadene to apply to the area and recommends ibuprofen for the pain.

How should I code this encounter? Would this warrant a burn treatment CPT^® code?

Nebraska Subscriber

Answer: No, it would not warrant a burn treatment code; the work your physician performed treating the burn should be rolled into the overall work units when deciding on the ED evaluation and management (E/M) level. Choose a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set to represent the entire encounter.

ICD-10-CM coding: This is where things get a little tricky. You’ll need three diagnosis codes to properly code this encounter: one for the burn type, one for the amount of body surface burned, and one to represent the cause of the burn. Report the following ICD-10-CM codes for this patient:   

• T23.251A (Burn of second degree of right palm, initial encounter)
• T31.0 (Burns involving less than 10% of body surface)
• X12.XXXA (Contact with other hot fluids, initial encounter)

We know this is a second-degree burn because of the description in the physician’s notes. According to Cleveland Clinic, “There are three main degrees of burns. You can identify what type of burn you have by its appearance. A first-degree burn may only cause skin discoloration. A second-degree burn includes blisters, a darker tone and a shiny, moist appearance. A third-degree burn may cause your skin to turn black and dry out.”

Also, we know that the burn only affected the hand, which is less than 10 percent of the patient’s body surface, since an entire hand is about 1 percent of total body surface area (TBSA).

Finally, you’ll choose X12.XXXA to indicate how the burn occurred, which provides a more complete picture of the injury the patient suffered.

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