ED Coding and Reimbursement Alert

Question: A patient presents with second-degree burns on the forearm. The physician dictates that wounds were dressed with Silvadene. The nursing notes state that the physician debrided the area. Should I include this work in the E/M code, or should I separately report the debridement and dressing work under the physician?

Pennsylvania Subscriber

Answer: You should check the 16000 code series, Burns, Local Treatment. Most ED burns warrant code  16020* (Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small). Look at another burn code, 16000 (Initial treatment, first degree burn, when no more than local treatment is required), as well, in case your physician's documentation doesn't show debridement and therefore justify 16020.

If the current documentation in the doctor's notes is incomplete, consider making copies of it for quality-assurance purposes or sending it back for an addendum if that is part of your compliance process.