ED Coding and Reimbursement Alert

Question: A patient reported to the emergency department with a burn to his left eyelid after an accident with a gas grill during a church picnic. Documentation only supports a level-two evaluation and management service, but I've never reported eye burn treatment before. Which E/M code should I report for this visit?

Montana Subscriber 
 
Answer: Report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem focused examination; and medical decision making of low complexity) for the eye burn treatment.

Unfortunately, your doctor's documentation may have limited the E/M in this case. While some minor burns are low-complexity, more extensive burns, including those involving critical structures such as the eye, may often qualify for moderate medical decision-making.

Patients with eye burns from fire or sparks (a common occurrence this time of year) are typically treated with a topical antibiotic and possible pain medication, given an eye patch and sent home. As in this example, the documentation only supports a low-level E/M code.

Don't forget ICD-9 codes. Choosing the right burn diagnosis code is important to this claim's success. If the burn is confined to the eye, check the 940.x series (Burn confined to eye and adnexa). (For a more detailed discussion of burn diagnosis coding, see the December 2003 issue of ED Coding Alert.)

Note: Eye burn diagnosis codes are only four digits, but remember that burns on other areas of the body usually require a five-digit code. Also, depending on the clinical care and documentation provided, a burn code from the 16000 series (Initial treatment, first-degree burn, when no more than local treatment is required) may apply when treating eye burns.