Dig Into Documentation for Burn Encounter Specifics
Hint: Not all burn visits will warrant a code from the 16000 series. When burn patients present to your practice, there’s a big difference between how sunburn and a second-degree burn are treated. The procedure and diagnosis codes you select must be carefully chosen to avoid miscoding these services, while still ensuring that you’re able to collect for the providers’ work. Keep reading to discover how to select the right codes to report when your providers treat burns. Learn How to Justify Burn Code Selections Depending on the provider’s documentation, you may be able to report a burn code for their services. But the decision will hinge on the specific services that the physician performs. Consider the following codes for first- and second-degree burns: Local Treatment? Look to 16000 If your provider treats a first-degree burn using local treatment, such as cleansing and ointment, then you’d use 16000. A first-degree burn affects the epidermis only. Usually, these types of burns just involve erythema (redness or discoloration), but may also exhibit some swelling or minor pain. The most likely treatments reported with 16000 involve the use of cool towels, soothing balms, and topical medication application. The provider might apply substances such as Silvadene or triplebiotic ointment. These burns rarely require dressings, but some physicians may apply topical anesthetics to relieve pain. Example: A 17-year-old established patient presents to your office with a burn on the bottom left side of their torso after accidentally spilling a pot of boiling water. The physician examines the patient’s wound and the surrounding area. The first layer of skin is burned, but there are no blisters, particulate matter, or signs of further injury. The physician applies Silvadene and instructs the patient on how to care for the burn. Notes indicate that a low level of medical decision making (MDM) applied to the situation. Solution: In this example, you’d assign 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) for the evaluation and management (E/M) service. You’d also use 16000 for the burn treatment. Don’t forget to append 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) to 99213. This shows that the E/M and the burn treatment were significant, separately identifiable services. For your ICD-10-CM code, you’ll assign T21.10XA (Burn of first degree of trunk, unspecified site, initial encounter). Dressings or Debridement? Consider Higher-Level Burn Codes When patients present with more serious partial-thickness burns or second-degree burns, you would typically select a code from the 16020-16030 range. In this situation, the burn would involve blistering. The provider should document whether the burn is superficial (involving only the epidermis and superficial layers of the dermis) or deep (involving the deep layers of the dermis). Depending on the extent of the partial-thickness burn, the physician may have to debride the injury. In some cases where a partial-thickness burn covers a larger body area, surgical treatment may be needed to prevent scarring. Keep in mind that these codes are delineated based on the percentage of total body surface area (TBSA). Example: An established patient presents to your office with right forearm pain and blistering after hitting the roof of the oven with their forearm. The provider performs a low level of MDM and diagnoses the patient with second-degree burns comprising 3 percent TBSA. The provider debrides charred skin from the patient’s arm, applies cream, and lightly dresses the burn with a non-adherent dressing. Solution: Assign 16020 for the burn treatment, along with 99213-25 for the E/M service. For your ICD-10-CM code, you’ll use T22.211A (Burn of second degree of right forearm, initial encounter). Addressing Third-Degree Burns? Check Skin Graft and Eschar Removal Codes When patients suffer from third-degree burns, it means the burn has extended below the dermis into full-thickness tissue loss. The skin has been destroyed, but so have hair follicles, sweat glands, and oil glands. For that reason, these patients will always need skin grafting. The same is true for burns that are higher than third-degree, such as those that involve muscle, ligaments, or even bones. If the surgeon performs skin grafting of the wound, you should select the appropriate skin graft codes depending on the amount of skin being addressed and the location. For example, the surgeon uses a free, full-thickness graft measuring 40 sq cm to close a third-degree burn wound. In this case, you should report 15220 (Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less) and +15221 (... each additional 20 sq cm (List separately in addition to code for primary procedure)) for placement of the skin graft. In addition, your provider may need to report an escharotomy code. Why? “Third- and fourth-degree burns create eschar or coagulated tissue,” according to CPT® Assistant, Volume 22, Issue 10. To address the eschar, the physician may perform the escharotomy, which is when they cut through the burned skin (eschar) to help blood flow and to relieve pressure. Report the first escharotomy using 16035 (Escharotomy; initial incision) and any initial incision beyond the first with +16036 (... each additional incision (List separately in addition to code for primary procedure)). For example, a patient with full-thickness burns on the trunk, back, and both legs undergoes escharotomies on all four sites. In this case, you would use 16035 to describe the first escharotomy and +16036 x 3 for the three subsequent escharotomies. Know When to Report the E/M Service Only Not every burn patient will require treatment that qualifies for a code from the 16000-16030 series. If the burn was minor enough that no real treatment was provided, such as minor sunburn that required no dressing, debridement, or local treatment, you should include burn treatment in the E/M code for your service that day. Torrey Kim, Contributing Writer, Raleigh, North Carolina
