General Surgery Coding Alert

Question: Our surgeon treated a 14 year old patient in the emergency room who had a second-degree burn on the palm of his left hand caused by grabbing a hot fire poker. The surgeon debrided and dressed the blistered areas. How should we code this?

Connecticut Subscriber

Answer: Because the surgeon documents debriding and dressing second-degree burns with blistering, which typically involves tissue below the dermis, the appropriate procedure code would probably be 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)). If the treated area is larger than that, you may choose a different code from the same code family.

Don’t forget: You should not bill a separate E/M code unless the surgeon documents assessing more than just the burn. A zero or 10 day global procedure includes the E/M necessary to assess the problem and determine it needs treatment.

To describe the diagnosis that led to the procedure, you should add the following diagnosis codes:

• T23.252A (Burn of second degree of left palm, initial encounter)
• T31.0 (Burns involving less than 10% of body surface)
• X17.XXXA (Contact with hot engines, machinery and tools, initial encounter)

For ICD-10-CM sequencing purposes, you should observe the note for T31, which states that the code “should be used as a supplementary code” when the site of the burn is specified.