Code the Residual Scar Before the Healed Burn
Question: A patient sustained a second-degree skin burn of the right forearm several years ago. The burn has completely healed, but the patient says the resulting scar feels tight and uncomfortable and restricts their elbow movement. The physician evaluates the scar and documents that the limited range of motion is due to post-burn scarring. Should we report a current burn code, a scar code, or both? Louisiana Subscriber Answer: Report the residual condition first, followed by the burn code with the 7th character “S” to identify the injury as a sequela. In this situation, you can assign L90.5 (Scar conditions and fibrosis of skin) to report the post-burn scarring, followed by T22.211S (Burn of second degree of right forearm, sequela) to identify the prior burn responsible for the condition. Even though the patient is receiving treatment now, you should not report an active-treatment 7th character. The original burn has healed, and the current treatment is directed at a residual effect of that injury. According to ICD-10-CM Official Guidelines, Section I.C.19.b, “there is no time limit on when a sequela code can be used.” So you can report the burn code with 7th character “S” even though several years have passed since the burn occurred. If the physician documents a distinct symptom, such as pain, itching, or altered sensation, consider whether an additional symptom code is supported and clinically relevant — don’t infer pain from the word “uncomfortable.” The record should also identify the original burn’s site and degree and clearly link the current scar problem to that burn. If you don’t have that information at hand, query the physician before selecting a specific sequela code. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
