Revenue Cycle Insider

Question: The physician had a 13-year-old patient come in with second-degree burns on their upper back and entire right arm after they tripped over firewood and fell into a campfire. The physician debrided the burn and dressed it. How should I code this?

AAPC Forum Participant

Answer: When a burn affects more than one anatomical site, you will need to use multiple codes to accurately report the locations of the injury. For instance, if the 13-year-old sustained burns on their upper back and right arm, which together cover more than 10 percent of their total body area, you would need to assign separate codes for each affected area. This ensures that the severity and location of the burn are properly documented for accurate billing and coding purposes.

The burn you described occurs over part of the back and the whole arm, so you will need four codes to document the injury site, which means six total ICD-10-CM codes for this encounter:

• T21.23XA (Burn of second degree of upper back, initial encounter)
• T22.231A (Burn of second degree of right upper arm, initial encounter)
• T22.221A (Burn of second degree of right elbow, initial encounter)
• T22.211A (Burn of second degree of right forearm, initial encounter)
• T31.10 (Burns involving 10-19% of body surface with 0% to 9% third degree burns)
• X03.0XXA (Exposure to flames in controlled fire, not in building or structure, initial encounter)

Guideline alert: Pay attention to varying degrees of severity when there are multiple burn sites. ICD-10-CM Guideline I.C.19.d.1 says to “Sequence first the code that reflects the highest degree of burn when more than one burn is present.” Guideline I.C.19.d.2 instructs you to assign to the highest degree in instances when different degrees of burn occur at the same anatomical site.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC