Pediatric Coding Alert

Question: One of our patients recently received a second-degree burn to the palm of her left hand when she accidentally placed it around Mom’s hot curling iron. The burn was not serious enough to merit a visit to the emergency room (ER), so we saw and treated the patient in our practice. How should I go about coding this encounter?

California Subscriber

Answer: Unlike first-degree burns, which are usually treated locally, second-degree burns, which go below the dermis and produce blisters, require debridement and dressing. This means you will choose a code from 16020-16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent ...).

Code choices in this group are determined by size, so if the burn is less than 5 percent of the total body surface area, which is likely the case with your patient, you would use 16020 (… small (less than 5% total body surface area)) to describe your provider’s service. And you would also bill the appropriate office visit from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) with 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) appended to indicate that the visit was to determine the need for treatment.

To justify the procedure, you would 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)
• X15.8XXA (Contact with other hot household appliances, initial encounter).

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