Wiki Please help ASAP!

[JAB86]

First visit was: 2% 2nd degree burn. Less than 1% 3rd degree burn. And cleaning & dressing were also provided.
Each additional visit was described as: Treatment and dress sounds exam for S/S of infection.

For the burns, I would code it as: 946.2, 946.3, 948.00, V58.30? If I had the location of the burns I would've coded by location - so I've queried it. How would you code it?

Also, I am stuck on the Each Additional visit portion. Please help ASAP!

 

[JAB86]

^bump

 

[FTessaBartels]

You'll need to query physician

For burns the physician must document
1) degree of burn
2) TBSA
3) location of burn
4) treatment

This has to be documented on EACH note because as burns heal the physician may not be treating ALL the original burns on each subsequent visit.

Hope that helps.

F Tessa Bartels, CPC, CEMC