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How to code burns

How To Code Burn Treatments

BURNS TREATMENT

A burn is an acute wound, defined as an injury to the skin or other organic tissue primarily caused by thermal or other acute trauma.

Caused By –

  1. Hot liquids (scalds)
  2. Hot solids (contact burns)
  3. Flames (flame burns)
  4. Radiation,
  5. Radioactivity,
  6. Electricity,
  7. Friction or contact with chemicals

Burn Depth and Classification

First Degree (Superficial or Epidermal) Burns These burns involve only the epidermis. They do not blister, but are red and quite painful. Over 2-3 days the erythema and the pain subside. By about day 4, the injured epithelium peels away from the newly healed epidermis underneath, a process which is commonly seen after sunburn.

Second Degree (Partial Thickness) Burns Partial-thickness burns involve the epidermis and portions of the dermis.

  1. Superficial partial-thickness
  2. Deep partial-thickness burns.

Superficial partial-thickness burns – Blisters between the epidermis and dermis.

Deep partial-thickness burns –  Extend into the lower layers of the dermis.

Third Degree (Full-Thickness) Burns Full-thickness burns involve all layers of the dermis and often injure underlying subcutaneous adipose tissue as well. Burn eschar is structurally intact but dead and denatured dermis. Some fullthickness burns involve not only all layers of the skin, but also deeper structures such as muscle, tendon, ligament and bone, and are classified as deep full-thickness or fourth-degree. Grafting may use autologous skin grafts or biologic dressings and skin substitutes or both. Deep full-thickness burns may require amputation or closure with alternative techniques (such as adjacent tissue transfer or microvascular procedures).

Burn Coding

Escharotomy —An escharotomy is defined as a surgical incision through burn eschar (necrotic skin). Technique—Escharotomy (incision through the eschar) releases the constricting tissue allowing the body tissues and organs to maintain their normal perfusion and function.

Debridement of Burn —Debridement is the removal of loose, devitalized, necrotic, and/or contaminated tissue, foreign bodies, and other debris on the wound using mechanical or sharp techniques (such as curetting, scraping, rongeuring, or cutting). The level of debridement is defined by the level of the tissue removed, not the level exposed by the debridement process. Debridement cleans the wound and allows it to heal more rapidly with reduced risk of infection. In general, debridement is performed on shallow burns that are expected to heal without the need for skin grafting.

Excision of Burn Wounds —Excision is a surgical procedure requiring incision through the deep dermis (including subcutaneous and deeper tissues) of open wounds, burn eschar, or burn scars. Excision is typically performed on deep burns that would not heal on their own. The goal is to remove all necrotic and non-viable tissue and to prepare the wound for immediate or delayed wound closure.

Burn debridement (cleaning) and excision (escharectomy) are routinely performed by experienced burn surgeons. Though the techniques and instruments used for debridement and excision are often similar, burn excision is significantly more difficult and requires greater time and physical effort to achieve meticulous burn wound preparation for subsequent grafting with synthetic or biological materials.

Tangential excision (which is usually performed on deep partial thickness burns) Tangential excision involves surgical removal of successive layers of the burn wound down to viable dermis

Full thickness excision —often using electrocautery—involves removal of the burn wound down to viable subcutaneous tissue or to fascia.

 

Skin Substitutes and Skin Replacements

Skin substitute : A biomaterial, engineered tissue or combination of materials and cells or tissues that can be substituted for skin autograft or allograft in a clinical procedure.

Skin replacement: A tissue or graft that permanently replaces lost skin with healthy skin.

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The procedure codes (16020 – 16030) are used to report the local treatment of the burn wound itself. These codes do not include evaluation and management services. The usual pre- and post-procedural services (e.g., explaining procedures to the patient/family, supervising the positioning and prepping of patient; monitoring stability of the patient, as appropriate; and after care instruction) are included in the debridement/dressing CPT code and not reported separately.

Surgical preparation  for Burn Surgery codes (15002 – 15005) Vs Burn Debridement/Dressing change codes (16020 – 16030)

Burn coding

Burn Codes

There are several CPT codes related to burn coding that I want to share with you to enhance your coding and reimbursement. These codes refer to local treatment of burned surface area only.

Burn dressing and/or debridement codes (16020-16030) are divided based on whether the dressing or debridement is of a small, medium, or large area. Small is less than 5% of the total body surface area, medium is the whole face or whole extremity, or 5% to 10% of the total body surface area, and large is more than one extremity or greater than 10% of the total body area.

  1. 16000 – Initial treatment, first degree burn, when no more than local treatment is required
  2. 16020 – Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small
  3. 16025– Dressings and/or debridement, initial or subsequent; without anesthesia, medium eg, whole face or whole extremity)
  4. 16030– Dressings and/or debridement, initial or subsequent; without anesthesia, large eg, more than one extremity)
  5. 16035 – Escharotomy
  6. 16036 – Escharotomy, each additional incision List separately in addition to code for primary procedure

When using these burns codes, remember to document percentage of body surface involved and depth of burn. Remember your “Rule of Nines” in calculating Total Body Surface Area.

Rule of Nines for Burns
Rule of Nines for Burns

These codes can be used in addition to an office visit; however, the office visit must be medically necessary and a modifier -25 must be appended to the office visit. An example of a medically necessary office visit would be to prescribe medications (such as antibiotics and/or pain medication, for example).

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How To Code – Adjacent Tissue Transfer, Skin Replacement and Flaps

Adjacent Tissue Transfer and Skin Replacement Procedures

  1. Recipient site – The area of defect that receive a graft
  2. Donor Site – The area from which healthy skin has been taken for grafting.

Skin Grafting –  To correct a defect site. Various types –

  1. Adjacent Tissue Transfer (1400-14350)
  2. Skin Replacement Surgeries (15002-15278)
  3. Flaps

Adjacent Tissue Transfer:  Various types of ATT like – Z Plasty, W Plasty, V-Y Plasty.

ATT includes moving a part of skin from one area to an adjacent area, while leaving at least one side of the flap (moved skin) intact to retain blood supply to the graft. Incisions are made, and the skin is undermined and moved over to cover the defective area, leaving connected portion intact. The flap is then sutured into place.

ATT Coding Guidelines:

  1. Codes are categorised as Size (in Sq Cm) and Location of defect (Recipient Site).
  2. Any excision of a lesion that is repaired by adjacent tissue transfer is always bundled in the tissue transfer code. No need of coding separately.
  3. Simple repair of the donor site is included in the tissue transfer code and is not reported separately.
  4. If a skin graft is required to close the donor site (Complex closure), the closure is reported as an additional procedure.
  5. When skin grafting is required to cover both the primary defect (results from the excision) and the secondary defect (results from the flap design), the measurements of each defect are added together to determine the code selection for the graft.

Always RememberDebridement necessary to perform a tissue transfer procedure is included in the procedure. It is inappropriate to report debridement (e.g., CPT® codes 11000, 11042-11047, 97597, 97598) with adjacent tissue transfer (CPT® codes 14000-14350) for the same lesion/injury.

 

Skin Replacement :  The grafts are completely freed from the donor site and placed over the recipient site. There is no connection left between the graft and the donor site .

Graft Terminology
Autograft: Graft from the same person
Allograft/Homograft: Graft from another member of the same species (often cadaveric)
Isograft: Graft from another member of the same species who is genetically identical to the patient (identical twin)
Xenograft/Heterograft: Graft from another species (often porcine or bovine)

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  1. Surgical preparation of defect site before repair – 15002-15005 based on the size of repair and site.
  2. Split Thickness Skin Graft (STSG) – Epidermis and part of dermis. E.g – Pinch graft
  3. Full Thickness skin Graft (FTSG) – Epidermis and full of dermis.
  4. Codes are categorized as recipient site, size of defect, and type of repair.
  5. Size of defect in square centimeters and a percentage of body area. The square centimeters measurement is applied to adults and children over 10 years of age, and the percentage of body area is applied to infants and children under the age of 10.

Codes Classification –

  1. Surgical preparation codes- 15002 – 15005
  2. Pinch Graft – 15050
  3. Epidermal Autografts – 15110- 15116
  4. Dermal Autografts – 15130-15136
  5. Tissue cultured skin autografts are grafts that are cultured (grown) from the patient’s own skin cells, thereby reducing the chances of rejection – 15150-15157.
  6. Acellular dermal replacement and temporary allograft – 15271-15278.
Skin Substitute Grafts Coding by Site and Size
Trunk, arms, legs Face, scalp, neck, ears, genitalia, hands, feet, digits
Total wound surface area by anatomical grouping less than 100 cm2
1-25 cm2 15271 15275
26-50 cm2 +15272 x 1 +15276 x 1
51-75 cm2 +15272 x 2 +15276 x 2
76-99 cm2 +15272 x 3 +15276 x 3
Total wound surface area by anatomical grouping greater than or equal to 100 cm2
100 cm2 15273 15277
101-200 cm2 +15274 x 1 +15278 x 1
201-300 cm2 +15274 x 2 +15278 x 2
301-400 cm2 +15274 x 3 +15278 x 3

 

Always RememberCPT® specifies codes in this section (15002-+15278) be reported for topical application of a skin graft. That is, 15002-+15278 do not include use of skin replacement materials as soft tissue reinforcement. To report skin replacement materials used for soft tissue reinforcement, CPT® 2012 includes a new add-on code, +15777 Implantation of biologic implant

 

Flaps:

  1. Sometimes physician develop a donor site far away from the recipient site (so grafting needs to complete in stages).
  2. when reporting transfer flaps (in several stages), report the donor site when a tube graft is formed for later use or when a delayed flap is formed before it is transferred .
  3. The recipient site is reported when the graft is attached to its final site.
  4. Delayed graft – a portion of the skin is lifted and separated from the tissue below, but it stays connected to blood vessels at one end.
  5. This keeps the skin viable while it is being moved from one area to another, and at the same time, it allows the graft to get used to living on a small supply of blood. It is hoped that living on a small blood supply will give the graft a better chance of survival when inserted into the recipient site.

Codes Classification:

  1. 15570-15738 – based on the type of flap (i.e., pedicle, cross finger, delayed, or muscle flaps) and then by the location of the flap (scalp, trunk, or lips)
  2. 15740-15777 – based on the type of flap (free muscle, free skin, fascial, or hair transplant).

 

Clinical Example:

A mechanic was admitted to hospital with burns on both arms and hands, after his gasoline-saturated clothing was ignited from a spark. Surgical excision of the burn tissue from his right hand beginning at the wrist was performed two days ago (reported separately). He now undergoes application of 250 sq cm of skin substitute graft on his arms and 180 sq cm of skin substitute graft on his hands and fingers.

The reportable procedures in this case are as follows:

Arms:
15273, Skin substitute graft, trunk, arms, legs, first 100 sq cm
+15274, Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof
+15274-59,     Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof

Hands, fingers:
15277, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, first 100 sq cm
+15278, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, additional 100 sq cm, or part thereof

The arms and hands and fingers are listed in different anatomic locations; thus, it would not be appropriate to add the wound sizes together. Procedures involving the wrist and/or ankle are reported with codes that include arm or leg in the descriptor. Instead, report 15273 and 15274 for the application of skin grafts of the arm, and codes 15277 and 15278 for application of skin grafts of the hands and fingers.

 

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How to Code – Debridement

Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound. The goal of debridement is to cleanse the wound, reduce bacterial contamination, and provide an optimal environment for wound healing or possible surgical intervention. The usual end point of debridement is removal of pathological tissue and/or foreign material until healthy tissue is exposed.

Techniques 

Debridement techniques include, among others, sharp and blunt dissection, curettement, scrubbing, and forceful irrigation. Surgical instruments may include a scrub brush, irrigation device, electrocautery, laser, sharp curette, forceps, scissors, burr, or scalpel Prior to debridement.

Debridement CPT Codes  : 11000 – 11047

  1. 11000 & 11001 – For Eczematous Debridement
  2. 11004 – 11006 – For debridement of Soft tissue infection(i.e. upto skin, subcutaneous tissue and muscle,fascia level)
  3. 11010 – 11012 – Excisional Debridement
  4. 11042 – 11047 – Wound Debridement

Excisional Debridement

defined as the “surgical removal or cutting away of devitalized tissue, necrosis, or slough,” which could be performed in the operating room, emergency room, or at the patient’s bedside.

Some surgical procedure codes include debridement as a part of the service. You may report a debridement as a separate service when the medical record indicates that a greater than usual debridement was provided. For example, if an extensive debridement of an open fracture was performed when usually a simple debridement would be performed, you report the additional service using a debridement code from the 11010-11012 range.

Divided according to location:

11010 – skin and subcutaneous level

11011 – Muscle , Fascia level

11012 – Bone level

Wound Debridement

11042 – 11047 – Wound Debridement

Divided according to – Depth of tissue –

11042 – skin and subcutaneous level

11043 – Muscle , Fascia level

11044 – Bone level

Diveded according to Surface Area –

11042,11043,11044 – upto 20 sq cm

11045, 11046 – More than 20 Sq cm

Coding tips –  When reporting one wound, report the depth of the deepest level of tissue removed. When reporting multiple wounds, sum the surface area of the wound at the same depth. Do not combine sums of different depths.

Other Important Points to Remember while coding for debridement

  1. These debridement codes do not apply to debridement of burned surfaces. For debridement of burned surfaces, CPT codes 16000-16036 are reported.
  2. Do not assign additional codes for debridement when these procedures are an integral part of the total procedure performed. A debridement carried out in conjunction with another procedure is often, but not always, included in the code for the procedure.
  3. Do not use these codes for pressure ulcers, for Pressure ulcers – code 15920-15999

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150-CPC-Exam-2008-questions

CPC 2008 ANSWERS

150-CPC-Exam-2010-questions

CPC 2010 ANSWERS

150-CPC-Exam-2011-questions

CPC 2011 ANSWERS

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Modifier 22

Modifier 22 – Procedural Service

  • The purpose of this modifier is to report services (surgical or nonsurgical) when the work required to provide a service is substantially greater than typically required.
  • This modifier must be used only when additional work factors requiring the physician’s technical skill involve significantly increased physician work, time, and complexity of than when the procedure is normally performed.

o   “Substantially Greater” refers to increased intensity, time, technical difficulty of procedure, severity of patient’s condition, and physical and mental effort required, etc.

o   Trauma extensive enough to complicate the procedure and cannot be reported with additional procedures.

o Significant scarring requiring extra time and work.

o Extra work resulting from morbid obesity.

o Increased time resulting from extra work by the physician.

  • Procedure codes with modifier 22 appended will price at 120% of the allowable charge.
  • This modifier may be used with codes in the following sections:

o Anesthesia (00100-01999)

o Surgery (11100-69990)

o Radiology (70010-79999)

o Laboratory and pathology (80047-89356)

o Medicine (90281-99607)

  • This modifier is not appended to ELM services (99201-99499).

Clinical Information Requirements:

  • Medical records must be available upon request.
  • Clinical information documented in the patient’s medical records must support the use of this modifier.

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Coding tips for burns

Coding Tips for Burns

Coding Burns 

Current burns (940 – 948) are classified by depth, extent and by agent (E code). Burns are classified by depth as first degree (erythema), second degree (blistering), and third degree (full-thickness involvement).

Sequence first the code that reflects the highest degree of burn when more than one burn is present.

Classify burns of the same local site three-digit category level, (940-947) but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis.

Non-healing burns are coded as acute burns. Necrosis of burned skin should be coded as non-healed burn.

Assign code  958.3,  Post-traumatic wound  infection, not  elsewhere classified, as  an additional code for any documented burn site.

When coding burns, assign separate codes for each burn site.  Category 946, burns of multiple specified sites, should only be used if the locations of the burns are not documented.  Category 949, burns, unspecified, is extremely vague and should rarely be used.

Assign codes form category 948, Burns classified according to extent of body surface involved, when the site of the burn is not specified or when there is a need for additional data. It is advisable to use category 948 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units.  It is also advisable to use category 948 as an additional code for reporting purposes when there is mention of a third-degree burn involving 20 percent or more of the body surface.

In assigning a code form category 948: Fourth-digit codes are used to  identify the percentage of total body surface involved in a burn (all degree).

Fifth-digits are assigned to identify the percentage of body surface involved in third- degree burn.

Fifth-digit zero (0) is assigned when less than 10 percent or when no body surface is involved in a third-degree burn.

Category 948  is  based  on  the  classic  “Rule  of  Nines”  in  estimating  body  surface involved: head and neck are assigned nine percent, each arm nine percent, each leg 18 percent, the anterior trunk 18 percent, posterior trunk 18 percent, and genitalia one percent.          Physicians  may  change  these  percentage  assignments  where  necessary  to accommodate infants and children who have proportionately larger heads than adults and patients who have large buttocks, thighs, or abdomens that involve burns.

Encounters for the treatment of the late effects of burns (i.e., scars or joint contractures) should be coded to the residual condition (sequelae) followed by the appropriate late effect code (906.5-906.9). A late effect E code may also be used if desired.

When appropriate, both a sequelae with a late effect code, and a current burn code may be assigned on the same record.

The body is divided into eight areas:

Head and Neck 9%
Posterior Trunk 18%
Anterior Trunk 18%
Left Arm 9%
Right Arm 9%
Posterior Leg 18%
Anterior Leg 18%
Genitalia 1%
Total body 100%

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ICD 9 Coding Tips

ICD 9 – Introduction

Volume 2 Footnotes, Symbols and Conventions

 

Volume 2 (Index) Example
SEE 

Directs the coder to a more specific term under which the correct code can be found.

Fracture 

Bursting – see Fracture, phalanx, hand, distal

SEE CATEGORY 

Indicates the coder should review the category specified before assigning the code.

Infection…. 

brain…..

 

late effect – see category 326

SEE ALSO 

Indicates where supplemental information is available that may provide another code.

Bartholin’s …. 

Adenitis (See also Bartholinitis) 616.

NEC Not elsewhere classifiable 

This abbreviation is used when the ICD-9- CM  system  does  not  provide  a  code specific for the patient’s condition.

Metabolism disorder 277.9 specified type NEC 277.89
( ) 

Parentheses enclose supplementary words, called non-essential modifiers, which may be present in the narrative description of a disease without affecting the code assignment.

198.4 Other parts of nervous system meninges (cerebral) (spinal)
Italicized 

Italicized  type  is  used  for  all  exclusion notes and to identify codes that should not be used for describing the primary diagnosis.

Foreign body
Note – For foreign body with open wound or other injury,  see  Wound,  open,  or  the  type  of  injury specified.

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Supplemental classification V Codes

Supplementary Classification of Factors Influencing Health Status and Contact With Health Services (V01-V84)

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Supplementary Classification of Factors Influencing Health Status and Contact With Health Services (V01-V84)

This classification system is provided to deal with occasions when circumstances other than a disease or injury classifiable to categories 001-999 (the main part of ICD-9-CM) are recorded as “diagnoses” or “problems”. This can arise in three main ways:

  • When a person who is not currently sick encounters the health services for some specific purpose, such as to act as a donor of an organ or tissue, to receive prophylactic vaccination, or to discuss a problem which is in itself not a disease or injury.
  • When a person with a known disease or injury, whether it is current or resolving, encounters the health care system for a specific treatment of that disease or injury.(e.g. dialysis for renal disease, chemotherapy for malignancy, or a cast change).
  • When some circumstance or problem is present which influences the person’s health status but is not in itself a current illness or injury.  Such factors may be elicited during population surveys, when the person may or may not be currently sick, or be recorded as an additional factor to be borne in mind when the person is receiving care for some current illness or injury classifiable to categories 001-999.

 

Supplementary Classification of Factors Influencing Health Status and

Contact with Health Services (V01 – V84)

 

 

Persons with Potential Health Hazards Related to Communicable Disease V01 – V06
Persons with Need for Isolation, Other Potential Health Hazards and ProphylacticMeasures V07 – V09
Persons with Potential Health Hazards Related to Personal and Family History V10 – V19
Persons Encountering Health Services in Circumstances Related to Reproduction and Development V20 – V29
Liveborn Infants According to Type of Birth V30 – V39

 

 

 

 

Persons with a Condition Influencing Their Health Status V40 – V49
Persons Encountering Health Services for Specific Procedures and Aftercare V50 – V59
Persons Encountering Health Services in Other Circumstances V60 – V69
Persons  without  Reported  Diagnosis  Encountered  during  Examination  andInvestigation of Individuals and Populations V70 – V84
In Patient coding

Reporting Additional Diagnoses for Inpatient Services

Reporting Additional Diagnoses for Inpatient, Short-Term, Acute Care and Long- Term Care Hospital Records

For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation, or therapeutic treatment, or diagnostic procedures, or extended length of hospital stay, or increased nursing care and/or monitoring.

The following guidelines are to be applied in designating “other diagnoses” when neither the Alphabetic Index nor the Tabular List in ICD-9-CM provides direction.   The listing of the diagnoses in the patient record is the responsibility of the attending physician.

Previous Conditions:

If the physician has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded.  However, history codes (V10 – V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Abnormal Findings:

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their critical significance.

Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a physician.

Uncertain Diagnosis:

If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, code the condition as if it existed or was established.  The basis for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.