Fourth, fifth digits are vital to these ICD-9 codes

To accurately code diagnoses for patients with burn injuries, coders must know whether the patient had any third-degree burns. They also need to know when to combine multiple burns into one ICD-9 code and when to submit a separate code for each burn.

Check out this expert advice on burn diagnosis coding, and heed these three steps each time you are coding for a burn victim.

1. Select Burn Location

The first diagnosis code you’ll select for burn victims represents the location of the burn (or burns) and the burn’s severity. You’ll find these codes in the 940-947 ICD-9 set, says Debra Williams, CPC, coding supervisor at Horizon Billing Specialists in Grand Rapids, Mich.

All the codes in the 940-947 set require at least a fourth digit, and some require five, says Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla. These codes "break down the classification first by anatomic site and then by degree of burn," she says.

Example: The ED physician’s notes indicate that a patient suffered a first-degree burn to his chest wall. Based on this description, 942.12 (Burn of trunk; erythema [first degree]; chest wall, excluding breast and nipple) is the correct diagnosis.

Exception: The codes that extend only to the fourth digit (940.x, 946.x, 947.x) do not describe both burn severity and burn location. In these cases, just code based on what ICD-9 requires for the burn. For instance, take a look at 940.3 (Burn confined to eye and adnexa; acid chemical burn of cornea and conjunctival sac), which does not require a fifth digit. This diagnosis is first defined as a burn confined to eye and adnexa (940.x), and the "3" further defines the injury, describing an acid chemical burn of the cornea and conjunctival area of the eye.

2. Check That You’ve Coded Each Burn

Patients who present to the ED for burn care will often have more than one burn. Check out this quick Q&A, which describes how to code for several multiple-burn scenarios:

Question: What if the patient has burns in different anatomical locations?

Answer: Code separately for each burn. So if the patient has first-degree neck burns and second-degree shoulder burns, you would report the following:

• 943.25 (Burn of upper limb, except wrist and hand; blisters, epidermal loss [second degree]; shoulder) for the second-degree burn

• 941.18 (Burn of face, head, and neck; erythema [first degree]; neck) for the first-degree burn.

On all multiple-burn claims, you should code the burn of the highest severity first, Williams says.

Question: What if the burns are of the same severity and in the same anatomic location?

Answer: You should be able to represent them with a single diagnosis code; just be sure to use the proper fifth digit to indicate that the burns are in the same area. For example, if a patient has second-degree burns to her left forearm and elbow, you’d code 943.29 (Burn of upper limb, except wrist and hand; blisters, epidermal loss [second degree]; multiple sites of upper limb, except wrist and hand).

Question: What if the patient has burns of varying degrees in the same body area?

Answer: In these scenarios, you’ll submit a code for each burn. "This is the only way to give the full picture as to the extent of the injury," Martien says. So if a patient has first- and second-degree burns on her lower leg, you report the following:

• 945.24 (Burn of lower limb[s]; blisters, epidermal loss [second degree]; lower leg) for the second-degree burn

• 945.14 (Burn of lower limb[s]; erythema [first degree]; lower leg) for the first-degree burn.

3. Heed ‘Rule of Nines’ for TBSA Diagnosis

Once you have selected a code (or codes) to represent the patient’s injuries, you’re ready to choose a code from the 948.xx group -- if the patient has suffered any third-degree burns.

Avoid extra work: Remember, if a patient has no third-degree burns, there is no need to report a 948.xx code in addition to the burn location code.

Explanation: Use the 948.xx codes to identify the percent of the body burned. Select the fourth digit according to the percentage of total body surface area (TBSA) burned. Then, use the fifth digit to specify the percentage of body surface that has third-degree burns.

To arrive at the TBSA burned, use the "Rule of Nines," which breaks body areas down by percentage. The breakdown differs slightly for children, whose anatomies are different from adults’.

"For instance, in an adult, the head is 9 percent of the TBSA. In an infant or small child, it counts for 18 percent due to the disproportionate size of their heads," Martien says. CPT breaks down TBSA percentages as follows:

Example: A patient presents with a small second-degree burn on her back and a burn covering most of her upper arm, 30 percent of which is a third-degree burn.

Step 1: You would first report 943.33 (Burn of upper limb, except wrist and hand; full-thickness skin loss [third degree NOS]; upper arm) and then report 942.24 (Burn of trunk; blisters, epidermal loss [second degree]; back [any part]) to account for both of the patient’s burns.

Step 2: Report 948.00 (Burns classified according to extent of body surface involved; burn [any degree] involving less than 10 percent of body surface; less than 10 percent or unspecified) to indicate the percent of body surface that is third-degree burn.

Use 949 as a Last Resort

While you’ll typically use the 948.xx codes as secondary diagnoses, there are situations in which it would be the primary, and only, diagnosis.

If the physician does not specify the burn site in the documentation, you should include a 948.xx code in lieu of a 940-947 diagnosis, Williams says.

Anatomical classifications get smaller as repairs get more complex

On your laceration claims, be sure to prove that the ED physician provided care that qualifies for the laceration repair codes.

Medicare also has some different rules for certain repairs using Dermabond -- if you code these encounters as you would for a private payer, you’ll likely end up with a denial.

Make Sure Service Qualifies as Repair

When the physician treats lacerations, you might be tempted to flip to the laceration repair section of CPT and choose a code. But before you do that, you’ll need to make sure that the service meets payer definition for a repair.

If the ED physician uses staples, stitches or sutures to close a wound, you can code laceration repair. But if the physician (or staff) uses only steri-strips, or some other kind of adhesive strip, to close the wound, you should consider the work an E/M service, says Kevin Solinsky, CPC, CPC-I, CPC-ED, president and CEO of Healthcare Coding Consultants LLC, Added Value Billing Inc.

Use an E/M code "when the adhesive strips are the sole repair material. If the adhesive is used in addition to sutures, staples, or tissue adhesives, then report the appropriate [laceration] repair code," says Kevin Arnold, CPC, business manager for the Emergency Medicine Department at Connecticut’s Norwalk Hospital.

Watch Anatomy Groupings on Repair Levels

Next, you should check the body area of the treatment. CPT groups laceration repair by anatomical location -- with a twist.

The grouping of anatomical locations for repair codes "depends upon which type of laceration repair you are doing," says Holly Barrett, CPC, CPC-H, ED and outpatient surgery coder at Northeastern Vermont Regional Hospital in St. Johnsbury.

Check out these different anatomical breakdowns for laceration repair:

Simple laceration groups:

• Codes 12001-12007: Scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet)

• Codes 12011-12021: Face, ears, eyelids, nose, lips and/or mucous membranes.

Intermediate laceration groups:

• Codes 12031-12037: Scalp, axillae, trunk and/or extremities (excluding hands and feet)

• Codes 12041-12047: Neck, hands, feet and/or external genitalia

• Codes 12051-12057: Face, ears, eyelids, nose, lips and/or mucous membranes.

Complex laceration groups:

• Codes 13100-13102: Trunk

• Codes 13120-13122: Scalp, arms and/or legs

• Codes 13131-13133: Forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet

• Codes 13150-13153: Eyelids, nose, ears and/or lips.

Example: A patient with a simple 2.2-cm laceration on her nose presents to the ED physician. On the claim, you would report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less).

Medicare exception: When coding simple repairs for Medicare patients, be on the lookout for Dermabond. If the physician uses Dermabond as the only closure material for a simple repair, report G0168 (Wound closure utilizing tissue adhesive[s] only) for the service.

This is for simple repairs only. If the physician performs an intermediate or complex closure with only Dermabond for a Medicare patient, report a laceration repair code from CPT.

Cuts Are Dirtier, Deeper on Intermediate Fixes

The rules regarding complexity of repair are pretty straightforward. A simple laceration repair involves a single-layer repair without any significant particulate debris or contamination.

For instance, if the ED physician uses surgical staples to close a single-layer 7.4-cm cut on a patient’s left leg, you’d report 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm) for the repair.

For intermediate repairs, the physician must perform layered closure of one or more of the deeper layers of subcutaneous tissue and superficial non-muscle fascia in addition to the skin, Arnold says. You can also report an intermediate code if the physician performs a single-layer repair that is heavily contaminated and requires extensive cleaning or removal of particulate matter.

Warning: The simple laceration repair codes have some cleaning and particulate removal figured into their work units. Make sure your physician goes "above and beyond" this work before considering an intermediate code, Arnold says.

Example: A construction worker presents to the ED following a power saw mishap that caused a 3.2-cm forearm laceration into the subcutaneous tissue and superficial fascia. The emergency physician performs a level-three E/M, examines and cleans the wound and performs a layered closure repair.

On this claim, report the following:

• 12032 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 to 7.5 cm) for the repair

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem- focused history; an expanded problem-focused examination; medical decision-making of moderate complexity) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 99283 to show that the E/M and laceration care were separate services

• 959.3 (Injury, other and unspecified; elbow, forearm, and wrist) linked to 12032 and 99283 to represent the patient’s injury

• E919.4 (Accidents caused by machinery; woodworking and forming machines) linked to 12032 and 99283 to represent the cause of the patient’s injury.

Patients reporting to the ED for complex laceration repair are rare; these patients usually head to the OR. However, your ED physician may perform a rare complex repair, so check out this explanation on the elements of a complex repair:

If the wound requires more than a layered closure, or the service includes scar revision, debridement of traumatic lacerations, or extensive undermining, it might be a complex repair. When you use complex repair codes, be sure the physician includes documentation explaining why the repair was complex.

On Multiple Repairs, You Might Need Only 1 Code

When the ED physician performs multiple laceration repairs to the same patient during the same encounter, coding will depend on the repairs’ types and location, Solinsky says.

"You will total all repairs of the same anatomical area that are the same level of repair," he says. For example, the ED physician performs three separate, simple 2-cm repairs to a patient’s arm.

Since the fixes are all simple and in the same anatomical location, you should add up the lengths of the repairs and choose one code. In this scenario, report 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm) to account for all three repairs.

But suppose the physician makes two simple, 2-cm repairs to the patient’s arm, and then has to make an intermediate repair on another 2-cm arm injury. In this scenario, you’ll need two codes. On the claim, you would report the following:

• 12002 for the simple arm repairs

• 12031 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) for the intermediate repair.

You should also submit separate codes for repairs the physician makes in different anatomical locations, regardless of repair levels.

Example: The notes indicate that the ED physician made the following repairs:

• a 3.1-cm simple repair on the face

• a 2.2-cm intermediate repair on the neck

• a 7.2-cm intermediate repair on the right forearm.

On the claim, you would report the following:

• 12032 (… 2.6 cm to 7.5 cm) for the forearm repair

• 12041 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less) for the neck repair

• 12013 (… 2.6 cm to 5.0 cm) for the face repair.