Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.

Question: What do I need to document to bill for burns and their treatment?

Answer: In addition to documenting an appropriate E/M encounter (eg, Current Procedural Terminology [CPT] 99283), four things should also be documented for patients with burns: location, size relative to total body surface area (TBSA), depth of the burn, and whether dressings or debridement were performed and by whom. Anatomical location should include laterality, left or right, and the specific part of the body involved (eg, palm and/or back hand surface, each finger).

TBSA can be estimated using the rule of nines or a burn diagram. A diagram is especially useful in children since the rule of nines may be inaccurate. The depth of burns should be documented as first degree, partial thickness, or full thickness. CPT 16000 (1.32 relative value units [RVUs], $48.04 Medicare) is for first-degree local treatment, 16020 (1.55 RVUs, $55.87 Medicare) applies to dressings/debridement of <5 percent TBSA partial thickness burns, 16025 (3.16 RVUs, $113.88 Medicare) is for dressings/debridement of TBSA 5 to 10 percent partial thickness burns, and 16030 (3.82 RVUs, $137.67 Medicare) is for dressings/debridement of TBSA >10 percent partial thickness burns.

Brought to you by the ACEP Coding and Nomenclature Committee.

Dr. Green is associate professor of emergency medicine at University of Texas Southwestern Medical School, Dallas.