What type of documentation regarding the patient’s history, examination, and diagnosis will verify the medical necessity...

What type of documentation regarding the patient’s history, examination, and diagnosis will verify the medical necessity of your chosen procedure above?

burn care code 16000

Expert Solution

The documentation regarding the patient history,physical examination and the diagnosis is based on the CPT Coding.
CPT Code 16000 -is for the innitial treatment,first degree burn,when no morethan local treament is required. this is to make sure the first degree burn,that is superficial burn of the outermost layer of the skin or epidermis.And also the percentage of the burns ,body surface area also examined for the diagnosis of the degree of burns.
usually body surface area is calculated based on the Rule of nine formula.
next regarding the diagnosis part made by the ICD-9 CM code can be found in INJURY AND POISONING section 940-949.
this procedure of coding helps the physician to evaluate and avoid the errors in providing the care to the pateint and follow ups.
inaddition to the burn codes E-Codes describes the type of the injury like is it due to fire ,hot liquid or accident etc.

Nightingale answered 2 years ago

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