Question

Inpatient             Gender: M          Age: 31

Preprocedural Dx: Second-degree burns to both upper arms, subsequent encounter

Procedure: Debridement of blisters and skin on both upper arms measuring 180 sq cm. A skin substitute was applied.

TIP: Remember that a second-degree burn is also called a partial thickness burn.

4 CPT Codes:

Answer 1

CPT CODING FOR SECOND DEGREE BURNS .

To determine a CPT code for burn treatment , the medical record must document the degree of the burn and the percentage of body area affected . For second - degree burns , it's important to document information on what is done during the visit because burn coding can be used for a dressing change or debridement . Typical procedure codes include ;

16000 - Initial treatment , first degree burn , when no more than local treatment is required .

16020 - Dressings and / or debridement of partial - thickness burns , initial or subsequent ; small ( less than 5 % total body surface area )

16025 - Dressings and / or debridement of partial - thickness burns , initial or subsequent ; medium ( eg , whole face or whole extremity , or 5 % to 10% of total body surface area )

16030 - Dressings and / or debridement of partial thickness burns , initial or subsequent ; large ( eg , more than 1 extremity , or greater than 10 % of total body surface area )

CPT code 16000 is for initial treatment only , whereas codes 16020 , 16025 , and 16030 are for initial and subsequent visits . Note that 16020 , 16025 ,and 16030 state dressing and or debridement . It is appropriate to report these codes when patients are coming in specifically for dressing changes and the application of a burn product , such as Silvadene cream ( silver sulfadiazine )

CPT code 16030 is appropriate in this example because these are partial thickness burns covering more than one extremity or 10 % of body surface area .