Don't have a TCI SuperCoder account yet? Become a Member >>

Family Practice Coding Alert

Reader Questions:

Code 16000 Requires Burn Treatment

Question: A family physician diagnoses a patient with a second-degree burn on her right palm (944.25). The treatment plan calls for the patient to apply ice or run cold water over the area two or three times a day, and to apply Silvadene cream twice a day. The physician notes that blisters had formed over the base of the right thumb and palm that measured about 6 cm in diameter. Should I use a burn code for the FP's service?

Arkansas Subscriber

Answer: No. You should reserve a burn code, such as 16000 (Initial treatment, first-degree burn, when no more than local treatment is required) or 16010 (Dressings and/or debridement, initial or subsequent; under anesthesia, small), for when the physician provides actual treatment.

In your example, the FP only evaluates the patient's problem and provides a treatment plan the patient could perform herself. Therefore, you should instead report the appropriate E/M code (99201-99215). Choose the level based on the documentation's history, exam and medical decision-making components and the patient's status as new or established.

For example, if the patient is established and the physician documents expanded problem-focused history and low-complexity medical decision-making, you could assign 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Other Articles in this issue of

Family Practice Coding Alert

View All