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Burn Coding: Calculate Total Body Surface Area (TBSA)

Posted on 17. Feb, 2010 by in Coding Challenge, Hot Coding Topics

Investigate your physician’s documentation to determine the body area percentage actually debrided.

Question: My anesthesiologist administered anesthesia for a burn excision on the leg of a middle-aged adult male, but he didn’t give clear notes on the patient’s affected body surface area. How do I code for this?

Kansas Subscriber

Answer: You will start by coding 01952 (Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area [TBSA] treated during anesthesia and surgery; between 4 percent and 9 percent of total body surface area) and add +01953 ( . . . each additional 9 percent total body surface area or part thereof [List separately in addition to code for primary procedure]) as necessary.

Next, you’ll need to don your Sherlock Holmes hat. You’ll need find documentation of the patient’s affected total body surface area (TBSA). The attending surgeon typically...

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