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?
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 …
documents the TBSA of the burn victim. The history and physical (H&P) portion of the surgeon’s documentation may have an anatomic chart showing the burn area. Alternately, you can call the surgeon’s office, and code based on what they are billing.
Physicians determine TBSA percentage using “The Rule of Nines.” To help determine the extent of burn wounds, doctors divide the body into 11 sections of 9 percent (99 percent) with the genitals adding the missing 1 percent. The sections break down as follows:
- front trunk = (2 X 9 percent) rear trunk = (2 X 9 percent)
- each arm = 9 percent (2 X 9 percent bilaterally)
- each leg = 9 percent in front, 9 percent on the back (4 X 9 percent)
- head = 9 percent (4.5 percent for the front and 4.5 percent for the back).
Note that the arms represent 4.5 percent...
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