Question: An established patient reports to our physician with first and second-degree burns to his abdominal wall from a steam burn. During an E/M service, the physician uses gauze and topical ointment to treat the patient’s burn. Notes indicate that the anterior trunk is “18% burned.” How many diagnosis codes should I include on the claim?
Answer: You’ll report two diagnosis codes; one for the burn and one for the total body surface area (TBSA) burned. On your claim, report the following:
- The appropriate burn treatment code. Since the patient suffered both first and second degree burns on 18% of the body, consider 16030 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area). Had the burns been first-degree only, the alternative code would be 16000 (Initial treatment, first
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