mike strong, sfm the work comp experts strong, sfm the work comp experts skin deep •burns...

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Skin Deep

Skin Deep

Presented by:

Mike Strong,

SFM The Work Comp Experts

Skin Deep

• Burns

• Wounds

• Debridement

• Evaluation and Management Services

Agenda

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Skin Deep

• Types of Burns

– First Degree

– Second Degree

– Third Degree

• Rule of 9

– Adults

– Infants

• Burn Coding

– CPT 16000-16036

– CPT 15100-15278

Burns

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Skin Deep

• Types of Burns

– First Degree

• Redness, Swelling, Pain, Dry/Peeling Skin

• Surface Burns / Local Burns

– Second Degree

• Deeper than top layer, blistering, extremely red and sore

• Partial (Local) or Full Thickness (Possible need for skin grafting)

– Third Degree

• Full-thickness. May include bloodstream, major organs, bones. Can be

deadly

• Surgery, physical therapy, antibiotics, rehab, other extensive care

Burns

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• Rules of 9

Burns

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Body Location Adult Child

Head & Neck 9% 18%

Chest 18% 18%

Back 18% 18%

Arms (Each) 9% 9%

Legs (Each) 18% ~14%

Genitalia 1% 1%

Total 100% 100%

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Burns

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• Why is this important?

– Provides the background needed to determine how the diagnosis,

treatment, and severity of burn can affect the coding

• How does this affect me as a coder?

– Codes vary depending on the depth of the skin burn, the

percentage of total body surface area (TBSA) of the burn or amount

of square centimeters (sq. cm.), grafts and flaps, and/or use of

debridement.

Burns

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• Local Burns

– First and Partial Thickness Second degree burns

– CPT 16000-16036

– Burned surface only

– Includes the application of materials, such as dressings

– Documentation must include the percentage of body surface

involved and depth of burn.

Burns

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• Example 1:

– A 42-year-old tourist to Daytona Beach fell asleep in the sun. Upon

waking, the tourist noticed red skin on the legs and feet with pain

upon movement and contact. Some swelling is noted in the joints.

The individual presents to a local urgent care center and receives a

diagnosis of first degree sun burn. The provider applies some aloe

vera cream and wrapped some gauze around the knees. The

patient was advised to take some over-the-counter pain killers and

apply the cream vigorously for 2 days. Patient was advised that

symptoms should resolve within a week.

– What is the code?

Burns

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• Answer:

– CPT 16000

– Initial treatment for the first degree burn

– Follow-up is uncommon so future care not needed

– Only local treatment required

Burns

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• Example 2:

– A 30-year-old chef got burned at work when he accidentally

bumped into a cook carrying boiling hot water. Some of the water

spilled and burned the chef’s right arm. The burns were second

degree partial thickness. Approximately 7% of the arm has second

degrees partial thickness burns. The patient presents to the

emergency room, where the ER physician performs some

debridement to the burns on the hands with the entire arm treated

with aloe vera cream. The entire arm is wrapped in gauze.

– How is this initial treatment coded?

Burns

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• Answer:

– CPT 16025

– 7% second degree partial thickness burn to the right arm

– Initial treatment: dressings & debridement

• Follow-up:

– He follows-up with his primary care physician in 10 days. Partial

thickness second degree burns remain on the hands and part of the

forearm (~2%). Treatment include dressings with aloe vera cream.

– This would be coded as CPT 16020.

Burns

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• Guidelines

– 11042-11047 are not used for debridement of burns

– 97597-97610 are not used for debridement/treatment of burns

– Only use 16000-16036 for debridement of burns

– Skin grafting for full-thickness or deep partial thickness second

degree burns are reported separately with 15100-15278

– 16000-16036 do not require skin grafting (CPT Assistant Oct. 2012)

– NCCI edits bundle 16000-16030 into the grafting codes

– NCCI edits do not bundle 16035-16036 with skin graft codes

Burns

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• What about full-thickness burns for skin grafting?

– First report skin preparation codes 15002-15005

– Second report appropriate code for the placement of the autograft,

flap, or skin substitute graft.

Burns

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• Requirements for Code Selection for Skin Replacement

Surgery (15002-15738)

– Type of Procedure*

• Surgical preparation, Autografts, Skin substitute grafts, flaps

– Location

• Trunk, arms, legs

• Face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or

multiple digits

– Size/Area

• Size in sq. cm. for adults or % infants and children

Burns

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• Type of Procedure may have additional requirements

– Surgical Preparation

• Location

• Size of the defect

• Sum size of all wounds from the anatomic sites that are grouped into the

same code descriptor

Burns

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– Autografts

• Include harvest and/or application of autologous skin graft

• Includes removal of current graft and/or simple cleansing of the wound

• Repair of donor site reported separately

• Do not report CPT 97602

• Code from 15040-15261

• Code based on type of autograft, location, and size of the defect



Burns

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– Skin substitute grafts

• Include non-autologous human skin, non-human skin, and biological products

that form scaffolding for skin growth

• Not for non-graft wound dressings or injected skin substitutes

• Do not report CPT 97602

• Code from 15271-15278

• Code based on location and size of the defect



• “The supply of skin substitute graft(s) should be reported separately in

conjunction with 15271-15278.” (CPT 2016)

Burns

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– Flaps

• Regions refer to recipient area not the donor for transfer or final site

• Regions refer to donor area when a tube is formed for later transfer or delay

of flap occurs prior to the transfer.

• “Codes 15732-15738 are described by donor site of the muscle,

myocutaneous, or fasciocutaneous flap.” (CPT 2016)

• Extensive immobilization not included in 15570-15738

Burns

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• Example 3:

– A 50-year-old female chemist received 3rd degree chemical burns in

the lab to her hands, face, and arms. The provider performs

surgical preparation for 50 sq. cm. wounds to the face and hands

with a surgical preparation for the 125 sq. cm. wounds on the arms.

The provider applies a xenograft to the surgically prepared defects.

175 sq. cm. of Mediskin was required.

– How is this coded?

Burns

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• Answer:

– 15004

– 15002 + 15003 x 1

– 15275 + 15276 x 1

– 15273 + 15274 x 1

– Q4135 x 175

– 15004, 15275, and 15276 are for the 50 sq. cm to the face & hands

– 15002, 15003, 15273, and 15274 are for the 125 sq. cm. arms

– Q4135 x 175 sq. cm. Mediskin

Burns

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• Active Wound Care Management (CPT 97597-97610)

– CPT 97597-97610 are for wounds other than burns

• CPT 97597-97598 are for debridement of the skin (epidermis and dermis)

• CPT 97602 is a Status B code on the Medicare Relative Value Unit Table

• CPT 15002-15005 can be used for Negative Pressure Wound Therapy (CPT

97605-97608)

– June 2005 CPT Assistant state these codes are for non-physicians

(Nurse Practitioners, Physician Assistants, Wound Care Nurses,

Physical Therapists, Enterostomal Therapy Nurses). Physicians

should use the surgical debridement codes 11042-11047.

Wounds

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• Surgical Preparation (CPT 15002-15004)

– Intended for wounds that are healing by primary intention.

– Negative Wound Therapy

– Do not use if wounds healed by secondary intention

• CPT 97597-97598

• CPT 11042-11047

• Selective Debridement (CPT 97597-97598)

– Based on total surface area of wound size

Wounds

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• Negative Pressure Wound Therapy (CPT 97605-97608)

– Based on total surface area of wound size

– Based on use of durable medical equipment (DME) or disposable,

non-durable medical equipment

• DME – CPT 97605-97606

• Disposable, non-durable medical equipment – CPT 97607-97608

– Do not report 97605-97606 with 97607-97608

– Dressings are not reported separately and are included in the

services performed

Wounds

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• Low Frequency Ultrasound (LFU) (CPT 97610)

– Used for various chronic wounds

– Used to help restore adequate blood flow

– Stimulates cells within and below the wound

– Not the same as selective debridement (CPT 97597-97598)

– Not the same as other PT services for ultrasound, infrared, or low

level laser (CPT 97035, 97026, or S8948)

– Sharp debridement, negative pressure wound therapy, and skin

substitutes may be performed before or after LFU and is reported

separately

Wounds

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Skin Deep

• Surgical Debridement (CPT 11042-11047)

– All wounds of the same depth treated by surgical debridement are

summed together and reported as one code

– Surgical debridement of wounds at different levels/depths are

reported separately with modifier 59.

– Reported based on the deepest level of a wound debrided even if

multiple levels of the same wound are debrided

• Example single wound debrided at the subcutaneous level and at the bone

would be reported based on the debridement of the bone

– Cannot be reported with Active Wound Care Management (CPT

97597-97602) for the same wound

Debridement

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• Surgical Debridement (CPT 11042-11047)

– Based on surface area and depth:

• Wound surface biofilm/epidermis/dermis

• Subcutaneous tissue

• Muscle or fascia

• Bone

– Wound surface for the epidermis and dermis are coded with CPT

97597-97598

– Measurement of the wound size is determined after the

debridement procedure occurred

Debridement

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• Other debridement services:

– Dermabrasions (CPT 15780-15783)

– Nail debridement (CPT 11720-11721)

– Burns (CPT 16000-16036)

– Pressure ulcers (CPT 15920-15999)

• CPT 15920-15999 requires excision

• If no excision, use CPT 97597-97598 or 11042-11047

Debridement

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Evaluation and Management Services

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E/M Distribution for New Patient Office Visits

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CMS Utilization Files 2012

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E/M Distribution for Est. Patient Office Visits

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E/M Distribution for Initial Hospital Visits

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E/M Distribution for Subsequent Hospital Visits

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• CMS Data most recent as of December 31, 2015

• Office Visits 99203 and 99213 most prevalent

• Hospital Visits 99222 and 99232 most prevalent

• Deviation from the prevailing norm increases risk of audits

and allegations of upcoding, fraud, abuse, overutilization,

medically unnecessary services

E/M Distribution

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• Established Problems

– What is the benefit of obtaining a past medical, family, or social

history?

– Will an extended or comprehensive examination change the

treatment plan?

– Is it likely that an extended or comprehensive examination will

produce any unanticipated changes in the patient’s condition?

Questions to Consider

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• Example:

– A 25-year-old female chemistry student returns to the clinic for

follow-up of superficial, partial thickness, second degree chemical

burns. Patient was last seen in this clinic a week earlier for the

initial treatment for these burns. The patient’s wounds are

continuing to heal as expected and is returning for an examination

of the scar tissue. A 10-point ROS was performed today with a

review of the patient’s past medical, family, and social history.

Exam of the blood flow, pulses, and nerves were normal. Minimal

scarring present. Patient is A&Ox3 and is in no apparent distress.

– Service is coded as a 99214.

Questions to Consider

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Skin Deep

• Type of wound (burns vs. non-burns)

• Depth of wound (epidermis, dermis, subcutaneous, muscle, fascia,

bone)

• Type of procedure (surgical, selective, non-selective, negative

pressure)

• Type of skin replacement (autografts vs. skin substitute grafts)

Summary

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• Centers for Medicare and Medicaid Services (CMS) Utilization Files

• EncoderPro

• 1997 Documentation Guidelines

• American Burn Association

• CPT Manual

References

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• AMA CPT Assistants:

– June 2005

– May 2011

– March 2012

– January 2012

– October 2012

– June 2014

– November 2014

References

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Questions??

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Picture obtained from WebMD

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Michael Strong, MSHCA, MBA, CPC, CEMC

Cell: (952) 838-4359

Email: [email protected]

Thank You!

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mike strong, sfm the work comp experts strong, sfm the work comp experts skin deep •burns...

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