February 19, 2026

Medical Coding “clarified” Burn ED Visit

AAPC | Certification | Certified Medical Coder | CPC | Medical Coding

By Janine Mothershed

Burn

Medical Specialty: General Medicine

Description: First-degree and second-degree burns, right arm secondary to hot oil spill – Workers’ Compensation industrial injury.

CHIEF COMPLAINT: Burn, right arm.

HISTORY OF PRESENT ILLNESS: This is a Workers’ Compensation injury. This patient, a 41-year-old woman, was at a coffee shop, where she works as a cook, and hot oil splashed onto her arm, burning from the elbow to the wrist on the medial aspect. She has had it cooled and presents with her friend to the Emergency Department for care.

PAST MEDICAL HISTORY: Noncontributory.

MEDICATIONS: None.

ALLERGIES: None.

PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished 21-year-old female adult who is appropriate and cooperative. Her only injury is to the right upper extremity. There are first and second-degree burns on the right forearm, ranging from the elbow to the wrist. Second-degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves her hands well. Pulses are good. Circulation to the hand is fine.

FINAL DIAGNOSIS:
1. First-degree and second-degree burns, right arm secondary to hot oil spill.
2. Workers’ Compensation industrial injury.

TREATMENT: The wound is cooled and cleansed with soaking in an antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but she refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with her and take one or two every four hours p.r.n. for pain. She is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers’ Compensation first report and work status report are completed.

DISPOSITION: Home.

CPT Coding

Evaluation & Management (ED Visit)

CPT: 99283 – Emergency department visit for the evaluation and management of a patient, moderate level.

Rationale:

Problem: Acute burn injury (first and second degree)
Location: Right forearm from the elbow to the wrist
No circumferential or deep burn
Treatment included wound care, medication management, dressing application, and discharge instructions
Moderate medical decision-making (acute injury with treatment and prescription medication given)

This supports 99283.

Burn Treatment

CPT: 16020 – Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)

Rationale:

Second-degree (partial-thickness) burns present
No surgical debridement
Burn dressing is applied with a topical antibiotic
Area described (forearm only) = small TBSA (<5%)
No mention of extensive debridement or large surface area

Therefore, 16020 is appropriate.

Note: First-degree burns are not separately coded. The highest degree (second-degree) determines coding.

ICD-10-CM Diagnosis Coding

Primary Burn Code

T22.211A – Burn of second degree of right forearm, initial encounter

Why this code?

Forearm specifically documented
Second-degree present (highest severity documented)
Right side specified
Initial encounter (“A”)

Additional Burn Code (First-degree portion)

T22.111A – Burn of first degree of right forearm, initial encounter

Rationale:

Both first- and second-degree burns were documented
ICD-10-CM guideline: When multiple burn depths occur in the same site, assign separate codes for each depth

External Cause Code

X10.2XXA – Contact with hot cooking oils and fats, initial encounter

Rationale:

Hot oil spill
Required for workers’ compensation and injury reporting
Initial encounter

Place of Occurrence

Y92.511 – Coffee shop as place of occurrence

Rationale:

Injury occurred at place of employment (coffee shop)

Activity Code

Y99.0 – Civilian activity done for income or pay

Rationale:

Work-related injury
Required for Workers’ Compensation documentation

HCPCS Coding

Medication Provided to Take Home

No HCPCS code reported

Reason:

Tylenol #3 prescription written for take-home use
Outpatient ED prescriptions are not separately billable to Medicare under HCPCS

Demerol (Refused)

Not administered → not coded.

Final Code Summary

CPT:

99283
16020

ICD-10-CM:

T22.211A – 2nd degree burn right forearm
T22.111A – 1st degree burn right forearm
X10.2XXA – Contact with hot oil
Y92.511 – Coffee shop
Y99.0 – Work-related activity

HCPCS:

None applicable

Key Coding Tips for CPC Exam

Code the highest degree burn first.
Assign separate codes for different burn depths at the same site.
Always use the 7th character “A” for active treatment.
External cause codes are required for workers’ comp.
First-degree burns alone are often not reported, but here they are reported because a higher-degree burn exists at the same site.
Burn treatment codes are based on depth and TBSA.