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, works as a cook at a coffee shop. While she was at work, hot oil splashed onto her arm, burning from the elbow to the wrist on the medial aspect. Since the injury, 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 41-year-old female adult who is appropriate and cooperative. Overall, her only injury is to the right upper extremity. Specifically, 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. However, there is no circumferential burn, and I see no areas of deeper burn. In addition, the patient moves her hands well. Pulses are also good. Circulation to the hand is fine.
Diagnosis and Treatment
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 then 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. Then a burn dressing is applied with Neosporin ointment. The patient also receives Tylenol No. 3, tabs #4, to take home with her. She may take one or two every four hours p.r.n. for pain. She is to return tomorrow for a dressing change. Tetanus immunization is also up to date. In addition, she receives preprinted instructions. Finally, the 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, with a low level of medical decision making.
Rationale:
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Problem: Acute burn injury (first and second degree)
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Location: Right forearm from the elbow to the wrist
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No circumferential or deep burn
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In addition, treatment included wound care, medication management, dressing application, and discharge instructions
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Low medical decision making overall: prescription drug management is moderate risk, but the problem (acute uncomplicated injury) and the data reviewed are low
Therefore, 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:
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Specifically, second-degree (partial-thickness) burns are present
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No surgical debridement
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The provider applied a burn dressing with a topical antibiotic
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Area described (forearm only) = small TBSA (<5%)
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Also, no mention of extensive debridement or large surface area
Therefore, 16020 is appropriate.
Note that you do not code first-degree burns separately here. Instead, 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?
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Forearm specifically documented
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Second-degree present (highest severity documented)
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Right side specified
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Initial encounter (“A”)
First-Degree Portion (Not Coded Separately)
Do not report T22.111A (burn of first degree of right forearm) for this case.
Rationale:
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Both first- and second-degree burns were documented
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ICD-10-CM guideline: When burns of different degrees occur at the same site, code only the highest degree, so T22.211A covers the whole forearm burn
External Cause Code
X10.2XXA – Contact with fats and cooking oils, initial encounter
Rationale:
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Hot oil spill
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Required for workers’ compensation and injury reporting
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Initial encounter
Place of Occurrence
Y92.511 – Restaurant or cafe as the place of occurrence of the external cause
Rationale:
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Injury occurred at the place of employment, specifically a coffee shop
Activity Code
Y99.0 – Civilian activity done for income or pay
Rationale:
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Work-related injury
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Also required for Workers’ Compensation documentation
HCPCS Coding
Medication Provided to Take Home
No HCPCS code reported
Reason:
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Tylenol #3 tablets dispensed for take-home use rather than given in the ED
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Also, Medicare Part B generally does not cover self-administered take-home drugs
Demerol (Refused)
Not administered, so not coded.
Final Code Summary
CPT:
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99283
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16020
ICD-10-CM:
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T22.211A – 2nd degree burn right forearm
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X10.2XXA – Contact with hot oil
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Y92.511 – Coffee shop
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Y99.0 – Work-related activity
HCPCS:
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None applicable
Key Coding Tips for CPC Exam
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Code the highest degree burn first when multiple burns are present.
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For different burn depths at the same site, code only the highest degree.
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Always use the 7th character “A” while the patient receives active treatment.
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Also, workers’ comp requires external cause codes.
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Here, the first-degree burn is not coded separately because a higher-degree burn exists at the same site.
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Finally, burn treatment codes depend on depth and TBSA.
Medical Coding Wound Care
Medical Coding Debridement
American Society of Plastic Surgeons
American Society of Ophthalmic Plastic and Reconstructive Surgery
American Academy of Cosmetic Surgery
American Academy of Dermatology