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Reader Question: Measure the Wound for Burns

Question: A patient presented with second-degree burns to his thigh and wrist. The physician debrided the wound without anesthesia, and there was no mention of size or depth in her notes. Should I report 16020 for this? If so, should I charge 16020 twice - once for each body part?

Connecticut Subscriber

Answer: Question the physician to determine the extent of the dressing, because you have three codes to choose from, and they all depend on the size of the burn: 16020 (Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small), 16025 (... without anesthesia, medium [e.g., whole face or whole extremity]), and 16030 (... without anesthesia, large [e.g., more than one extremity]).

Regardless of which burn treatment code you report, you shouldn't charge it twice or append a modifier. The codes for dressings of larger wounds include the dressing of smaller wounds.