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March 22, 2004
Coding
for Burns
Vol. 16 No. 6 p. 42
Burns are classified to ICD-9-CM category codes
940 to 949, which include burns from electrical heating appliances,
electricity, flames, hot objects, lightning, radiation, chemical
burns, and scalds. The specific code assignment will depend on the
site and depth of the burn.
Degrees of Burns
The following is a summary of the degrees of burns, which are identified
by the fourth-digit subcategory in ICD-9-CM:
• A first-degree burn is the least serious. Only the outer
layer of skin (epidermis) is burned, but not burned completely through.
The skin is red (erythema), with swelling and pain sometimes present.
• A second-degree burn involves the first layer of skin and
into the second layer of skin (dermis). Blisters develop and the
skin takes on an intensely reddened, splotchy appearance. It will
also cause severe pain and swelling. There are two types of second-degree
burns, which include superficial partial-thickness and deep partial-thickness
burns.
• A third-degree burn involves all layers of the skin (full
thickness skin loss) and the tissue under the skin. Fat, muscle,
and even bone may be involved, which may be documented as fourth-degree.
Third-degree burns are painless and may appear as charred black
or dry and white. They may also be accompanied by smoke inhalation.
ICD-9-CM has separated third-degree burns at the fourth-digit subcategory
to classify not otherwise specified, without mention of loss of
a body part, and with loss of a body part.
Causes of Burns
The following are common causes of burns:
• heat burns (thermal burns), such as fire, steam hot objects,
or hot liquids;
• electrical burns, which include contact with electrical
sources or lightning;
• chemical burns, such as contact with household or industrial
chemicals in a liquid, solid, or gas form;
• radiation burns caused by sun, tanning booths, sunlamps,
x-rays, or radiation therapy for cancer treatment; and
• friction burns, which include contact with any hard surface,
such as roads, carpets, or a gym floor surface. They involve both
abrasion or heat burn.
Most burns are classified to categories 940 to 949.
However, the following types of burns are classified elsewhere:
• Sunburn (692.71, 692.76, 692.77)
• Friction burns (go to superficial injury by site; 910 to
919 with 0.0 or 0.1 as fourth digit)
• Burn secondary to a tanning bed (692.82)
Coding Guidelines for Burns
The following is a summary of the coding guidelines for burns as
listed in AHA Coding Clinic for ICD-9-CM, 2002, fourth quarter,
pages 149 to 154:
• If more than one burn is present, sequence the highest-degree
of burn first. Therefore, if a patient had a third-degree burn of
the leg and a second-degree burn of the arm, the third-degree burn
of the leg would be sequenced first.
• Code only the highest degree burn with burns of the same
site (coded to the same category code) but different degrees. Therefore,
if a patient had a first- and second-degree burn of the arm, assign
only a code for the second-degree burn.
• Code nonhealing burns or necrosis of burned skin as acute
burns by site and degree.
• Any infected burns would be classified to code 958.3, Posttraumatic
wound infection, which would be sequenced as a secondary diagnosis.
• Multiple three-digit category codes should be assigned if
the burn is of documented specified multiple sites. If the physician
does not document the burn sites, assign a code from category 946.
• Treatment of late effects of burns should be coded to the
residual condition (such as scars or contractures) followed by the
appropriate late effect of burn code (906.5 to 906.9).
• Late effects and current burn codes may be used on the same
record, if appropriate.
Category 948
A code from category 948, Burns classified according to extent of
body surface involved, may be sequenced as the principal diagnosis
when the site of the burn is not specified. However, coders are
instructed to code the site of the burn first, when known. It can
also be sequenced as a secondary diagnosis to provide additional
information on the extent of body surface burned and what amount
was third-degree.
In category 948, the fourth-digit subcategory classifies
the percent of total body surface area burned and represents all
degrees. The fifth-digit subclassification classifies the percentage
of the body surface area burned that was third-degree. Only the
percentage of third-degree burns is identified in the fifth-digit
subclassification. It is the physician’s responsibility to
document the total body surface area burned and what percentage
is third-degree.
It is important to assign a code from category 948
as either the principal diagnosis or more frequently as the secondary
diagnosis because it could make a difference between diagnosis-related
group (DRG) assignments.
DRG Classifications for Burns
The DRG classifications for burns are based mainly on the following:
• Extensive — burns with a total body surface area burned
of greater than 20% with greater than 10% of third-degree
• Full-thickness — other third-degree burns that do
not qualify as extensive or nonextensive
• Nonextensive — first-degree or second-degree burns
of specified body sites. Also includes unspecified sites with less
than 10% total body surface area being third-degree (948.x0).
A code from category 948 will determine whether
the burn is extensive or nonextensive and will drive the DRG assignment
if sequenced as either the principal diagnosis or secondary diagnosis.
Other aspects that determine the DRG assignment
include the presence or absence of a significant trauma, inhalation
injury, including respiratory failure, complication or comorbidity,
or skin graft procedure. The only set of procedures that will affect
DRG assignment for burns is skin graft procedures. Excisional debridement
(86.22) will no longer affect DRG assignment.
Coding and sequencing for burns are dependent upon
the physician documentation in the medical record and application
of the Official Coding Guidelines for inpatient care. Also, use
specific AHA Coding Clinic for ICD-9-CM and American
Medical Association CPT Assistant references to ensure
complete and accurate coding.
— This information was prepared by Audrey
Howard, RHIA, of 3M Health Information Systems (800-367-2447), a
leading supplier of coding and classification systems to nearly
4,000 healthcare providers. The company and its representatives
do not assume any responsibility for reimbursement decisions or
claims denials made by providers or payers as the result of the
misuse of this coding information.
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