A patient presents for evaluation of wounds that have been there for approximately 3 weeks. The wounds are described as “non healing (graft failure) secondary to burn from electrocution.” The patient underwent a severe electrical shock, which subsequently resulted in the loss of his right lower arm and an above the knee amputation on the right, extensive burns and deformity to the left hand and arm, as well as extensive burns and deformity to the left foot. The wounds on the left foot have developed in an area where previous skin grafts had been performed.
During the present encounter, the wound on the left medial foot was debrided using a disposable #15 scalpel blade, removing devitalized tissue in the epidermal and dermal layers for an area measuring 2.6 square cm.
The wound of the left lateral foot was debrided using a disposable #15 scalpel, removing devitalized tissue from the epidermal and dermal layers for an area measuring 5.16 square cm and lastly, the wound on the dorsal surface of the left foot, debridement was performed, removing devitalized tissue from the epidermal and dermal layers using a disposable #15 scalpel blade for an area of 2.4 square cm.
Is it appropriate to report the services provided as burn treatment or surgical debridement?
We have always noted “once a burn always a burn” that is treated, however, that may not be the case every time and we would like clarification to help us decide if burn care would be reported in the Wound Care Clinic over surgical debridement in the above case.
Based on the documentation submitted, report CPT code 16020, Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area), for debridement of the burns, both acute and chronic, which have not completely healed. CPT codes 16020-16030 describe the application and change of dressings for second-degree burn wounds, which also include any associated debridement or curettage.
Other debridement codes in the CPT code set should not be reported to describe debridement of burn wounds.
If the wounds debrided are on previously healed skin grafts, then it would be appropriate to report CPT code 97597, Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wounds(s) surface area; first 20 sq. cm or less, for the procedure performed.
You may wish to further clarify the nature of the wounds with the physician.