Burn Coding: Calculate Total Body Surface Area (TBSA)

Investigate your physician’s documentation to determine the body area percentage actually debrided.

Question: My anesthesiologist administered anesthesia for a burn excision on the leg of a middle-aged adult male, but he didn’t give clear notes on the patient’s affected body surface area. How do I code for this?

Kansas Subscriber

Answer: You will start by coding 01952 (Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area [TBSA] treated during anesthesia and surgery; between 4 percent and 9 percent of total body surface area) and add +01953 ( . . . each additional 9 percent total body surface area or part thereof [List separately in addition to code for primary procedure]) as necessary.

Next, you’ll need to don your Sherlock Holmes hat. You’ll need find documentation of the patient’s affected total body surface area (TBSA). The attending surgeon typically …

documents the TBSA of the burn victim. The history and physical (H&P) portion of the surgeon’s documentation may have an anatomic chart showing the burn area. Alternately, you can call the surgeon’s office, and code based on what they are billing.

Physicians determine TBSA percentage using “The Rule of Nines.” To help determine the extent of burn wounds, doctors divide the body into 11 sections of 9 percent (99 percent) with the genitals adding the missing 1 percent. The sections break down as follows:

• front trunk = (2 X 9 percent) rear trunk = (2 X 9 percent)
• each arm = 9 percent (2 X 9 percent bilaterally)
• each leg = 9 percent in front, 9 percent on the back (4 X 9 percent)
• head = 9 percent (4.5 percent for the front and 4.5 percent for the back).

Note that the arms represent 4.5 percent on the anterior and 4.5 percent on the posterior. In contrast, each leg is 9 percent on the anterior and 9 percent on the posterior. Knowing these “rules” may help you decipher reports when coding for your anesthesiologist.

You can find the reference diagram in your CPT manual under code 16000 (Initial treatment, first degree burn, when no more than local treatment is required).

Important note: You should use +01953 as an add-on. A CPT parenthetical note dictates that you can’t skip 01951 (… less than 4% total body surface area) or 01952 just to get to the add-on code.

Educate your anesthesiologist to document the extent of the burn. As always, you should review CPT guidelines for the burn codes and check them against the anesthesia codes to be sure you are using the appropriate codes based on the percentage of the body that was actually debrided.

@ Anesthesia & Pain Management Coding Alert

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