CPT 2014 incorporates a major update for coding local
treatment of burns (16000-+16036) and skin grafting used for burn care (15100-
+15157). Although the codes and descriptors are unchanged, a newly applied
classification system affects how you’ll calculate the percentage of the body
treated. This, in turn, may change how you apply the codes in a particular
situation.
Rules of Nines
Codes to report local treatment of burns, and many skin
grafting procedure codes, specify the total body surface area (TBSA) treated. For
example, 16020 describes, “Dressing and/or debridement of partial-thickness
burns, initial or subsequent; small (less than 5% total body surface area).”
Similarly, 15115 specifies, “Epidermal autograft, face, scalp, eyelids, mouth,
neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100
sq cm or less, or 1% of body area of infants and children” [emphasis added in
both descriptors]. In previous years, TBSA was calculated using the so-called
“rule of nines” for adult patients, which assigned 1 percent of TBSA to the
genitalia, and multiples of 9 percent to other body areas (e.g., 9 percent
head, 9 percent per arm, 18 percent per leg, etc.). A modified rule of nines
was applied for infants, to account for their relatively larger head (18
percent) and smaller legs (14 percent, each). For 2014, CPT scraps the rule of
nines in favor of the more precise Lund-Browder classification method. This
method is not itself new, but this is the first time it’s being used in CPT to
calculate TBSA for burns and grafts. Whereas the rule of nines cites only
general body areas (head, trunkfront, trunk-back, arms, legs, and genitalia),
Lund-Browder divides the body into nearly 20 distinct areas, including neck,
left and right buttocks, left and right hand, upper and lower arm, etc.
LundBrowder specifies six age groups (rather than just adult and infant) to
account for changes in body makeup as individuals develop into adulthood.
Collectively, these changes allow for more accurate calculation of the TBSA affected
and, potentially, more exact coding.
Calculation
CPT guidelines require the provider to document both the
percentage of body surface involved and the depth of burn. Looking at chart,
you can quickly determine that a 6-year-old child with second-degree burns to
the anterior trunk, left upper and lower arm, and left hand would have an estimated
burn area of 22.5 percent TBSA (13 anterior trunk + 4 upper left arm + 3 lower
left arm + 2.5 left hand = 22.5).
Tip: The above percentages would work out the same for a
patient of any age. As with the rule of nines, TBSA discrepancies by patient
age occur only in the head (from a high of 19 percent for patients less than 1
year old, to a low of 7 percent for adults) and thighs/legs.
Presently, the Lund-Browder classification method applies
only to CPT coding. ICD-9-CM continues to rely on the rule of nines when
calculating TBSA, such as when assigning a code from category 948 Burns
classified according to extent of body surface involved. The ICD-10-CM Official
Guidelines for Coding and Reporting likewise states: “Categories
[Burns classified
according to extent of body surface involved] and T32 [Corrosions classified
according to extent of body surface involved] are based on the classic ‘rule of
nines’ in estimating body surface involved.” But the guidelines do provide
leniency by saying, “Providers may change these percentage assignments where
necessary to accommodate infants and children who have proportionately larger
heads than adults, and patients who have large buttocks, thighs, or abdomen
that involve burns.”
