How to Dx More Than One Severity Level on Your Medical Billing Claim

Example: a patient presents with both first and second degree burns on their face.

You should report only the more severe (in this case second degree) burns when assigning diagnoses for burns in the same anatomical location. For example, the codes beginning with 941 describe the face, head and neck burns. For burns to the trunk, you would use the 942 series, and codes 943, 944, and 945 are for burns to the arms, hands, and legs, respectively.

Remember that you should never report a first degree burn separately with the 941-946 series if there are more severe burns on any other part of the body, except when treatment is specifically directed at the first degree burn.

You must indicate the severity of a burn by assigning a fourth digit attached to the 941-946 codes. 0 is unspecified degree, 1 is Erythema, or first degree, 2 is blisters, epidermal loss, or second degree, 3 is dull thickness skin loss, or third degree NOS, 4 is deep necrosis of underlying tissue without mention of loss of a body part, and 5 is with loss of a body part. In this particular case, report 941 (which is for face) with a fourth digit of 2 (which is for second degree burns).

When reporting the 941-946, you must also assign a fifth number to describe the specific location of a burn within a body area. For example, you would use a fifth digit of one when applied to 941, to describe the ear. Higher degree burns take precedence over lesser degree burns in the same area.

View all Articles by: Melissa Clark, CCS-P