tci General Surgery Coding Alert - 2007 Issue 7

Reader Questions: Burn Severity Is Important to Dx Accuracy

Question: I know that it's important to know a burn's severity when assigning a diagnosis code, but how should  we determine this information? Massachusetts Subscriber Answer: When dealing with burns, physicians and coders have to work especially closely to ensure that the selected diagnosis accurately reflects the patient's condition.Above all, this means that physicians must thoroughly document the burn's location(s), extent and severity. All the information you need should be included in the operative report. If it's not, you should ask the documenting physician for additional details, informing him of the importance of complete documentation when assigning burn...

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