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Official Description

Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 16030 refers to the medical procedure involving the treatment of large partial-thickness burns, which may encompass more than one extremity or exceed ten percent of the total body surface area (TBSA). This procedure includes both the debridement of damaged tissue and the application of dressings to promote healing. Partial-thickness burns are characterized by injury to the epidermis, which is the outer layer of skin, as well as the dermis, the deeper layer beneath it. The physician begins by assessing the burn area and inquiring about the cause of the injury to gather relevant clinical information. Following this assessment, the affected area is cleansed with an antiseptic solution to reduce the risk of infection, and any foreign materials present are meticulously removed. Additionally, any necrotic or damaged tissue is debrided to facilitate the healing process. After the necessary cleaning and debridement, a soothing cream may be applied to alleviate discomfort, and the burn is subsequently covered with a sterile dressing to protect it from external contaminants. This code is specifically designated for larger burns, distinguishing it from codes for smaller burns, which are classified based on the extent of TBSA involved.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 16030 is indicated for the treatment of large partial-thickness burns. These burns may present under the following conditions:

  • Multiple Extremities Affected The procedure is indicated when burns affect more than one extremity, necessitating comprehensive treatment to manage the injuries effectively.
  • Exceeding 10% Total Body Surface Area The procedure is also indicated for burns that cover more than ten percent of the total body surface area, which requires specialized care to ensure proper healing and minimize complications.

2. Procedure

The procedure for CPT® Code 16030 involves several critical steps to ensure effective treatment of large partial-thickness burns:

  • Assessment of the Burn Area The physician begins by thoroughly examining the burn area to evaluate the extent of the injury. This assessment includes determining the depth of the burn and the total body surface area affected. The physician also queries the patient regarding the cause of the burn to gather pertinent clinical information that may influence treatment decisions.
  • Cleansing the Burn Area Following the assessment, the burn area is cleansed using an antiseptic solution. This step is crucial to reduce the risk of infection and prepare the area for further treatment. The cleansing process may involve gentle washing to remove any debris or contaminants that could impede healing.
  • Debridement of Damaged Tissue After cleansing, the physician performs debridement, which involves the careful removal of dead or damaged tissue from the burn site. This step is essential to promote healing and prevent infection, as necrotic tissue can harbor bacteria and delay recovery.
  • Application of Soothing Cream Once debridement is complete, a soothing cream may be applied to the affected area. This cream helps to alleviate pain and discomfort associated with the burn, providing relief to the patient.
  • Covering with a Sterile Dressing Finally, the burn area is covered with a sterile dressing. This dressing serves to protect the burn from external contaminants, supports the healing process, and helps to maintain a moist environment conducive to recovery.

3. Post-Procedure

Post-procedure care for patients treated under CPT® Code 16030 includes monitoring the burn site for signs of infection, such as increased redness, swelling, or discharge. Patients are typically advised on how to care for the dressing and when to seek further medical attention. Follow-up appointments may be necessary to assess healing progress and to perform additional debridement or dressing changes as required. Patients should also be educated on pain management strategies and the importance of keeping the burn area clean and protected during the recovery period.

Short Descr DRESS/DEBRID P-THICK BURN L
Medium Descr DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE
Long Descr Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area)
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6A - Minor procedures - skin
MUE 1
CCS Clinical Classification 169 - Debridement of wound, infection or burn
GC This service has been performed in part by a resident under the direction of a teaching physician
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
AG Primary physician
CR Catastrophe/disaster related
FT Unrelated evaluation and management (e/m) visit on the same day as another e/m visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (report when an e/m visit is furnished within the global period but is unrelated, or when one or more additional e/m visits furnished on the same day are unrelated)
GA Waiver of liability statement issued as required by payer policy, individual case
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
SA Nurse practitioner rendering service in collaboration with a physician
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2011-01-01 Changed Short description changed.
2010-01-01 Changed Code description changed.
2006-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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