Burn Wound Debridement
1602016025wRVU: 1.7 — Burn debridement, medium (5-10% TBSA)16030wRVU: 2.03 — Burn debridement, large (>10% TBSA or more than one extremity)
[Partial-thickness / full-thickness] burns, [X]% TBSA, [location]
Same
Burn wound debridement and dressing, [X]% TBSA, [location], day [X] post-injury
[Attending name], MD
[Resident / Nurse name]
[General endotracheal / IV sedation and analgesia]
Patient presents on [day X] post-[flame / scald / chemical / electrical] burn with [X]% TBSA [partial-thickness / full-thickness] burns involving [location]. [Wound requires debridement of devitalized tissue and dressing change under anesthesia given pain/extent.] [Wounds not yet ready for excision and grafting; dressing planned.] Consent [obtained / waived].
[Partial-thickness / full-thickness] burn wounds [X]% TBSA. [Blistered / de-epithelialized / eschar formation] noted at [location]. [Wound culture sent, results pending.] [Wound bed [healthy / infected / colonized].]
The patient was brought to the operating room [/ procedure room] and placed under [general / IV sedation]. The burn wounds were exposed and assessed.
Burn wounds debrided by removal of [loose / devitalized] tissue, blisters, and necrotic debris using [gauze / forceps and scissors / hydrosurgery unit (Versajet) at [X] setting]. [Superficial eschar removed with [gentle scrubbing / blade], viable dermis underlying.] Wound beds irrigated with normal saline.
Wounds covered with [Mepitel Ag / Mepilex Ag / Aquacel Ag / Xeroform / silver sulfadiazine cream (legacy; requires daily changes, impairs re-epithelialization)] followed by [ABD pads / elastic gauze wrap]. [Facial burns treated with [bacitracin / petrolatum gauze] and left open.]
Patient tolerated the procedure well.
None
[Wound culture swab sent / None]
Minimal
None
Patient returned to burn ICU / burn unit. Next wound assessment in [2-3] days.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Partial-thickness / full-thickness] burns, ***% TBSA, [location], day *** post-injury
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Burn wound debridement and dressing, ***% TBSA, [location]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General endotracheal / IV sedation]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX on day *** post-[flame / scald / chemical] burn with ***% TBSA [partial- / full-thickness] wounds. Debridement and dressing change under anesthesia indicated. Consent [obtained / waived].
FINDINGS: [Partial-thickness / full-thickness] wounds ***% TBSA. [Blistered / eschar / de-epithelialized] at [location]. Wound bed [healthy / infected]. [Culture sent.]
DESCRIPTION OF PROCEDURE:
Patient to [OR / procedure room]; [general / IV sedation]. Wounds exposed and assessed. Debridement of devitalized tissue, blisters, and necrotic debris with [gauze / Versajet at *** setting]. Wound beds irrigated with normal saline. Wounds dressed with [Mepitel Ag / Aquacel Ag / Xeroform] and ABD pads. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Wound culture sent / None]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to burn [ICU / unit]. Reassessment in 2-3 days.
Signed: .ME, .MYDEGREE
.TODAYVariants
Hydrosurgical debridement (Versajet)
Precise, low-trauma debridement using high-velocity waterjet. Useful for hands, face, and irregular surfaces. Document power setting and area treated. Same CPT codes apply.
Chemical/electrical burn
Chemical burns require copious irrigation before debridement. Electrical burns may have deceptively small surface area with deep tissue injury. Document wound appearance vs. mechanism mismatch.
Charting Tips
- Document TBSA debrided in the note (determines CPT selection)
- Note wound depth assessment at each session (superficial vs. deep partial vs. full thickness)
- Document dressing selection and rationale (antimicrobial, non-adherent, absorptive)
- Send wound cultures when infection suspected; document site and result
- Note day post-injury, as changes in wound depth at serial assessments guide excision timing
Billing Tips
- Bill 16020 for burn dressing or debridement, small (less than 5% TBSA, 0.69 wRVU, 0-day global). Bill 16025 for medium (e.g., whole face, whole extremity, or approximately 5% TBSA, 1.70 wRVU). Bill 16030 for large burns (more than one extremity or greater than 10% TBSA, 2.03 wRVU). These are standalone codes — 16030 is not a per-unit add-on. Document TBSA carefully, as it determines code selection.
- These codes apply to debridement and dressing change under anesthesia. Bedside dressing changes at a lower level of care (no anesthesia) are typically billed as wound management E/M. When anesthesia is used, bill the procedure code; anesthesia is billed separately by anesthesia.
- Initial burn wound evaluation and first dressing are included in the E/M for the admission day. Subsequent debridements under anesthesia use 16020-16030. Document each session separately with date, TBSA debrided, and dressing applied.
- 0-day global period: each debridement session is separately billable. Routine daily dressing changes by nursing staff are not surgeon procedure fees; they are facility charges. The surgeon's procedure fee applies when the surgeon personally performs or directly supervises the wound care session.
- Enzymatic debridement with NexoBrid (anacaulase-bcdb, FDA-approved 2022) is billed with Category III codes 0973T (selective enzymatic debridement, first 20 sq cm, requiring anesthesia) and 0975T (each additional 20 sq cm). These replaced the previous practice of using unlisted code 16999. CPT 97602 (non-selective debridement, no anesthesia) is NOT appropriate for NexoBrid. Prior authorization is typically required. Document agent, concentration, application time, and area treated.
General coding reference. Verify with your institution’s billing department before submitting claims.