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2025 CPT code 16000

Initial treatment of a first-degree burn, when no more than local treatment is required.

Use this code only for first-degree burns requiring local treatment. For deeper or more extensive burns, use the appropriate codes.This code includes application of materials (like dressings). Do not report separately for services like evaluation and management unless clearly distinct and medically necessary.

Medical necessity is established by the presence of a first-degree burn requiring medical attention. The documentation should clearly support the diagnosis and treatment provided.

The clinician assesses the burn, cleanses it with cool water or a mild disinfectant, and may apply a topical ointment or dressing.Pain management is also considered.

In simple words: This code covers the basic treatment of a mild burn, like a sunburn, where only the outer skin layer is affected. It involves cleaning the burn, cooling it down, and applying a dressing or ointment.

This code describes the initial treatment of a first-degree burn (superficial burn) that involves only the epidermis (outer layer of skin).It encompasses local treatments such as cleaning, cooling, and applying dressings or topical agents. It does not include skin grafting, surgical debridement, or treatment of deeper burns.

Example 1: A patient presents with a mild sunburn after spending a day at the beach. The physician cleanses the area and applies aloe vera gel., A child briefly touches a hot stove and sustains a small, superficial burn on their hand. The burn is cooled with water and covered with a sterile dressing., A patient experiences a first-degree burn from a brief exposure to steam. The area is cleaned and antibiotic ointment is applied.

Documentation should include the size and location of the burn, the cause of the burn, the depth of the burn (specified as first-degree), and the treatment provided.

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