2025 CPT code 16036
(Active) Effective Date: N/A Surgery - Burns, Local Treatment Surgery/Integumentary System Feed
Each additional escharotomy incision performed during the same surgical session.It is reported in addition to the primary escharotomy incision (16035).
Modifiers, such as 22 (Increased Procedural Services), 50 (Bilateral Procedure), or 76, 77, 78 (Repeat procedure), might be applicable in certain circumstances.
Medical necessity for escharotomy is established when there is evidence of compromised circulation or respiratory function due to constricting eschar from deep burns. The additional incisions (16036) must also be medically necessary to fully relieve the pressure and restore blood flow, or improve breathing if the burn is circumferential on the chest.
The physician performs additional incisions through the eschar to the level of the deep fascia, taking care not to damage major nerves.Hemostasis is achieved following the incision(s).
In simple words: If a severe burn causes the skin to tighten and restrict blood flow, a doctor may need to make several cuts to relieve the pressure.This code covers each cut after the first one.
This code describes each additional incision made during an escharotomy procedure beyond the initial incision. An escharotomy is a surgical procedure where incisions are made through burned skin (eschar) to relieve pressure caused by the tightening of the skin due to swelling from the burn. This pressure can impair blood flow to the affected tissues and underlying structures.This code is used for each additional incision made during the same procedure, and it is always reported in addition to the primary procedure code for the initial escharotomy incision (16035).
Example 1: A patient presents with a circumferential third-degree burn to the forearm. The physician performs an initial escharotomy incision (16035) and then makes two additional incisions (16036) to fully relieve the pressure and restore blood flow., A patient has deep burns on their leg and chest. The physician performs an escharotomy on the leg (16035) with one additional incision on the leg (16036). A separate escharotomy on the chest is also done (16035) with three additional incisions on the chest (16036) to adequately decompress the area., A child with a circumferential burn to the torso requires multiple escharotomies. After the initial incision (16035), the physician makes four additional incisions (16036) due to the extent of the burn and the need for complete pressure relief.
Documentation should include the location, depth, and extent (percentage of body surface area) of the burn, the number and location of escharotomy incisions performed, and the reason for the additional incisions. Operative report should document the depth of the incision.
** It's crucial to distinguish between debridement of burns (16020-16030) and escharotomy. Escharotomy is performed to relieve pressure, while debridement involves removal of dead tissue. Modifier 59 may be appropriate when reporting other distinct procedures performed in conjunction with escharotomy, like debridement or fasciotomy, to indicate that it is separate from the escharotomy.
- Revenue Code: P6A (MINOR PROCEDURES - SKIN)
- Payment Status: Active
- Specialties:Burn Surgery, Critical Care, Emergency Medicine, Plastic Surgery, Trauma Surgery
- Place of Service:Inpatient Hospital, Emergency Room - Hospital,Ambulatory Surgical Center, Military Treatment Facility