2025 ICD-10-CM code T31
Burns classified according to extent of body surface involved. This category is to be used as the primary code only when the site of the burn is unspecified. It should be used as a supplementary code with categories T20-T25 when the site is specified.
Medical necessity for the use of T31 is established by the presence of burns. The percentage of BSA involvement and depth of the burn are used to determine the severity of the injury and guide treatment decisions, which impacts medical necessity.
The clinician is responsible for assessing the burn's extent using the rule of nines or Lund and Browder chart, and documenting the percentage of body surface area (BSA) affected.They must also document the depth of the burn (first, second, third, or fourth degree), the cause of the burn, and any other relevant details like associated injuries.
- 19
- Injury, poisoning and certain other consequences of external causes (T07-T88), Burns and corrosions (T20-T32)
In simple words: This code describes the extent of burns based on the percentage of the body surface affected.It is used when the doctor doesn't know the exact location of the burns or in addition to codes describing the location, to record how much of the body was burned.
Burns classified according to extent of body surface involved. This code is primarily used when the specific location of the burn is unknown.When the burn site is known, T31 should be used as a supplementary code in conjunction with codes T20-T25 to specify the location.
Example 1: A patient arrives at the emergency room with burns covering their entire back, but the exact location of burns on the back are not specified.The burn is assessed to cover approximately 18% BSA.The code T31.1 would be used., A patient is admitted with burns on their arms and legs sustained in a house fire. The arms are coded with T22 (burns of shoulder and upper limb, except wrist and hand), and the legs are coded with T24 (burns of lower limb, except ankle and foot).The total BSA affected is estimated at 40%, so T31.7 is used as an additional code to capture the overall extent., A patient has chemical burns due to industrial accident on their face (T20), neck (T21), and chest (T21). Since the site of the burn is specified, codes T20, T21 are used primarily. The total BSA affected is 12%, thus T31.1 is used as a supplementary code.
Documentation must include the total percentage of body surface area burned, the depth of the burn (e.g., first-degree, second-degree, third-degree), the cause of the burn, and the location of the burn. If the location is unspecified, the documentation must support why it is not possible to determine it.
** For burns that involve multiple body sites, ensure the codes T20-T29 are also used for each specific body area.Do not assign a burn code if the only documentation available refers to a "blister" or an "area of redness". Blisters and redness can be a sign of a first-degree burn, but are not always indicative of one. Specific descriptions of burn characteristics must be present to code as a burn.
- Specialties:Emergency Medicine, Burn Specialists, Critical Care, General Surgery, Plastic Surgery
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Outpatient Hospital, Military Treatment Facility