Extremities FAQs

Q: How would you code the following injury; small intraventricular hemorrhage in the third and fourth ventricles with associated obstructive hydrocephalus?

A: The only codes for intraventricular hemorrhage are located within the cerebrum chapter of the dictionary and are listed on page 48 of your dictionary, but the answer will depend upon whether the patient is unconscious. As you can see there are 3 separate codes and if you patient was unconscious for > than 6 hours you would use the code 140677.4. Remember though you can only apply this coma modifier one time when you are coding your injuries. This will change in the 2015 dictionary and you will code the coma with each injury. We have no code for the obstructive hydrocephalus which is a consequence of the hemorrhage, and a sequela that cannot be coded.

Q: How do you code a large abdominal wall hernia on the R side of the abdomen (NOT the Rectus Abdominus muscle) with a 15 cm fascial defect that required open operative management to close. The skin was intact. This was a seatbelt injury in a 12 yr old.

A: This should be coded as 510602.1. This is a “skin” code (assigned to the External ISS body region) and includes subcutaneous and muscle lacerations or tears. Although the outer skin was intact, clearly there was damage below the surface. I realize this seems quite low in severity for an injury that was clearly complex, but it”s the best AIS has to offer.

Q: Scenario: Man falls from a ladder while trimming a tree striking the upright post of a mental fence before impact on the ground. 1. Deep 18cm laceration across the abdomen with obvious evisceration of bowel. Exploratory Lap report only describes a 2. serosal tear at the junction of the duodenum and jejunum with a small hematoma. How would you code these injuries?

A: Cannot code evisceration, code the abdomianl laceration as minor laceraton < 20 cm 510602.1, code serosal tear assign to jejunum as partial thickness injry 541422.2 hematoma is part of this injury, Lis Franc injury is a dislocation of tarsometatarsal joints with no mention of fracture, cartilage involvement or ligament injury so code 878030.1

Q: Pedestrain struck by vehicle who expires 10 minutes after arrival in ED. No CTs taken. Medical Examiner report: fracture dislocation at C1/C2. Cause of death blunt cervico spinal trauma. Trauma sheets have Trauma Surgeon documentation: 1. Crepitus R femur mid shaft, 2. Obvious open fracture L femur midshaft 3. Distinct crepitus ribs R side 1-6 4. Multiple lacerations/abrasions over back and flank 5. Crepitus and abnormal alignment cervical spine appears to be dislocation with fracture

A: 1. There is nomention of spinal cord injury at all so that cannot be coded even through it is very likely. It appears the cervical injury may be the cause of expiration but there is always the possibility of internal injury not mentioned and an abbreviated examination due to the mechanism. We cannot presume there is cord injury based on the documentation present.

We must code conservatively based on what we do know.

Code 650216.2. Fracture with or without dislocation no cord involvement NFS.

Why would we not use the box directions to code specific for C1? We have no description at all as to what part of C1 is fractured or if there are multiple fractures. The same is true for C2. In the case of fracture dislocation you code once to the superior vertebrae involved.

2. Crepitus R ribs 1-6 here there is a minimal Med Examiner report that is hardly complete so we can use the AIS guidelines to code these rib fractures based on clinical observation since the patient did expire. code 450210.2 (See the boxed rule p.82)

Note: Normally you are not to code fractures without radiological evidence but in this case it was appropriate to code based on the very obvious clinical evidence of extremity fracture and expiration precluding any diagnostics. You would use a NFS code since you don’t have radiological evidence to “place” the fracture location.

3. Crepitus R femur NFS-830001.3
4. Open fracture mid shaft L femur-8532223 (you can see this location)
5. Multiple lacerations/abrasions over back and flank: Two ISS body regions are included here since the flank is included in the abdomen body region and AIS directions encourage coding in the correct body chapter but assigning superficial injury to the external ISS body region.

Laceration back-410600.1 we know no specifics about the lacerations so use the NFS code.

Flank-510600.1 we use the NFS code.

You may assume the abrasions and lacerations are in the very same location with the laceration as the deepest part of the injury but it would be an assumption. Since the trauma sheets state abrasions without location you can also code the abrasions in each region they occur as you did the lacerations. Abrasions thorax 410202.1 Abdomen 510202.1.

Both the lacerations and abrasions could each be coded with one external body region code as multiple injury without specific location 910200.1 and 910600.1. The ISS will be the same either way these superficial injuries are coded.

Q: A motorcyclist crashes and sustains 15 % partial and full thickness “œroad rash” in addition to multiple lower extremity fractures. Following operative treatment of his fractures he is transferred to the Burn Unit for management of his skin injuries. How should the skin injuries be coded?

A: Although the skin injuries are being described in terms usually used for burns, the correct codes to use are the abrasion codes. If you know the precise location of the abrasions, we recommend using the Whole Area abrasion codes in each chapter. The code 9xxxxx.1 for multiple abrasions found in the External and Other Trauma chapter is also appropriate.

Q: A patient sustains a basilar skull fracture, fractured L zygoma and a nasal fracture. She has bilateral periorbital ecchymosis. There is no mention in the chart of cerebral spinal fluid (CSF) leak. How would you code the basilar skull fracture?

A: The correct code is 150202.3. If the patient has a CSF leak, the treating physician(s) will always mention it in the chart. When there is no mention of CSF leak, the coder may use the “without CSF leak” code. The periorbital ecchymosis could be due to the nasal fracture and is not necessarily a sign of bleeding from the base fracture.

Q: The autopsy describes the following injuries from blunt trauma to the chest: “There is a 6 inch by 12 inch open wound below the left axilla with portions of the left chest missing, with underlying multiple left rib fractures and portions of ribs 3-8 missing.” How should these be coded?

A: Thanks to everyone who participated this month. Roberta, Jo and Paula all had interesting answers. The answer we were looking for is 451022.5. This is a new code in AIS 2005. Since this is only described as a chest injury we cannot use the “Whole body (explosion-type) injury” code. As for figuring the percentage of the chest involved, I envision the front and back portions as 50% each, and one half of the front to be 25%. With 6 ribs missing and such a large injury described, it seems reasonable to use the “major, > 15% of chest wall including rib cage”.

Q: The patient’s injury is described as a ‘fractured’ larynx. What is the correct code?

A: Thanks to Abbie, Jo and Hideo for participating in this month”s question. The correct code to use for this injury description is 340208.3. If the larynx is described as “crushed” the code 340212.5 would be appropriate.
Because this is a relatively common description for some laryngeal injuries, we are adding the word “fracture” to this descriptor in the AIS dictionary. Watch for a notice that the AIS 2005, Update 2008 is available. This update will include the long awaited FCI codes, some new codes and descriptors, and further clarification of some coding rules and guidelines.

Q: A patient with diffuse axonal injury (DAI), confirmed by both clinical and radiologic evidence, also has an intraventricular hemorrhage and subarachnoid hemorrhages. This patient remained unconscious from the time of the insult until discharge from the ICU 7 days after admission. How would you code the intraventricular hemorrhage and subarachnoid hemorrhages in AIS 2005?

A: These injuries should not be coded. DAI is an example of a global injury which may or may not be accompanied by other radiologic findings. A clarification for coding DAI is now included on page 40 in the Updated Pages found at www.aaam1.org/ais .

Q: The patient ingested Draino and Tilex and has a mild caustic injury to the take-off of the LUL and LLL of the respiratory system. Patient also has a grade II injury (friable) to the esophagus and grade III injury (deep ulcers) to the stomach and pylorus. How should these injuries be coded and what is the ISS?

A: AIS 98: Bronchus distal to main stem, partial thickness injury – 440206.2
ISS = 13

AIS 2005: Bronchus distal to main stem, partial thickness injury – 440206.2
Esophagus partial thickness ingestion injury – 440807.3
Stomach ulcers (also a partial thickness ingestion injury) – 5444153
ISS = 18
Note that the codes change slightly in AIS 2005 because we have added descriptors for caustic ingestion injuries. In this case it also increases the ISS.

Q: A patient involved in an ATV wreck has multiple facial fractures that do not meet the criteria for a LeFort fracture diagnosis. How should they be coded? The highest AIS severity code for individual facial fractures is .2 and that doesn’t seem to reflect the severity of these multiple fractures.

A: The patient with multiple complex facial fractures that do not meet the criteria for LeFort fractures presents a dilemma for the coder using the AIS 90 Update 98 dictionary. There really isn’t a good option in that version. The IISC has added a new code in AIS 2005 — Panfacial Fracture. Panfacial fracture is defined as “multiple and complex fractures that may involve middle and lower face, upper and middle face, or all three, but not LeFort fractures.” It assigns severity codes of .3 or .4 depending on the amount of associated blood loss. It provides another reason to consider upgrading to AIS 2005.

Q: What is the correct code for an internal carotid artery occlusion?

A: This is impossible to answer correctly unless you have a little more information. The internal carotid artery can be coded under HEAD 121004.4 if the occlusion occurs in that portion of the artery, or under NECK 320220.3 if the occlusion occurs lower. This question illustrates the importance of knowing exactly where the injury occurs when a structure traverses more than one body region. The coder must delve deeper into the chart to locate and code the injury properly.