Q: You have a patient with a penetrating knife injury to the extremity that lacerates (only) the muscle. Should you use just the penetrating codes or muscle laceration under skin subcutaneous tissue. Is this a blunt or penetrating injury?
A:This is considered penetrating trauma and you would code penetrating trauma using the penetrating injuries section. If you look at the rule box above the skin subcutaneous muscle section it identifies that you should code blunt soft tissue injury in that section.
A: The pterygoid plates are a part of the sphenoid bone and are therefore part of the skull base for AIS coding. The exception to this is if they are included in a confirmed LeFort fracture. In that case the injury is coded to the face and the sphenoid (base fracture) is not coded additionally.
Q: Have the following finding on a patients MRI – “œsmall epidural hematoma from C7-T1 which is likely emanating from the compression fracture of T1″ ““ He does not have a C7 fracture. What would you code especially considering it involves the cervical and thoracic spine?
A: You should code the epidural at the highest level (C7) unless you have evidence of deficit at a lower level. You may not “double dip” and code the epidural again in the T-spine. Again, if there is no deficit, code 640200.3 for the epidural hematoma and 650430.2 for the compression fracture of T 1. If there would be a deficit with this injury then you would code the deficit at the level that it occurs.
A The surgical “neck ” of the humerous is located at the proximal end of the humerus shaft. Therefore you would go to the proximal humerus codes and go down to the description of extra- articular. Since only one fracture line is described the correct code is 751151.2. The humerus has two (2) areas described as “necks”. The anatomic neck code is found lower in the proximal humeral code and is considered articular. The following link is also another great resource for defining orthopaedic injuries. – http://ota.org
A: From what we can tell the septum pellucida is the structure that separates the anterior horns of the lateral ventricles, so when it is torn we would expect to see intraventricular hemmorage. The faculty seems to agree that the cerebral laceration should be coded (140688.3) in addition to the IVH. Although the IVH is a sequela of the tear, it is codable sequela, so please code both.
Q: According to Organ Injury Scaling (OIS) guidelines in many cases you may advance one grade for multiple lacerations of an organ. (“œAdvance one grade for multiple injuries to same organ up to Grade III.” AAST) How should multiple Grade II liver lacerations be coded in AIS?
A: Although the Organ Injury Scale allows one to assign a higher grade for multiple lacerations to an organ, the AIS does not allow that for our coding. Multiple Grade II liver lacerations should be coded as 541822.2.
Q: 56 yr old admitted to the ED with documentation of 15% second and third degree burns to her chest and bilateral arms. Two days later Burn specialist documentation states patient has 30% second and third degree burns to same body regions. What is the most accurate code for this injury
A: Code 912024.4 30% patient is older than 5 years. Burns can appear less severe at the time of incident but can evolve in degree and extent so the Burn specialist documentation should be most accurate in this case
Q: The patients arrives after a MVC in which their chest and neck were pinned between the seat and the steering wheel for a period of time; After all the scans are complete, a diagnosis of asphyxia from loss of airway while trapped is given. At 24 hours, she is awake and alert with no neurologic deficits. How would you code this injury? To what ISS body region is this severity assigned?
A: Asphyxia, although a sequelae of injury, is codeable when it is the direct result of the trauma. The code is found in the external and other trauma chapter of the dictionary. Code: 020002.3 and assign to the head body region for ISS.
Q: A burn patient arrives in the ED after being involved in a house fire where she was removed from the bedroom engulfed in smoke and unresponsive. The initial evaluation included intubation, a carbon monoxide level and ABG showing pO2 60 mmHg. In addition, a bronchoscopy was done to assess the airways. The results were positive carbonaceous deposits requiring lavage to clear the airway and erythema with friable membranes.
A: 419206.5; The mechanism of injury implies inhalation burn from breathing the superheated air along with the smoke. Inflammation of the airways, friability with obstruction of the bronchi requiring clearance is evidence of severe inhalation injury; ABG demonstrates hypoxemia as well
Q: Patient arrives after a 20′ fall from a height landing on his right leg; examination shows a visibly shortened RLE; plain film of the pelvis demonstrates that the right iliac wing is higher than the left with apparent SI joint dislocation and fractures of the superior and inferior pubic rami on the right; CT scan confirms a Malgaigne shear fracture of the pelvis; blood loss is not known.
:A: 856171.4; A Malgaigne fracture is a vertical shear fracture with instability and complete separation of one side of the pelvis from the other (disruption of the pelvic ring). If blood loss had been provided, more definition could have been used. However, in this case NFS was the best choice.
Q: What is the correct code for a stroke following seat belt trauma which caused occlusion to the vertebral artery?
A: The code 321020.4 is used in this case. There is no evidence given of a laceration so the coder must use the thrombosis code, and the neurological deficit is not related to an injury to the head, but rather an injury to the neck vessel.
A: Malleolar fractures may be coded on either the tibia or fibula. AIS 2005 Update 2008 provides codes for isolated medial malleolar fractures under tibia and codes for bimalleolar and trimalleolar fractures under the fibula. Be sure to read the boxed bold directive under the fibula which reminds the coder to use Fibula NFS if the specific site of the bimalleolar fracture is unknown.
Q: A patient with clinical diagnosis of diffuse axonal injury (DAI) recorded by the neurosurgeon and a radiologic finding described as “petechial hemorrhages in the basal ganglia and corpus callosum consistent with DAI” who remains comatose until he dies 15 hours after injury should be assigned which AIS code?
A: The correct code is 140627.5. This question highlights the rule box on page 45 of the AIS dictionary, which directs the coder to “code only the more severe” when both corpus callosum and basal ganglia are noted. An important additional point to note is the directive If coma exceeds 24 hours, use 161011.5, no matter what anatomic description is recorded. The coder should note that DAI may also be coded on page 51 of the dictionary, under CONCUSSIVE INJURY. In all cases where coma exceeds 24 hours, DAI should be coded in this section of the dictionary rather than under Cerebrum. (This directive was clarified in the January 2008 edition of the AIS dictionary. See www.aaam1.org/ais for all dictionary updates and information on how to access the latest version of the dictionary.
Q: The patient is an unrestrained passenger admimtted following a high speed MVC. He has been unconscious without sedation of paralytic medications since admission 48 hours ago. His CT demonstrates petechial hemorrhages in the area of the corpus callosum and basal ganglia. The neurosurgeon diagnoses diffuse axonal injury (DAI). What is the correct AIS code?
A: In AIS 98 the correct code is 140628.5
In AIS 2005, there are two areas in which DAI may be coded. The correct code in AIS 2005 is 140627.5 Cerebrum, DAI involving corpus callosum. If the CT had noted only hemorrhages in the basal ganglia, or more broadly, petechial hemorrhages in the cerebrum, the correct codes would have been 140625.4 (for the basal ganglia) or 140628.4 (note the change in severity between AIS 98 and AIS 2005 for this code) for the cerebrum NFS.
AIS 2005 also makes the distinction as to whether an anatomical site has been noted for the DAI. If the chart simply states DAI (confirmed by both radiologic and clinical diagnoses) it should be coded in the Concussive Injury section of the chapter, in this case the correct code being 161011.5.
A: Reference to the thyroid is made in the Neck chapter of the AIS dictionary under Larynx. A common coding mistake is to code thyroid cartilage injuries using the thyroid gland descriptors.