Head and Neck FAQs
A: You may use codes 161002.2 through 161006.3 when the MD confirms “positive LOC”. This does not have to be witnessed by the MD. If they believe there was LOC and document it, we may code it. We do not need to have the word “concussion” in the chart in order to code LOC. If the EMS agency notes LOC, the physician must corroborate this finding in the medical record for you to code it in AIS.
Q: If you have a LeFort I fracture and bilateral mandibular fractures how would you code the injury?
A: The LeFort I fracture does include the maxillary alveolar process, but NOT the mandible so you would code that separately, depending upon the type of mandibular fracture. Remember that the mandible only gets one code even if the fractures are bilateral.
A: Gray’s Anatomy lists the vomer as one of the facial bones. Specifically it is the posterior part of the nasal septum. So the code would be 2510006.2.
Q: A patient fell and now has a significant traumatic pleural effusion as their only injury. How would you code this?
A: Traumatic pleural effusion is a consequence or sequela of injury. It is not listed in the AIS dictionary and is therefore not codable in AIS.
Q: If there is a cerebral hemorrhage NFS and LOC of some duration, how can this be coded? May we use concussive injury codes in addition to the hemorrhage code?
A: Do not code coma in addition to the hemorrhage. When there is an anatomic brain injury the concussive codes are not used additionally. If the only injury is a skull fracture (no damage to the brain substance) and there is documented LOC you may use the concussive injury codes additionally.
A: Traumatic pleural effusion is a consequence, or sequela, of injury and cannot be coded. Remember that only those sequelae listed in the AIS Dictionary may be coded- if you can’t find it, you can’t code it.
Q: A man touched a high voltage line with injury to the soft tissue and muscle of the thumb side of his R hand requring serial debridement of necrotic muscle tissue. Please code this injury
A: Code 080002.3 the muscle necrosis is indicative of the severity of the injury.
Q: MVC with man trapped at the Left knee by the dashboard. Upon extrication he has gross deformity at the knee with large blood loss and no sensation or movement in the L lower leg, no pedal pulse. Diagnostics indicate open severely comminuted distal L femur fracture with all ligaments in disruption to the knee. There is also an open midshaft fracture of the left tibia. An above the knee amputation was done on day 2. Please code the L lower extremity injuries
A: Code the injury at the L knee as a crush injury at or above the knee code 813002.4, bone, soft tissue, vascular and nerve were all involved. You would also code the open L mid shaft tibia fx even though the leg was amputated this was still an injury
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: A child is admitted to the ED after playing on the trampoline where another child landed on him. Xrays are done and a navicular fracture is identified. Please code this injury
A: This fracture requires more information as to whether or not this is a tarsal or a carpal bone; In an actual clinical situation, the physical examination and xray would b labeled as wrist or foot; If this is a tarsal navicular fx then the appropriate code would be 857451.2; if this is a carpal navicular then code 752461.2
Q: A trauma activation is called for a patient with a GSW to the lower abdomen. Immediate laparotomy is undertaken and a perforation to the sigmoid colon identified. The sigmoid is resected, colostomy placed, and the patient moves to the ICU. Please code this abdominal injury
A: The sigmoid is part of the colon and therefore coded to the “colon” in the abdomen chapter. A perforation is identified. The injury should not be coded any more severely just because the sigmoid was resected. Code:540824.3
Q: Patient arrives after a fall down a flight of outdoor stairs. The patient experiences an unknown period of exposure prior to being found and brought to the ED. The initial core temperature on arrival is 90.1 degrees Fahrenheit; What would you do with this information?
A: A tempreature of 90.1F is equivalent to a temperature of 32.3 C and therefore meets criteria for the hypothermia code 010004.2; this is not induced for medical treatment but rather from exposure and is included as an injury.
Q: Coming out from church, Ida trips and falls and is unable to get up. She is brought into the ED by family c/o ankle pain; Xray reveals a R bimalleolar fx; How would you code this injury?
A: There is not enough information to determine the degree of articular involvement; therefore fibula nfs must be used according to the rule box Code: 854441.2
Q: A young lady arrives to the ED. She was on her way home from school and as usual climbed over a fence as a short cut. However today suffered a straddle injury while going over the fence. She has evidence of a large contusion of the vulva. There are no lacerations and there is no vaginal injury.
A: 545610.1; although the injury appears to be a skin contusion, the vulva is part of the abdomen and is coded there. It is also coded to the abdomen for the ISS.
A: 251231.2; The lamina papyracea is the medial wall of the orbit.
A: If there is no documentation of injury to the heart muscle the correct code is 441605.4. An injury to the heart would be coded additionally.
A: This is really two injuries. The bimalleolar fracture is coded 854441.2 since the exact location of the fracture is not known (see the rule box at the top of page 151 in AIS 2005 Update 2008). The dislocation is also coded. In this case (since no other information is given) the code is 877130.2.
A: In the AIS 2005, Update 2008 we clarified coding of the temporal artery in FACE. 220200.1 now reads “External carotid artery branch(es) laceration NFS [includes facial, temporal, and internal maxillary]. The two codes indented under that code apply as well.
A: Asphyxia codes are now available in AIS 2005, located in the Other Trauma section. Since we have no information as to neurological deficit, the correct code to use is 020000.3. There are also codes in the Head chapter for “hypoxic or ischemic brain damage secondary to systemic hypoxemia, hypotension or shock” but these codes have a severity code of 9.
A: Bilateral fractures should be entered two times, coding right and left sides separately. The clarification can be made in the written description in the registry, indicating ‘right’ or ‘left’. In AIS 98 there is some opportunity to describe where on the bone the fracture occurs, so there may also e some difference in the codes between left and right if different portions of the bones are affected. In AIS 2005 these distinctions are much more specific, so again there may be sligth differences in the codes. Additionally AIS 2005 has introduced Locator codes which can be used to indicate side and aspect of injuries, however the ability to include these in a computerized trauma registry will be a matter for the software vendors to address.
Q: Pelvic fractures are coded much differently in AIS 2005. What are the most specific AIS codes for the following three different pelvic fracture descriptions? 1) Complex fractures of pelvis with comminuted fractures of superior and inferior public rami bilaterally, separation of pubic symphysis and separation of L sacroiliac joint. 2) Multiple severe fractures of pelvis. 3) Non-displaced fracture R sacrum. Fracture of anterior column of R acetabulum extending along R iliac bone and comminuted fracture through R sacral ala.
A: 1) The involvement of the SI joint indicates partial instability of the posterior arch of the pelvis. All of the other fractures are in the anterior portion of the pelvic ring, and are not factors in the stability of the pelvis. The correct code is 856161.3.
2) Although this sounds like a potentially unstable pelvic fracture, there is not enough detail given to code it to anything more specific than 856100.2.
3) This fracture description will provide two distinct codes. In AIS 2005 the acetabulum is coded spearately from the pelvic ring. The sacral fractures do not involve the SI joint and do not affect stability of the pelvis. The correct code for the pelvic ring fractures is 856151.2. The correct code for the acetabulum fracture is 856251.2.
Q: A 30 year old patient sustains the following burns: 20% first degree (superficial) 30% second degree (partial thickness) 5% third degree (full thickness) How are these burns coded in AIS 2005?
A: The correct codes are as follows:
912002.1 for the first degree burns
912024.4 for the second and third degree burns combined.
This question highlights a change in the manner in which we are now addressing multiple burns. In the January 2008 revision of the AIS dictionary the burn rule has been restated as follows:
When burns occur in varying degrees assign an AIS code to the first degree burns separately from second and third degree burns. If second degree burns are less than 10% TBSA and/or third degree burns are < 100 cm2 or > 100 cm2 but < 10%, then both the second and the third degree burns get coded separately. If the combined second and third degree burns cover > 10% TBSA, assign AIS code based on their combined TBSA.
Example 1: Adult sustains 40% first degree burns, 5% second degree burns and 2% third degree burns.
Code: 912002.1 for the 1st degree burns
912006.1 for the 2nd degree burns
912008.2 for the 3rd degree burns
Example 2: Adult sustains 40% first degree burns, 15% second degree burns and 5% third degree burns.
Code: 912002.1 for the 1st degree burns
912018.3 for the combined 2nd and 3rd degree burns
Q: The patient has extensive, unstable pelvic fractures with complete SI joint disruption and the CT also demonstrates a large retroperitoneal hematoma with shift of the urinary bladder to the left of midline. What is the best code for these pelvic fractures?
A: The correct code is 856173.5. The blood loss of >20% will probably not be found clearly documented in the chart, since physicians do not want to disturb the hematoma and rarely estimate its volume. However, the extensive fractures and the shift of the urinary bladder are objective signs that can be used to estimate that blood loss has been substantial. As always, if the signs are “soft” and the coder is unsure about blood loss, s/he should code more conservatively, but in this case, it is safe to “assume” the blood loss.
Q: A patient sustains a duodenal laceration involving > 75% of D3 (the transverse portion). How is this injury coded in AIS 2005?
A: The correct code is 541023.3. The coder should note that the portion of the duodenum that is inolved will affect the severity code. D2 (the descending portion) carries a higher severity when it is involved.
Q: A patient sustains a stab wound to the left ventricle which also penetrates the septum. What are the correct codes for this injury?
Left ventricle laceration – 441012.5
Septum laceration – 441300.5
Pericardium laceration – 441602.2
The rule for penetrating injury is to code the underlying injuries but not the skin wound. Although the pericardium is not mentioned, the only way to the ventricle and the septum is through the pericardium and it may also be coded.
Q: The patient was involved in a rollover crash and sustained a vertebral artery thrombosis in the neck with resultant hemiplegia. What is the correct code?
A: The correct code is 321020.4. A common coding error is to assign the code 321016.4 which is the first code referring to thrombosis seen in the dictionary. That code refers to thrombosis resulting from a laceration to the artery so we must use the code below which states “thrombosis (occlusion) secondary to truama”. In AIS 2005 this is further clarified to read “thrombosis (occlusion) secondary to trauma from any lesion but laceration”.
Q: The patient sustains an injury to his lungs with peripheral pulmonary hemorrhages following a gas well explosion. How would this be coded?
A: In AIS 98, the only option for this injury is 441499.3 Lung NFS
In AIS 2005, this is one of many new descriptors that have been added to the dictionary. The correct code for his injury is 441424.4.
Q: A patient sustains vertebral body fractures of C7 and T1 with complete quadriplegia due to cord contusion at C6-7 level. How should this injury be coded and what is the ISS?
A: AIS 98 – The correct codes are 640224.5 and 650430.2. The ISS is 29. It would be incorrect to assign the deficit twice but it is important to capture the two fractures which occur in two different ISS body regions. These codes are the same in AIS 2005.
A: The correct code in AIS 98 is 140606.3. Thanks to everyone who participated and congratulations to our three contributors who gave the correct answer. The answer 140604.3 identifies a single contusion, but does not get as specific (“small”) as the correct code. You will notice however that the severity is not affected in this case. In AIS 2005 we have added a new code for these very small lesions in the brain. It is 140605.2 tiny:< 1 cm in diamter and it more correctly reflects the lesser severity of these lesions. Remember to submit your questions here or to AIS@aaam1.org.
Q: If a patient develops an extremity compartment syndrome after admission, would it be included as an anatomical diagnosis?
A: Compartment syndrome is one of those tricky diagnoses that make a coder’s life difficult. It can be both a diagnosis and a complication. If it is a complication or sequela of an injury, it is not coded. If it is an injury, it is coded. Here’s an example we use in the AIS Course:
A patient who develops a compartment syndrome from swelling related to a broken tibia has a complication, and in this case the comopartment syndrome is not coded. A patient whose arm gets trapped in a vacuum line and comes to the ED with marked swelling but no broken bones and is daignosed with compartment syndrome is coded.
Q: How would the following be coded and scored? L rib disarticulations … Per autopsy report: “On the left, ribs 2, 3, and 4 are hypermobile medially and apparently dislocated from their vertebral articulations. No fractures are palapable or evident.”
A:Thanks to Jody and Terri for participating in our online discussion. One of the difficulties for those who are experienced in ICD 9 coding is that AIS and ICD 9 just don’t always work the same way. As Jody noted, there are no AIS codes for rib dislocations, and Terri’s spine code is used for a thoracic spine injury, not a rib injury. Disarticulation of the rib at its connection to the thoracic spine is treated as a rib fracture, so the correct code in AIS 98 is 450220.2. In AIS 2005 one of several changes in the Thorax chapter includes this code, which changes to 450203.3.