Q: If you have a penetrating injury to the upper extremity that involves > 20% blood loss from the brachial artery should you use the Penetrating Injury with blood loss code (716006.3), or should you code only the artery laceration (720608.3), or should you code both?
A: The rule for penetrating injuries is to code the underlying injury(ies) when known. In this case, code only the brachial artery 720608.3.
Q: On page 67 of the AIS 2005 Manual, the last code 321021.5 has “œbilateral” as descriptor. Does “œbilateral” mean “œbilateral thrombosis” or “œbilateral neurological deficit”? We have a patient who sustained bilateral vertebral artery dissection and thrombosis with left PCA territory infarction. CT scan states” Apparent migration of intraluminal thrombus arising from the left vertebral artery, resulting in occlusion of the calcarine branch of the left posterior cerebral artery” How should we code this case?
A: Artery dissections are coded under intimal tear and we do not have a code for bilateral under intimal tear. I would code 321004.3 for the left vertebral artery with its subsequent PCA infarction, and 321002.2 for the right side.
Q: A patient is found down in PEA in a burning house. Soot in airway, but no burns in mouth or airway when intubated by Medics. Prolonged CPR, then a rhythm for a short period of time, then PEA. Pupils fixed, dilated, 3T, no response to pain, movement, etc. Minimal partial thickness burns. Can I code asphyxia for her? Her carboxyhemoglobin level was 13.8. Can I code inhalation injury as well?
A: We aren’t allowed to code based on carboxyhemaglobins… just the observed airway stuff for inhalation. Asphyxiation is reserved for things like hanging and strangulation… sort of the more mechanical side. So we use inhalation only and the best code is for minor – 419202.3 based on your description.
A: The zygomatico-maxillary complex (ZMC) describes the are which includes the zygomatic arch where it joins the maxilla and the frontal skull. It describes a region of the face and is not a description of the severity of the fracture. The correct code is 251800.1.
Q: Child got under the kitchen sink ingesting a variety of caustic agents, vomiting induced immediately but chemical burn and sloughing of esophageal lining documented. No gastric injury evident. Please code this injury
A: The actual region of the esophagus injured is not stated as thorax( below the sternal notch) or to the neck so the default code is to the neck region. This is an ingestion injury with partial thickness necrosis, the sloughing of the lining of the esophagus, 340104.3
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: 50 y.o. male was working on the roof of a house under construction when he fell at least 20′; he is complaining of backpain and the CT of the chest reveals a T12 compression fx of 50% with additional fractures of the T12 pedicle and facet on the left. There is no demonstrated neurologic deficit. How would you code this injury?
A: This case demonstrates the use of the multiple fracture within one vertebra code however the major compression fx must be identified separately due to the severity;It of course, is always acceptable to code each fracture individually is you so choose; Code: 650434.3 and 650417.2; or 650434.3 and 650426.2 and 650422.2
Q: Tibia-fibula xray states distal tibia fracture; CT extremity – better defines the injury as a pilon fracture; How would you code this fracture?
A: 854331.2; A pilon fracture is located at the distal shaft of the tibia but not part of the malleoli; the code for this fracture is found within the “distal tibia”. This fracture may also be called a plafond.
Q: A patient arrives after an MVC in which the car rolled several times. CT head – negative for injury, skull normal; CT cervical spine – occipital condyle fracture, normal alignment; neurologic examination is normal- able to move all extremities, GCS= 15; there is no drainage from the ears or nose, no ecchymosis.
A:150202.3; The occipital condyles are part of the base of the skull despite the diagnosis frequently appearing on the cervical CT scan. As with any basilar skull fracture, an assessment for CSF leak as well as head injury is important. In addition, since the occipital condyles articulate with the first cervical vertebrae, assessment for spinal cord injury is also important.
Q: A 4 y o child is accidentally burned when his pajamas catch fire from a candle. His burns are described as 15 % first, 10 % second and 9 % third degree. What is the correct way to code this injury?
A: The revised burn rule states that in cases described this way, the first degree burns should be coded separately from the second and third. Therefore, the first degree burns are coded as 912002.1. The second and third degree burns together total 19 % so they are coded together as 912014.3. (Remember that this child is less than 5 years old.)
A: Although this process is at the end of the neck, the most correct answer is 750900.2 Scapula fracture NFS.
Q: A patient sustains several cervical spine fractures in a fall. They include C1 lateral mass fracture, and both spinous process and transverse process fractures of C4 and C5. What are the correct codes in AIS 2005?
650226.2, C1 lateral mass (pedicle) fracture
650217.2, C4 multiple fractures of same vertebra
650217.2, C5 multiple fractures of same vertebra
Each vertebra is coded separately. AIS 2005 clarifies where to code various portions of the C1 vertebra, and also adds a new code for multiple fractures of the same vertebra.
Q: The patient sustained a gun shot wound to the eye which penetrated the skull base and lodged in the parietal area of the brain. It was noted that there was brain tissue extruding from the wound. What is the best way to code the head injuries?
A: There are two correct codes — 150206.4 for the complex basilar skull fracture and 140690.5 for the penetrating injury to the cerebrum.
In AIS 2005 the codes would be the same for the base fracture and 140692.5. Note that in AIS 2005 the code for penetrating injury to the cerebrum has a lower severity of 3 if the depth of teh injury is not known.
A: All penetrating injuries that do not involve underlying structures are assigned to the External body region when calculating an ISS with the exception of penetrating injuries to the head and massive penetrating injuries to the face. The AIS 2005 dictionary spells this rule out more clearly than previous editions. Remember, when coding penetrating injuries, always code the underlying injuries if known, and when they are known, the skin injury is considered to be included in that code and is not coded separately.
Q: Patient A sustains a gun shot wound to the head with greater than 2 cm penetration. What is the correct AIS code and to which body region is this assigned for ISS purposes? Patient B sustains a gun shot wound to the chest, into the pleural cavity but with no known lung or vessel involvement. What is the correct AIS code and to which body region is this assigned for ISS purposes?
A: Patient A is coded 116004.5 and is assigned to the ISS Head region. Patient B is coded 416002.1 and is assigned to the ISS External region.
Penetrating injury codes listed under the Whole Area section of the dictionary are generally assigned to the External body region for ISS purposes. An exception is made for penetrating injuries to the head.
In AIS 2005 there is a new code for massive destruction of the whole face (216008.4) which is assigned to the Face region for ISS purposes although all the other penetrating codes for Face are assigned to the External body region for ISS purposes.