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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: Female farm worker got the front of her jacket caught in a piece of farm machinery with complete avulsion of her R chest including the pectoralis muscle down to the exterior ribs from just below her clavicle to the level of last rib, no rib fractures evident but over 2000cc blood loss from transected mammary artery. Please code these injuries.
A: 411000.2 breast avulsion female, 410102.2 pectoral muscle laceration, 422008.3 transected mammary artery with > 20% blood loss
Q: Elderly patient after fall down the stairs with MRI showing cord compression due to traumatic spondylolisthesis at L5 on S1. Patient is in severe pain and scheduled for surgery. Please code this spinal injury
A: Only when there is evidence of a codeable cord injury associated with the spondylolisthesis would you code this injury which is actually a slippage of one vertebrae on another. For the spine this is coded as a dislocation with the cord compression of first...
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: Woman in MVC with facial trauma multiple fractures of R obit complains of loss of visual acuity in R eye. Her globe is intact but a hole in her R macula is discovered. Please code this injury to the eye.
A: Code 240904.2
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: Apneic with GCS of 3 at scene. Bullet entry in the occipital region of the skull with trajectory down and forward with exit at the throat. CT shows massive damage of the cerebrum, cerebellum, and brain stem along the bullet pathway Please code the brain injury.
A: No matter how many regions of the brain are involved in a penetrating injury if the brain stem is involved you code the injury as 140216.6 must have CT, MRI or other evidence
Q: A person with a full bladder is struck by a car while crossing the street. He is able to ambulate but experiences severe abdominal pain and faints. In the ED he has low volume hematuria and the FAST scan shows intraperitoneal fluid. He is taken to surgery and repair of a 3cm laceration on the posterior surface of the dome of his bladder is done. Please code this bladder injury.
A: 540625.3 urinary bladder laceration intraperitoneal wall > 2cm This is an OIS grade IV 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: A baseball player was accidentally struck in the throat by a hard swung bat. He had immediate pain and difficulty speaking. In the ED a laryngotracheoscopy was performed with diagnosis of nondisplaced fracture of the larynx with vocal cord contusion and edema. Please code this injury.
A: Code 340210.4 the vocal cord involvement raises the severity level of this 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...
Q: I have a patient that had a left vertebral artery dissection. Two days later the patient had an MRI that showed a brain stem infarction. I am not sure if I should code the brain stem infarction, since it didn’t show up until 2 days later and could possibly be caused by the dissection.” What is the correct code for this injury?
A: The correct code for this injury is 321004.3. This was described as a "dissection" in the conclusion of the MRI and the patient had subsequent neurologic deficit (infarcts). The brain "injuries" occurred as a result of the dissection, not direct trauma to the brain...
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...
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...
Q: Driver of a motorcycle without a helmet is struck by a large truck on the highway. He arrives with a GCS 4 and has the usual workup with a CT-head that does not demonstrate any injury. He remains in coma for several days and undergoes an MRI which clearly identifies diffuse axonal injury (DAI) located at the corpus callosum; How would you code this injury and what is your rationale for the choice?
A: Because of the length of coma, the DAI is coded from the concussive section of the head chapter even though we know it is located at the corpus callosum. The coma is consistent for > 24 hours with the MRI appropriately done to confirm the diagnosis and reason for...
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: 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 patient is admitted after an assault with a baseball bat to the head; among his injuries, a tympanic membrane rupture; How do you code this injury?
A: a tympanic membrane rupture is coded as 240216.1; note that frequently this injury is also associated with a basilar skull fracture so look for that on the CT scan or a clinical diagnosis of such.