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Q: 36 y.o. female is running across the highway and struck by a vehicle at high speed; she is unresponsive at the scene and has an immediate CT-head which identifies a large bleed likely at the sagittal sinus; Operative craniotomy revealsa laceration to the sagittal sinus with a 2000ml blood loss; the injury is irreparable; How do you code this injury?
A: sadly the blood loss, although massive, cannot be attached to this injury specifically and laceration is the only available code. Code: 122402.4
Q: Elderly patient fell out of bed, landing on his right side and c/o RUQ pain; CT of the abdomen demonstrates an injury to the ligamentum teres hepatis; What would you do with this injury?
A: The ligament teres hepatis represents the remnant of the fetal left umbilical vein. As such, it is not a codeable 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: Passenger involved in an MVC arrives c/o neck pain; a CT of the neck demonstrates a C6 fx through the transverse foramina; as a result, a CTA was done with identifies a complete occlusion of the vertebral artery at the level of C6 and corresponding the the side of the fracture; How would you code this VASCULAR injury?
A: The vertebral artery is frequently injured at the level of the cervical spine fracture; the srtery traverses the transverse foramina and is vulnerable at this point, thus the CTA examination. Code: 321018.3
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:...
Q: Driver of vehicle in MVC struck on driver’s side; unstable vital signs and a widened mediastinum on the initial CXR; a CTA of the chest is performed demonstrating a major aortic tear at the root of the aorta itself; the patient is rushed to the OR; how would you code this vascular injury?
A: Major thoracic aorta injury involving the root Code: 420212.5
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:You receive a patient with a stab wound to the chest. He says it was a short knife. The wound is actively bleeding. Examination and CXR are negative for pneumothorax, however the patient’s blood pressure is dropping. In the OR a transection of the internal mammary artery is evident and repaired.
A: 422008.3; the internal mammary artery is found under "other named arteries" in the chest; a transection is a major injury; even without blood loss information, major is the correct choice. Just a review of terms - in the dictionary the separator ";" means "or" so...
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.
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...
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...
Q: Your newest trauma patient has suffered a basilar skull fracture. While reading the CT scan of the head, you notice that there is also a dislocation of the ossicles on othe left. After coding the basilar skull fracture correctly, you are left with a decision about the ossicular dislocation. How do you code this specific injury?
A: 240212.1; the ossicles are seen on CT scan but they are the skeletal component of of the ear. Thus, the AIS code for the ossicles is found in the face, under the organ "ear". This injury is frequently associated with a basilar skull fracture, which would be coded...
Q: CT scan abdomen/pelvis – spleen normal; kidneys and adrenal glands normal; liver laceration gr IV injury – multiple deep lacerations. The patient is taken to OR where the operative note states liver laceration gr V injury. What would you code?
A: 541828.5; The surgeon is visually observing the liver and thus the operative grading is more accurate than the CT scan. An autopsy would also over-ride the reading of the CT if the grade is different.
Q: Motocross collision, wearing helmet; multiple soft tissue injuries; no other injury identified.
A: 910000.1; Since the skin injuries are not clearly defined, the external "soft tissue injury NFS" code is the best choice; even if the site of injury was known, this is the best code since the type of soft tissue injury is not provided.
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...
Q: CT scan face – fracture of the lamina papyracea.
A: 251231.2; The lamina papyracea is the medial wall of the orbit.
Q: A patient arrives to the ED with a severe head injury; he is transported to the ICU in anticipation of organ donation and while the brain death evaluation is completed. His final diagnoses include the expected head injury and brain death. What do you do when coding this chart regarding the brain death itself?
A: Brain death is a situation not an injury. The coder would appropriately code the lesions identified on CT as well as any edema. However, brain death is a sequelae of those injuries. Even if the patient had no codeable injuries in the brain, there would still be no...
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...