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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...
Q: What is the correct code for pericardial tamponade?
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.
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.
Q: What do the initials KN mean in the zygoma fracture descriptions?
A: KN refers to Drs. Knight and North who described a grading system for the type and amount of displacement of zygomatic fractures. The Knight North scale describes increasing severity from I to VI.
Q: A patient sustains bilateral lacerations to the internal iliac arteries. What is the correct code for this injury?
A: The bilateral code in the AIS dictionary refers specifically to the common iliac artery. In this case the two internal iliac artery injuries would be coded separately, using 520604.3 for the left and the right internal iliac arteries.
Q: A patient has an unstable C7 vertebral body fracture, a fractured spinous process at C2 and a subluxation C6/C7 with sensory/motor loss below T2. The CT/MRI states ‘multilevel cord contusion’ (cord contusion at lower cervical and upper dorsal level). At 24 hrs post injury pt remains paralysed and sedated, pt not moving upper and lower limbs prior to intubation. How should these injuries be coded?
A: Code the C2 spinous process with one code (650218.2) and the C6/C7 fx/dislocation with the cord contusion as one code (with complete tetraplegia) as 640228.5. Although the cord contusion is multilevel, you should only code it with the fracture dislocation. If you...
Q: What is the correct code for a patient with hypothermia and a core temperature of 31.8 degrees Centigrade?
A: The correct code is 010006.3. The coder should record the whole number and should not round up or down.
Q: What is the correct code for a bimalleolar fracture/dislocation of the ankle?
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...
Q: How do you code cerebral shear injuries that have loss of consciousness less than 6 hours?
A: The correct code is 140643.2 found under Cerebrum, hematoma, intracerebral, tiny - petechial hemorrhage(s) [includes radiographic "shearing" lesions] not associated with coma > 6 hours
Q: A motorcyclist crashes and sustains 15 % partial and full thickness “œroad rash” in addition to multiple lower extremity fractures. Following operative treatment of his fractures he is transferred to the Burn Unit for management of his skin injuries. How should the skin injuries be coded?
A: Although the skin injuries are being described in terms usually used for burns, the correct codes to use are the abrasion codes. If you know the precise location of the abrasions, we recommend using the Whole Area abrasion codes in each chapter. The code 9xxxxx.1...
Q: Where are malleolar fractures (medial malleolar, bimalleolar, and trimalleolar) coded?
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...
Q: How do you code a temporal artery laceration?
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.
Q: How should one code asphyxia related to hanging?
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...
Q: A patient sustains a basilar skull fracture, fractured L zygoma and a nasal fracture. She has bilateral periorbital ecchymosis. There is no mention in the chart of cerebral spinal fluid (CSF) leak. How would you code the basilar skull fracture?
A: The correct code is 150202.3. If the patient has a CSF leak, the treating physician(s) will always mention it in the chart. When there is no mention of CSF leak, the coder may use the "without CSF leak" code. The periorbital ecchymosis could be due to the nasal...
Q: How do you code a fracture of the acromium process?
A: Although this process is at the end of the neck, the most correct answer is 750900.2 Scapula fracture NFS.
Q: The autopsy describes the following injuries from blunt trauma to the chest: “There is a 6 inch by 12 inch open wound below the left axilla with portions of the left chest missing, with underlying multiple left rib fractures and portions of ribs 3-8 missing.” How should these be coded?
A: Thanks to everyone who participated this month. Roberta, Jo and Paula all had interesting answers. The answer we were looking for is 451022.5. This is a new code in AIS 2005. Since this is only described as a chest injury we cannot use the "Whole body...
Q: What is the best way to describe bilateral fractures in the trauma registry?
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...
Q: What is the correct code for the diagnosis “Subdural hematoma 7mm thickness”?
A: The correct code is 140652.4. If the specific region of the brain (brain stem, cerebellum or cerebrum) is not indicated, the injury should be assigned to the cerebrum.