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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)...
Q: The patient’s injury is described as a ‘fractured’ larynx. What is the correct code?
A: Thanks to Abbie, Jo and Hideo for participating in this month"s question. The correct code to use for this injury description is 340208.3. If the larynx is described as "crushed" the code 340212.5 would be appropriate.Because this is a relatively common description...
Q: How can a coder decide if a fracture is extra-articular, partial articular or articular?
A: The Orthopaedic Trauma Association offers a very helpful guide which includes definitions and drawings which may be helpful to the coder when comparing radiologic descriptions from the chart to the definitions in the AIS 2005 dictionary. Go to...
Q: What is the correct code for a closed bimalleolar fracture?
A: The correct code is 854441.2Although there are three codes that mention bimalleolar fracture, the rule box on page 151 of AIS 2005 directs the coder to use this code when the specific anatomic location of the bimalleolar fracture is not known.
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 burns912024.4 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...
Q: A patient with clinical diagnosis of diffuse axonal injury (DAI) recorded by the neurosurgeon and a radiologic finding described as “petechial hemorrhages in the basal ganglia and corpus callosum consistent with DAI” who remains comatose until he dies 15 hours after injury should be assigned which AIS code?
A: The correct code is 140627.5. This question highlights the rule box on page 45 of the AIS dictionary, which directs the coder to "code only the more severe" when both corpus callosum and basal ganglia are noted. An important additional point to note is the...
Q: The patient’s CT demonstrates blood in the maxillary sinuses following blunt facial trauma. How is this coded?
A: The coder should look for evidence of maxillary or maxillary sinus fractures, but the information we have is insufficient for coding an injury here.
Q: If patient has a stab wound of the thigh extending into muscle (but not bone), what is the correct code and should it be assigned to the External ISS body region or the Extremity ISS body region?
A: The correct code is 816014.1 and the injury is assigned to the External ISS body region. Although the dictionary does inclue specific codes for muscle injuries in the Extremities chapters, those codes are intended for blunt injury. Penetrating injuries to the...
Q: The patient expired immediately from blast injuries which have, in addition to multiple other injuries, transected the spinal cord at the level of C5. How should the spinal cord injury be coded?
A: The correct code is 640261.5. Although we do not have specific information about paralysis, by definition "transection" means complete transection, and complete transection of the spinal cord results in paralysis, so the injury is coded as a complete cord syndrome.
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...
Q: The patient has sustined a single gun shot wound to the head with penetration greater than 2 cm into the right temporal lobe. In addition, he has an associated large subdural hematoma over the right parietal lobe. How would you code these findings?
A: All injuries associated with a gunshot wound to the head are coded as one injury. In this case the correct code is 116004.5 (Penetrating Injury to Skull, major – Whole Area) or 140692.5 (Penetrating Injury to Cerebrum > 2 cm deep) since we know it is in the...
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 with diffuse axonal injury (DAI), confirmed by both clinical and radiologic evidence, also has an intraventricular hemorrhage and subarachnoid hemorrhages. This patient remained unconscious from the time of the insult until discharge from the ICU 7 days after admission. How would you code the intraventricular hemorrhage and subarachnoid hemorrhages in AIS 2005?
A: These injuries should not be coded. DAI is an example of a global injury which may or may not be accompanied by other radiologic findings. A clarification for coding DAI is now included on page 40 in the Updated Pages found at www.aaam1.org/ais .
Q: How does one code a closed trimalleolar fracture?
A: In AIS 98 the correct code is 851612.2In AIS 205 the correct code is 854465.2Note that the early editions of AIS 2005 did not include this code. Over the last several months, there have been several additions and corrections. Please refer to www.aaam1.org/ais and...
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?
A:650226.2, C1 lateral mass (pedicle) fracture650217.2, C4 multiple fractures of same vertebra650217.2, C5 multiple fractures of same vertebraEach vertebra is coded separately. AIS 2005 clarifies where to code various portions of the C1 vertebra, and also adds a new...
Q: A patient sustains a stab wound to the left ventricle which also penetrates the septum. What are the correct codes for this injury?
A:Left ventricle laceration - 441012.5Septum laceration - 441300.5Pericardium laceration - 441602.2The 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...
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...
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...