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Q: The patient sustains an injury to his lungs with peripheral pulmonary hemorrhages following a gas well explosion. How would this be coded?
A: In AIS 98, the only option for this injury is 441499.3 Lung NFSIn AIS 2005, this is one of many new descriptors that have been added to the dictionary. The correct code for his injury is 441424.4.
Q: The patient is an unrestrained passenger admimtted following a high speed MVC. He has been unconscious without sedation of paralytic medications since admission 48 hours ago. His CT demonstrates petechial hemorrhages in the area of the corpus callosum and basal ganglia. The neurosurgeon diagnoses diffuse axonal injury (DAI). What is the correct AIS code?
A: In AIS 98 the correct code is 140628.5In AIS 2005, there are two areas in which DAI may be coded. The correct code in AIS 2005 is 140627.5 Cerebrum, DAI involving corpus callosum. If the CT had noted only hemorrhages in the basal ganglia, or more broadly, petechial...
Q: A 24 year old male is admitted after a fight. His facial CT demonstrates multiple linear fractures of the mandible, including L condyle, L body and R ramus. There is a deep laceration overlying the left portion of his jaw. The fractures are described as minimally displaced. How would you code these injuries?
A: These injuries present something of a dilemma. The rules and guidelines that apply include: Code bilateral mandible fractures as a single injury. Displacement must be significant (guideline added to AIS 2005 dictionary). With open fractures, do not code the...
Q: An elderly gentleman falls down stairs and sustains an injury to the neck with paralysis of the upper extremities with some movement of the lower extremities. There is a fracture noted at C5. He is diagnosed with central cord syndrome. Over the next several weeks he slowly regains function of his extremities. How would you code this injury?
A: Spinal cord injuries should be coded based on the patient's status at 24 hours. The correct code for this injury is 640214.4 -- cord contusion, incomplete cord syndrome, with fracture.Because the patient does improve, coders frequently want to use the code for...
Q: When are penetrating injuries assigned to the External body region for ISS purposes?
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...
Q: The patient ingested Draino and Tilex and has a mild caustic injury to the take-off of the LUL and LLL of the respiratory system. Patient also has a grade II injury (friable) to the esophagus and grade III injury (deep ulcers) to the stomach and pylorus. How should these injuries be coded and what is the ISS?
A: AIS 98: Bronchus distal to main stem, partial thickness injury - 440206.2ISS = 13AIS 2005: Bronchus distal to main stem, partial thickness injury - 440206.2Esophagus partial thickness ingestion injury - 440807.3Stomach ulcers (also a partial thickness ingestion...
Q: If a 1-year-0ld patient sustains TBSA 21% burns of 2nd degree with face involvement, what is the correct code to use?
A: There are two correct answers for this question in AIS 98. The code 912020.4 indicates burns to a child less than 5 years of age. The code 912022.4 indicates facial involvement. It is up to the coder to decide which of the two is more important to note their choice...
Q: A patient sustains closed fractures to the left acetabulum, left inferior and superior pubic rami and the left ilium. How should this injury be coded?
A: In AIS 98 the correct code is 852602.2In AIS 2005 the pelvic ring and the acetabulum are coded separately, so the correct codes are 856151.2 (pelvic ring) and 856200.2 (acetabulum). Note that the severity of the injury is unchanged, but the specificity of coding...
Q: A patient sustains vertebral body fractures of C7 and T1 with complete quadriplegia due to cord contusion at C6-7 level. How should this injury be coded and what is the ISS?
A: AIS 98 - The correct codes are 640224.5 and 650430.2. The ISS is 29. It would be incorrect to assign the deficit twice but it is important to capture the two fractures which occur in two different ISS body regions. These codes are the same in AIS 2005.
Q: What is the correct code for a single small (< 1 cm) cerebral contusion?
A: The correct code in AIS 98 is 140606.3. Thanks to everyone who participated and congratulations to our three contributors who gave the correct answer. The answer 140604.3 identifies a single contusion, but does not get as specific ("small") as the correct code. You...
Q: Where does one find the AIS code for a fractured thyroid cartilage?
A: Reference to the thyroid is made in the Neck chapter of the AIS dictionary under Larynx. A common coding mistake is to code thyroid cartilage injuries using the thyroid gland descriptors.
Q: A patient involved in an ATV wreck has multiple facial fractures that do not meet the criteria for a LeFort fracture diagnosis. How should they be coded? The highest AIS severity code for individual facial fractures is .2 and that doesn’t seem to reflect the severity of these multiple fractures.
A: The patient with multiple complex facial fractures that do not meet the criteria for LeFort fractures presents a dilemma for the coder using the AIS 90 Update 98 dictionary. There really isn't a good option in that version. The IISC has added a new code in AIS 2005...
Q: If a patient develops an extremity compartment syndrome after admission, would it be included as an anatomical diagnosis?
A: Compartment syndrome is one of those tricky diagnoses that make a coder's life difficult. It can be both a diagnosis and a complication. If it is a complication or sequela of an injury, it is not coded. If it is an injury, it is coded. Here's an example we use in...
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...
Q: How would the following be coded and scored? L rib disarticulations … Per autopsy report: “On the left, ribs 2, 3, and 4 are hypermobile medially and apparently dislocated from their vertebral articulations. No fractures are palapable or evident.”
A:Thanks to Jody and Terri for participating in our online discussion. One of the difficulties for those who are experienced in ICD 9 coding is that AIS and ICD 9 just don't always work the same way. As Jody noted, there are no AIS codes for rib dislocations, and...
Q: What is the correct code for an internal carotid artery occlusion?
A: This is impossible to answer correctly unless you have a little more information. The internal carotid artery can be coded under HEAD 121004.4 if the occlusion occurs in that portion of the artery, or under NECK 320220.3 if the occlusion occurs lower. This question...
Q: What is the appropriate code for femoral head dislocation? This is not a fracture. When I look under ‘Joints’ it states, “For femoral head, see femur.” When I look at femur it only lists fractures.
A: Many thanks to Terri and DeDe for their comments. Terri's code is correct and DeDe points out the importance of noting all the guidelines included in the dictionary.The dictionary is somewhat misleading the way it is currently written. The implication in the bolded...