Blog Grid Layout
For a full width blog, use the full-width blog module.
Q: What do I code if the patient has LOC and an associated anatomical head lesion?
A: If the patient has an anatomic injury to the brain (e.g. SDH, IVH, SAH, etc.) in addition to LOC, the LOC will only be acknowledged by AIS if there is a coma modifier listed with the injury, such as is found with several injuries on page 48 of the AIS 2008...
Q: When and how do I code LOC?
A: You may use codes 161002.2 through 161006.3 when the MD confirms "positive LOC". This does not have to be witnessed by the MD. If they believe there was LOC and document it, we may code it. We do not need to have the word "concussion" in the chart in order to code...
Q: How and when can I code “œconcussion”?
A: You may only code "concussion" (specifically codes 161000.1 and 161001.1) when the word "concussion" is given by the MD as the only brain injury diagnosis.
Q: Where do I code the pars interarticularis
A: This is coded to the pedicle. Anatomically it does lie between the lamina and pedicle, but our neurosurgeon consultants have identified that it is most appropriate to code it to the pedicle.
Q: How do I code Hypothermia?
A: Hypothermia is coded if it is a result of the primary injury, not treatment related or sequel of treatment. The temperature should be taken at your facility and be a core temperature - we would say you don't qualify for "Hypothermia" unless the environmental...
Q: When you start coding with ICD-10, there are many questions that arise. – Do you need to make a decision on how specific you want to be with your code selection? There are many thoughts on coding in trauma systems and you may ask should you code everything as specific as possible? – Or, can you code less specific and perhaps have a more efficient work process for your registrars? – Do very specific codes have an impact on our ISS? In other words, if I code super specific, will my ISS’s be higher?
A: In regard to theses question, we recommend coding as specifically as possible using theAIS Dictionary, and not relying on the computer to identify the codes since they don"t always match and may give you inaccurate AIS conversions and therefore inaccurate ISS...
Q: You have a patient with a penetrating knife injury to the extremity that lacerates (only) the muscle. Should you use just the penetrating codes or muscle laceration under skin subcutaneous tissue. Is this a blunt or penetrating injury?
A:This is considered penetrating trauma and you would code penetrating trauma using the penetrating injuries section. If you look at the rule box above the skin subcutaneous muscle section it identifies that you should code blunt soft tissue injury in that section.
Q: Do you consider a pterygoid fracture to be a skull base fracture? Or even a skull fracture?
A: The pterygoid plates are a part of the sphenoid bone and are therefore part of the skull base for AIS coding. The exception to this is if they are included in a confirmed LeFort fracture. In that case the injury is coded to the face and the sphenoid (base fracture)...
Q: If you have a LeFort I fracture and bilateral mandibular fractures how would you code the injury?
A: The LeFort I fracture does include the maxillary alveolar process, but NOT the mandible so you would code that separately, depending upon the type of mandibular fracture. Remember that the mandible only gets one code even if the fractures are bilateral.
Q: How would you code the following injury; small intraventricular hemorrhage in the third and fourth ventricles with associated obstructive hydrocephalus?
A: The only codes for intraventricular hemorrhage are located within the cerebrum chapter of the dictionary and are listed on page 48 of your dictionary, but the answer will depend upon whether the patient is unconscious. As you can see there are 3 separate codes and...
Q: You review a record where the Orthopaedic surgeon states “the patient has a patellar fracture which looks like an inferior pole and essentially an avulsion of the patellar tendon” The x-ray identifies – “œavulsion of the distal pole of patella with a small fragment of bone left.” How would you code this injury?
A: The infrapatellar component of the extensor mechanism is the patellar ligament, also known as the patellar tendon. The patellar ligament originates at the lower pole of the patella, where it has contributions from the aponeurosis mentioned above, and inserts on an...
Q: Have the following finding on a patients MRI – “œsmall epidural hematoma from C7-T1 which is likely emanating from the compression fracture of T1″ ““ He does not have a C7 fracture. What would you code especially considering it involves the cervical and thoracic spine?
A: You should code the epidural at the highest level (C7) unless you have evidence of deficit at a lower level. You may not "double dip" and code the epidural again in the T-spine. Again, if there is no deficit, code 640200.3 for the epidural hematoma and 650430.2 for...
Q: How would you code this finding? Acute left parasymphyseal fracture of the left hemi mandible. Fracture of the angle of the right hemi mandible. When reviewing the physician notes they state, “right angle and left parasymphseal displaced mandible fractures.”
A: The mandible is one of the ring – like bony structures that only receives 1 code. You should code it to the largest mass area. As you go down the codes under mandible, they increase in body mass, so you would use the code for symphysis/parasymphysis 250614.2
Q: What would the AIS code be for a fracture of the surgical neck of the humerus?
A The surgical "neck " of the humerous is located at the proximal end of the humerus shaft. Therefore you would go to the proximal humerus codes and go down to the description of extra- articular. Since only one fracture line is described the correct code is 751151.2....
Q: If your CT reported the following injuries ““ “œRight mandibular condyle, ramus and coronoid process fracture. Complex right maxillary fracture involving the anterior, medial and lateral and superior walls (orbital floor), fracture of right pterygoid plates and orbital fractures involving the apex, lateral, superior and inferior walls with complex fractures of the frontal bone” How would you code this case ?
A This sounds like a panfacial fracture since it involves all 3 regions of the face, and it is not a LeFort. If it involves both sides of the face it would meet the definition of multiple and complex fractures for panfacial. If unilateral, you should code each...
Q: If Hyperdensities are seen along interhemispheric falx and the tentorium, keeping with acute extra-axial haemorrhage. How and where do we code these?
A: Hyperdensities generally refer to blood and in these areas are usually either SDH or SAH. The falx separates the right side of the cerebrum from the left side and the tentorium separates the cerebrum from the cerebellum. When blood is described as being "along the...
Q: What is the correct code for epidural hematoma extending to various levels of the spine, for example T12-L2, or C1-2-3-4 with an epidural at level C2?
A: This question often leads to come confusion with what and how to code all the issues. What level do you code, what if there is an associated deficit? A spinal epidural with no deficit is coded at the most superior level at which it is found. In the case of the...
Q: A patient falls down outside during cold weather and cannot get up. They are brought in by EMS with a core temp of 32.5 degrees Celsius and a tibial shaft fracture. What codes would you use and why? Which body regions do you put the codes for ISS calculation and why?
A: Yes there is a hypothermia code in AIS and you would use the code 010004.2, since this is how the patient arrived and is not the result of treatment (or lack thereof) in the hospital. In this case, the hypothermia, would go to the external region for ISS...