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.
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) is not coded additionally.
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 the compression fracture of T 1.
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. The humerus has two (2) areas described
A: From what we can tell the septum pellucida is the structure that separates the anterior horns of the lateral ventricles, so when it is torn we would expect to see intraventricular hemmorage. The faculty seems to agree that the cerebral laceration should be coded (140688.3) in addition to the IVH. Although the IVH is
A: Although the Organ Injury Scale allows one to assign a higher grade for multiple lacerations to an organ, the AIS does not allow that for our coding. Multiple Grade II liver lacerations should be coded as 541822.2.
A: Code 912024.4 30% patient is older than 5 years. Burns can appear less severe at the time of incident but can evolve in degree and extent so the Burn specialist documentation should be most accurate in this case
A: Asphyxia, although a sequelae of injury, is codeable when it is the direct result of the trauma. The code is found in the external and other trauma chapter of the dictionary. Code: 020002.3 and assign to the head body region for ISS.
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 hypoxemia as well
: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 case NFS was the best choice.