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 LOC. If
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.
A: Gray’s Anatomy lists the vomer as one of the facial bones. Specifically it is the posterior part of the nasal septum. So the code would be 2510006.2.
A: Traumatic pleural effusion is a consequence or sequela of injury. It is not listed in the AIS dictionary and is therefore not codable in AIS.
A: Do not code coma in addition to the hemorrhage. When there is an anatomic brain injury the concussive codes are not used additionally. If the only injury is a skull fracture (no damage to the brain substance) and there is documented LOC you may use the concussive injury codes additionally.
A: Traumatic pleural effusion is a consequence, or sequela, of injury and cannot be coded. Remember that only those sequelae listed in the AIS Dictionary may be coded- if you can’t find it, you can’t code it.
A: Code 080002.3 the muscle necrosis is indicative of the severity of the injury.
A: Code the injury at the L knee as a crush injury at or above the knee code 813002.4, bone, soft tissue, vascular and nerve were all involved. You would also code the open L mid shaft tibia fx even though the leg was amputated this was still an injury
A: Cannot code evisceration, code the abdomianl laceration as minor laceraton < 20 cm 510602.1, code serosal tear assign to jejunum as partial thickness injry 541422.2 hematoma is part of this injury, Lis Franc injury is a dislocation of tarsometatarsal joints with no mention of fracture, cartilage involvement or ligament injury so code 878030.1
A: This fracture requires more information as to whether or not this is a tarsal or a carpal bone; In an actual clinical situation, the physical examination and xray would b labeled as wrist or foot; If this is a tarsal navicular fx then the appropriate code would be 857451.2; if this is a carpal