Q: A trauma activation is called for a patient with a GSW to the lower abdomen. Immediate laparotomy is undertaken and a perforation to the sigmoid colon identified. The sigmoid is resected, colostomy placed, and the patient moves to the ICU. Please code this abdominal injury

Sep 1, 2011 | Head/Neck | 0 comments

A: The sigmoid is part of the colon and therefore coded to the “colon” in the abdomen chapter. A perforation is identified. The injury should not be coded any more severely just because the sigmoid was resected. Code:540824.3

Q: Patient arrives after a fall down a flight of outdoor stairs. The patient experiences an unknown period of exposure prior to being found and brought to the ED. The initial core temperature on arrival is 90.1 degrees Fahrenheit; What would you do with this information?

Jun 1, 2011 | Head/Neck | 0 comments

A: A tempreature of 90.1F is equivalent to a temperature of 32.3 C and therefore meets criteria for the hypothermia code 010004.2; this is not induced for medical treatment but rather from exposure and is included as an injury.

Q: Coming out from church, Ida trips and falls and is unable to get up. She is brought into the ED by family c/o ankle pain; Xray reveals a R bimalleolar fx; How would you code this injury?

Mar 1, 2011 | Head/Neck | 0 comments

A: There is not enough information to determine the degree of articular involvement; therefore fibula nfs must be used according to the rule box Code: 854441.2

Q: A young lady arrives to the ED. She was on her way home from school and as usual climbed over a fence as a short cut. However today suffered a straddle injury while going over the fence. She has evidence of a large contusion of the vulva. There are no lacerations and there is no vaginal injury.

Sep 1, 2010 | Head/Neck | 0 comments

A: 545610.1; although the injury appears to be a skin contusion, the vulva is part of the abdomen and is coded there. It is also coded to the abdomen for the ISS.

Q: CT scan face – fracture of the lamina papyracea.

Jan 1, 2010 | Head/Neck | 0 comments

A: 251231.2; The lamina papyracea is the medial wall of the orbit.

Q: What is the correct code for pericardial tamponade?

Oct 1, 2009 | Head/Neck | 0 comments

A: If there is no documentation of injury to the heart muscle the correct code is 441605.4. An injury to the heart would be coded additionally.

Q: What is the correct code for a bimalleolar fracture/dislocation of the ankle?

Apr 1, 2009 | Head/Neck | 1 comment

A: This is really two injuries. The bimalleolar fracture is coded 854441.2 since the exact location of the fracture is not known (see the rule box at the top of page 151 in AIS 2005 Update 2008). The dislocation is also coded. In this case (since no other information is given) the code is 877130.2.

Q: How do you code a temporal artery laceration?

Dec 1, 2008 | Head/Neck | 0 comments

A: In the AIS 2005, Update 2008 we clarified coding of the temporal artery in FACE. 220200.1 now reads “External carotid artery branch(es) laceration NFS [includes facial, temporal, and internal maxillary]. The two codes indented under that code apply as well.

Q: How should one code asphyxia related to hanging?

Nov 1, 2008 | Head/Neck | 0 comments

A: Asphyxia codes are now available in AIS 2005, located in the Other Trauma section. Since we have no information as to neurological deficit, the correct code to use is 020000.3. There are also codes in the Head chapter for “hypoxic or ischemic brain damage secondary to systemic hypoxemia, hypotension or shock” but these codes

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Q: What is the best way to describe bilateral fractures in the trauma registry?

Jul 1, 2008 | Head/Neck | 1 comment

A: Bilateral fractures should be entered two times, coding right and left sides separately. The clarification can be made in the written description in the registry, indicating ‘right’ or ‘left’. In AIS 98 there is some opportunity to describe where on the bone the fracture occurs, so there may also e some difference in the

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