Q: Pelvic fractures are coded much differently in AIS 2005. What are the most specific AIS codes for the following three different pelvic fracture descriptions? 1) Complex fractures of pelvis with comminuted fractures of superior and inferior public rami bilaterally, separation of pubic symphysis and separation of L sacroiliac joint. 2) Multiple severe fractures of pelvis. 3) Non-displaced fracture R sacrum. Fracture of anterior column of R acetabulum extending along R iliac bone and comminuted fracture through R sacral ala.

May 1, 2008 | Head/Neck | 4 comments

A: 1) The involvement of the SI joint indicates partial instability of the posterior arch of the pelvis. All of the other fractures are in the anterior portion of the pelvic ring, and are not factors in the stability of the pelvis. The correct code is 856161.3.2) Although this sounds like a potentially unstable pelvic

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Q: A 30 year old patient sustains the following burns: 20% first degree (superficial) 30% second degree (partial thickness) 5% third degree (full thickness) How are these burns coded in AIS 2005?

Jan 1, 2008 | Head/Neck | 0 comments

A: The correct codes are as follows:912002.1 for the first degree burns912024.4 for the second and third degree burns combined. This question highlights a change in the manner in which we are now addressing multiple burns. In the January 2008 revision of the AIS dictionary the burn rule has been restated as follows: When burns

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Q: The patient has extensive, unstable pelvic fractures with complete SI joint disruption and the CT also demonstrates a large retroperitoneal hematoma with shift of the urinary bladder to the left of midline. What is the best code for these pelvic fractures?

Aug 1, 2007 | Head/Neck | 0 comments

A: The correct code is 856173.5. The blood loss of >20% will probably not be found clearly documented in the chart, since physicians do not want to disturb the hematoma and rarely estimate its volume. However, the extensive fractures and the shift of the urinary bladder are objective signs that can be used to estimate

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Q: A patient sustains a duodenal laceration involving > 75% of D3 (the transverse portion). How is this injury coded in AIS 2005?

Jun 1, 2007 | Head/Neck | 0 comments

A: The correct code is 541023.3. The coder should note that the portion of the duodenum that is inolved will affect the severity code. D2 (the descending portion) carries a higher severity when it is involved.

Q: A patient sustains a stab wound to the left ventricle which also penetrates the septum. What are the correct codes for this injury?

Feb 1, 2007 | Head/Neck | 0 comments

A:Left ventricle laceration – 441012.5Septum laceration – 441300.5Pericardium laceration – 441602.2 The rule for penetrating injury is to code the underlying injuries but not the skin wound. Although the pericardium is not mentioned, the only way to the ventricle and the septum is through the pericardium and it may also be coded.

Q: The patient was involved in a rollover crash and sustained a vertebral artery thrombosis in the neck with resultant hemiplegia. What is the correct code?

Jan 1, 2007 | Head/Neck | 0 comments

A: The correct code is 321020.4. A common coding error is to assign the code 321016.4 which is the first code referring to thrombosis seen in the dictionary. That code refers to thrombosis resulting from a laceration to the artery so we must use the code below which states “thrombosis (occlusion) secondary to truama”. In

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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?

Nov 1, 2006 | Head/Neck | 0 comments

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: 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?

Mar 1, 2006 | Head/Neck | 0 comments

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?

Feb 1, 2006 | Head/Neck | 0 comments

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 will notice however that the severity is not affected in this

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Q: If a patient develops an extremity compartment syndrome after admission, would it be included as an anatomical diagnosis?

Nov 1, 2005 | Head/Neck | 0 comments

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 the AIS Course:A

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