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 dictionary. If the
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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.
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.
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 temperature is low and causes chilling that requires additional treatment
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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 scores. The AIS book is the most reliable reference.
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 anterior prominence of the proximal tibia, the tibial tubercle.The correct answer would be
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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
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 fracture individually. If the frontal bone fractures
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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 first example T12-L1
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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 calculation and the tibia fracture (854221.2)
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