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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A: One fracture line gets only one code. Think of the most severe or important code you want to capture. If the line extends to the articular surface (an intraarticular fracture) we would code it there. If it just goes into the metaphysis but doesn”t involve the joint surface, code to the shaft.
A: A pseudoaneurysm, also termed a false aneurysm, is a leakage of arterial blood from an artery into the surrounding tissue with a persistent communication between the originating artery and the resultant adjacent cavity.
A: This would be coded as an inhalation injury. The asphyxia codes do not apply to inhalation injury. Carbon monoxide poisoning is not a codable injury and asphyxia applies to mechanical constriction or restriction of the airway. You may only code the inhalation injury.
A: The correct code for this injury is 321004.3. This was described as a “dissection” in the conclusion of the MRI and the patient had subsequent neurologic deficit (infarcts). The brain “injuries” occurred as a result of the dissection, not direct trauma to the brain stem.