A: 1. There is nomention of spinal cord injury at all so that cannot be coded even through it is very likely. It appears the cervical injury may be the cause of expiration but there is always the possibility of internal injury not mentioned and an abbreviated examination due to the mechanism. We cannot presume there is cord injury based on the documentation present.
We must code conservatively based on what we do know.
Code 650216.2. Fracture with or without dislocation no cord involvement NFS.
Why would we not use the box directions to code specific for C1? We have no description at all as to what part of C1 is fractured or if there are multiple fractures. The same is true for C2. In the case of fracture dislocation you code once to the superior vertebrae involved.
2. Crepitus R ribs 1-6 here there is a minimal Med Examiner report that is hardly complete so we can use the AIS guidelines to code these rib fractures based on clinical observation since the patient did expire. code 450210.2 (See the boxed rule p.82)
Note: Normally you are not to code fractures without radiological evidence but in this case it was appropriate to code based on the very obvious clinical evidence of extremity fracture and expiration precluding any diagnostics. You would use a NFS code since you don’t have radiological evidence to “place” the fracture location.
3. Crepitus R femur NFS-830001.3
4. Open fracture mid shaft L femur-8532223 (you can see this location)
5. Multiple lacerations/abrasions over back and flank: Two ISS body regions are included here since the flank is included in the abdomen body region and AIS directions encourage coding in the correct body chapter but assigning superficial injury to the external ISS body region.
Laceration back-410600.1 we know no specifics about the lacerations so use the NFS code.
Flank-510600.1 we use the NFS code.
You may assume the abrasions and lacerations are in the very same location with the laceration as the deepest part of the injury but it would be an assumption. Since the trauma sheets state abrasions without location you can also code the abrasions in each region they occur as you did the lacerations. Abrasions thorax 410202.1 Abdomen 510202.1.
Both the lacerations and abrasions could each be coded with one external body region code as multiple injury without specific location 910200.1 and 910600.1. The ISS will be the same either way these superficial injuries are coded.