CAISS-AIS FAQS CODING. EXAM
QUESTIONS WITH 100% CORRECT
ANSWERS L LATEST VERSION 2025/2026.
Q: How is an aneurysm coded? - ANS A: An aneurysm is a sac formed by the dilatation of the
walls of an artery or a vein and filled with blood; Code as an intimal tear
Q: How is a pseudoaneurysm coded: - ANS A: A pseudoaneurysm is a hematoma formed by a
leaking hole in an artery. Code as a vessel laceration
Q: How do I decided between coding Open vs. External approaches for procedures on open
wounds - ANS A: External approach is for procedures performed directly on the skin or
mucous membrane and procedures performed indirectly by the application of external force
through the skin or mucous membrane. Examples of external approach procedures are closed
fracture reduction, laceration repair of skin or mucous membranes, and excisional debridement
of skin only. Repair L lower arm subcutaneous tissue and fascia, OPEN approach
Q: A patient is found down in an apartment fire without cardiac activity and was resuscitated
and transported. She had a bronchoscopy and found to have a mild inhalation injury with
elevated carbon monoxide levels. How would you code this injury and why? - ANS A: This
would be coded as an inhalation injury. The asphyxia codes do not apply to inhalation injury.
Carbon monoxide poisoning is not a codeable injury and asphyxia applies to mechanical
constriction or restriction of the airway. You may only code the inhalation injury.
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Q: When you start coding with ICD-10, there are many questions that arise. You need to make a
decision on how specific you want to be with your code selection? There are many thoughts on
coding in trauma systems and you may ask should you code everything as specific as possible?
Or, can you code less specifically and perhaps have a more efficient work process for your
registrars? - Do very specific codes have an impact on our ISS? In other words, if I code super
specific, will my ISS's be higher? - ANS A: In regard to theses question, we recommend coding
as specifically as possible using the AIS 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.
Q: How are GSWs resulting in bony fractures or with the missile "lodged in" the bone are
coded? - ANS A: Gunshot wounds resulting in bony fractures or with the missile "lodged in"
the bone are coded as open fractures.
Q: CT scan abdomen/pelvis shows: - spleen normal; kidneys and adrenal glands normal; liver
laceration gr IV injury - multiple deep lacerations. The patient is taken to OR where the
operative note states liver laceration gr V injury. What would you code? - ANS A: 541828.5;
The surgeon is visually observing the liver and thus the operative grading is more accurate than
the CT scan. An autopsy would also over-ride the reading of the CT if the grade is different.
Q: Scenario: Man falls from a ladder while trimming a tree striking the upright post of a metal
fence before impact on the ground. 1. Deep 18cm laceration across the abdomen with obvious
evisceration of bowel. Exploratory Lap report only describes a Serosal tear at the junction of the
duodenum and jejunum with a small hematoma. How would you code these injuries? -
ANS A: You cannot code evisceration, code the abdominal laceration as minor laceration < 20
cm 510602.1, code serosal tear assigning it to the jejunum as partial thickness injury 541422.2
hematoma is already part of this injury.
Q: Elderly patient fell out of bed, landing on his right side and c/o RUQ pain; CT of the abdomen
demonstrates an injury to the ligamentum teres hepatis. What would you do with this injury? -
ANS A: The ligament teres hepatis represents the remnant of the fetal left umbilical vein. As
such, it is not a codeable injury.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Q: How do you code a renal artery psuedoaneurysm? - ANS 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 pseudoaneurysm is a hematoma formed by a leaking hole in an artery. Code
as a vessel laceration.
Q: How do you code a large abdominal wall hernia on the R side of the abdomen (NOT the
Rectus Abdominus muscle) with a 15 cm fascial defect that required open operative
management to close? The skin was intact. This was a seatbelt injury in a 12 yr. old. - ANS A:
This should be coded as 510602.1. This is a "skin" code (assigned to the External ISS body
region) and includes skin, subcutaneous and muscle lacerations or tears. Although the outer
skin was intact, clearly there was damage below the surface. I realize this seems quite low in
severity for an injury that was clearly complex, but it's the best AIS has to offer.
Q: A person with a full bladder is struck by a car while crossing the street. He is able to ambulate
but experiences severe abdominal pain and faints. In the ED he has low volume hematuria and
the FAST scan shows intraperitoneal fluid. He is taken to surgery and repair of a 3cm laceration
on the posterior surface of the dome of his bladder is done. Please code this bladder injury. -
ANS
Q: Scenario: Man falls from a ladder while trimming a tree striking the upright post of a mental
fence before impact on the ground. 1. Deep 18cm laceration across the abdomen with obvious
evisceration of bowel. Exploratory Lap report only describes a 2. Serosal tear at the junction of
the duodenum and jejunum with a small hematoma. How would you code these injuries? -
ANS
Q: A patient sustains a duodenal laceration involving > 75% of D3 (the transverse portion). How
is this injury coded in AIS 2005? - ANS A: The correct code is 541023.3. The coder should note
that the portion of the duodenum that is involved will affect the severity code. D2 (the
descending portion) carries a higher severity when it is involved.
Q: According to Organ Injury Scaling (OIS) guidelines in many cases you may advance one grade
for multiple lacerations of an organ. ("Advance one grade for multiple injuries to same organ up
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, to Grade III." AAST) How should multiple Grade II liver lacerations be coded in AIS? - ANS A:
Although the Organ Injury Scale allows one to assign a higher grade for multiple lacerations to
an organ, the AIS does not allow that for our coding. Multiple Grade II liver lacerations should
be coded as 541822.2.
Q: How is Hemoperitoneum coded? - ANS A: Hemoperitoneum is not codeable in AIS
Q: What are the Intraperitoneal organs - ANS A: Intraperitoneal organs are completely
wrapped by visceral peritoneum. These organs are the liver, spleen, stomach, superior part of
the duodenum, jejunum, ileum, transverse colon, sigmoid colon and superior part of the
rectum.
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 - ANS 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: 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. - ANS 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: How would you code an intertrochanteric femur FX w/ subtrochanteric extension? -
ANS A: I remember Kathy Cookman saying that if there's a fracture "extension", then you
would code to the main fracture, which in this case is the IT FX.
Q: When you have a fracture of the tibia and the fracture extends from the shaft into the distal
bone how do you code? In this situation, it is one fracture that is branching out over multiple
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
QUESTIONS WITH 100% CORRECT
ANSWERS L LATEST VERSION 2025/2026.
Q: How is an aneurysm coded? - ANS A: An aneurysm is a sac formed by the dilatation of the
walls of an artery or a vein and filled with blood; Code as an intimal tear
Q: How is a pseudoaneurysm coded: - ANS A: A pseudoaneurysm is a hematoma formed by a
leaking hole in an artery. Code as a vessel laceration
Q: How do I decided between coding Open vs. External approaches for procedures on open
wounds - ANS A: External approach is for procedures performed directly on the skin or
mucous membrane and procedures performed indirectly by the application of external force
through the skin or mucous membrane. Examples of external approach procedures are closed
fracture reduction, laceration repair of skin or mucous membranes, and excisional debridement
of skin only. Repair L lower arm subcutaneous tissue and fascia, OPEN approach
Q: A patient is found down in an apartment fire without cardiac activity and was resuscitated
and transported. She had a bronchoscopy and found to have a mild inhalation injury with
elevated carbon monoxide levels. How would you code this injury and why? - ANS A: This
would be coded as an inhalation injury. The asphyxia codes do not apply to inhalation injury.
Carbon monoxide poisoning is not a codeable injury and asphyxia applies to mechanical
constriction or restriction of the airway. You may only code the inhalation injury.
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Q: When you start coding with ICD-10, there are many questions that arise. You need to make a
decision on how specific you want to be with your code selection? There are many thoughts on
coding in trauma systems and you may ask should you code everything as specific as possible?
Or, can you code less specifically and perhaps have a more efficient work process for your
registrars? - Do very specific codes have an impact on our ISS? In other words, if I code super
specific, will my ISS's be higher? - ANS A: In regard to theses question, we recommend coding
as specifically as possible using the AIS 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.
Q: How are GSWs resulting in bony fractures or with the missile "lodged in" the bone are
coded? - ANS A: Gunshot wounds resulting in bony fractures or with the missile "lodged in"
the bone are coded as open fractures.
Q: CT scan abdomen/pelvis shows: - spleen normal; kidneys and adrenal glands normal; liver
laceration gr IV injury - multiple deep lacerations. The patient is taken to OR where the
operative note states liver laceration gr V injury. What would you code? - ANS A: 541828.5;
The surgeon is visually observing the liver and thus the operative grading is more accurate than
the CT scan. An autopsy would also over-ride the reading of the CT if the grade is different.
Q: Scenario: Man falls from a ladder while trimming a tree striking the upright post of a metal
fence before impact on the ground. 1. Deep 18cm laceration across the abdomen with obvious
evisceration of bowel. Exploratory Lap report only describes a Serosal tear at the junction of the
duodenum and jejunum with a small hematoma. How would you code these injuries? -
ANS A: You cannot code evisceration, code the abdominal laceration as minor laceration < 20
cm 510602.1, code serosal tear assigning it to the jejunum as partial thickness injury 541422.2
hematoma is already part of this injury.
Q: Elderly patient fell out of bed, landing on his right side and c/o RUQ pain; CT of the abdomen
demonstrates an injury to the ligamentum teres hepatis. What would you do with this injury? -
ANS A: The ligament teres hepatis represents the remnant of the fetal left umbilical vein. As
such, it is not a codeable injury.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Q: How do you code a renal artery psuedoaneurysm? - ANS 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 pseudoaneurysm is a hematoma formed by a leaking hole in an artery. Code
as a vessel laceration.
Q: How do you code a large abdominal wall hernia on the R side of the abdomen (NOT the
Rectus Abdominus muscle) with a 15 cm fascial defect that required open operative
management to close? The skin was intact. This was a seatbelt injury in a 12 yr. old. - ANS A:
This should be coded as 510602.1. This is a "skin" code (assigned to the External ISS body
region) and includes skin, subcutaneous and muscle lacerations or tears. Although the outer
skin was intact, clearly there was damage below the surface. I realize this seems quite low in
severity for an injury that was clearly complex, but it's the best AIS has to offer.
Q: A person with a full bladder is struck by a car while crossing the street. He is able to ambulate
but experiences severe abdominal pain and faints. In the ED he has low volume hematuria and
the FAST scan shows intraperitoneal fluid. He is taken to surgery and repair of a 3cm laceration
on the posterior surface of the dome of his bladder is done. Please code this bladder injury. -
ANS
Q: Scenario: Man falls from a ladder while trimming a tree striking the upright post of a mental
fence before impact on the ground. 1. Deep 18cm laceration across the abdomen with obvious
evisceration of bowel. Exploratory Lap report only describes a 2. Serosal tear at the junction of
the duodenum and jejunum with a small hematoma. How would you code these injuries? -
ANS
Q: A patient sustains a duodenal laceration involving > 75% of D3 (the transverse portion). How
is this injury coded in AIS 2005? - ANS A: The correct code is 541023.3. The coder should note
that the portion of the duodenum that is involved will affect the severity code. D2 (the
descending portion) carries a higher severity when it is involved.
Q: According to Organ Injury Scaling (OIS) guidelines in many cases you may advance one grade
for multiple lacerations of an organ. ("Advance one grade for multiple injuries to same organ up
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, to Grade III." AAST) How should multiple Grade II liver lacerations be coded in AIS? - ANS A:
Although the Organ Injury Scale allows one to assign a higher grade for multiple lacerations to
an organ, the AIS does not allow that for our coding. Multiple Grade II liver lacerations should
be coded as 541822.2.
Q: How is Hemoperitoneum coded? - ANS A: Hemoperitoneum is not codeable in AIS
Q: What are the Intraperitoneal organs - ANS A: Intraperitoneal organs are completely
wrapped by visceral peritoneum. These organs are the liver, spleen, stomach, superior part of
the duodenum, jejunum, ileum, transverse colon, sigmoid colon and superior part of the
rectum.
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 - ANS 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: 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. - ANS 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: How would you code an intertrochanteric femur FX w/ subtrochanteric extension? -
ANS A: I remember Kathy Cookman saying that if there's a fracture "extension", then you
would code to the main fracture, which in this case is the IT FX.
Q: When you have a fracture of the tibia and the fracture extends from the shaft into the distal
bone how do you code? In this situation, it is one fracture that is branching out over multiple
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
