CAISS-AIS FAQs coding
650217.2, C4 more than one fractures of same vertebra - ANS-
650217.2, C5 a couple of fractures of identical vertebra" - ANS-
650226.2, C1 lateral mass (pedicle) fracture - ANS-
C1 Lateral mass gets coded to the Pedicle" - ANS-
C1 Posterior arch gets coded to the Lamina - ANS-
Coding DAI: HEAD INTERNAL ORGANS (p. 41)
Cerebrum
- 140628.Four: diffuse axonal injury (DAI) NFS [requires coma ?6 hours or, if fatal within 6
hours, diagnosis is made by pathological examination]
- 140625.4: DAI restrained to white rely or basal ganglia
- 140627.Five: DAI involving corpus callosum
- If white count number/basal ganglia and corpus callosum are involved code only the more
intense; do now not code each. If coma exceeds 24 hours and prognosis meets coding
regulations for DAI, use 161011.Five no matter what anatomic description is recorded. Read
"Diffuse Axonal Injury" (page 50) for coding steering. - ANS-Coding DAI: HEAD CONCUSSIVE
INJURY (p. Fifty one)
- Use this class to code a substantiated diagnosis of DAI if no anatomical description is
recorded or if coma exceeds 24 hours and meets the coding regulations for DAI. Read "Diffuse
Axonal Injury" (page 50) for coding steering.
- 161007.4: Diffuse Axonal Injury (extended worrying coma LOC ?6 hours no longer because of
mass lesion) NFS
- 161008.Four: LOC 6-24 hours (mild DAI)
- 161011.5: LOC >24 hours NFS
- 161012.5: without brainstem signs (mild DAI)
- 161013.5: with brainstem symptoms (severe DAI)
Brainstem signs: decerebrate; decorticate
Q: 50 y.O. Male became operating at the roof of a house underneath production whilst he fell at
the least 20?; he is complaining of lower back pain and the CT of the chest reveals a T12
compression FX of fifty% with extra fractures of the T12 pedicle and side at the left. There is not
any verified neurologic deficit. How might you code this harm? - ANS-A: This case demonstrates
the usage of the multiple fracture inside one vertebra code however the essential compression
FX need to be recognized one at a time because of the severity; It of direction, is usually
acceptable to code every fracture for my part is you so pick; Code: 650434.3 and 650417.2; or
650434.3 and 650426.2 and 650422.2
Q: 56 12 months. Antique admitted to the ED with documentation of 15% 2nd and third degree
burns to her chest and bilateral hands. Two days later a Burn specialist files that the affected
person has 30% 2d and third degree burns to equal frame regions. What is the maximum
correct code for this injury - ANS-A: Code 912024.4 30% affected person is older than five
years. Burns can seem much less excessive on the time of incident but can evolve in degree
and quantity so the Burn expert documentation have to be most accurate in this case
,Q: A 24 year vintage male is admitted after a combat. His facial CT demonstrates multiple linear
fractures of the mandible, together with L condyle, L body and R ramus. There is a deep
laceration overlying the left part of his jaw. The fractures are described as minimally displaced.
How might you code those accidents? - ANS-A: The regulations and tips that practice
encompass: Code bilateral mandible fractures as a unmarried damage. Displacement ought to
be giant. With open fractures, do no longer code the overlying pores and skin damage. The fine
preference is to use 250610.2. Open/displaced/comminuted but NFS as to web site. Note that
despite the fact that the displacement is minimal, the code is chosen for the open fracture in
preference to displacement.
Q: A 30 yr antique affected person sustains the subsequent burns: 20% first degree (superficial)
30% second degree (partial thickness) five% 0.33 degree (complete thickness) How are those
burns coded in AIS 2005? - ANS-A: The correct codes are as follows: 912002.1 for the primary
diploma burns; 912024.4 for the second one and third degree burns blended.
Q: A 36 y.O. Lady is running across the motorway and struck by means of a car at high velocity;
she is unresponsive on the scene and has an immediate CT-head which identifies a big bleed
probably on the sagittal sinus. Operative craniotomy reveals a laceration to the sagittal sinus
with a 2000 ml blood loss; the damage is irreparable; How do you code this injury? - ANS-A:
The blood loss, even though big, can't be attached to this injury mainly and laceration is the best
to be had code. Code: 122402.Four
Q: A four y o infant is by chance burned while his pajamas seize fireplace from a candle. His
burns are defined as 15% first, 10% 2nd and nine% third diploma. What is the proper manner to
code this injury? - ANS-A: The burn rule states that in instances defined this manner, the first
diploma burns should be coded one by one from the second one and third. Therefore, the first
degree burns are coded as 912002.1. The 2nd and 0.33 diploma burns collectively total 19 % so
they are coded together as 912014.Three. (Remember that this baby is much less than 5 years
antique.)
Q: A forty five y.O. Male is apneic with GCS of three at scene. Bullet entry is within the occipital
region of the skull with trajectory down and forward with go out on the throat. CT indicates huge
harm of the cerebrum, cerebellum, and brain stem along the bullet pathway Please code the
brain damage. - ANS-A: No matter what number of areas of the brain are worried in a
penetrating harm if the brain stem is concerned you code the harm as 140216.6 and should
have CT, MRI or different proof
Q: A baseball participant turned into by accident struck inside the throat with the aid of a tough
swung bat. He had instant ache and difficulty speakme. In the ED a laryngotracheoscopy was
accomplished with prognosis of nondisplaced fracture of the larynx with vocal twine contusion
and edema. Please code this damage. - ANS-A: Code 340210.4 the vocal cord involvement
increases the severity level of this harm
Q: A burn affected person arrives within the ED after being involved in a house fire where she
was eliminated from the bedroom engulfed in smoke and unresponsive. The initial evaluation
covered intubation, a CO stage and ABG showing pO2 60 mmHg. In addition, a bronchoscopy
turned into done to assess the airlines. The consequences had been positive carbonaceous
deposits requiring lavage to clear the airway and erythema with friable membranes. - ANS-A:
419206.Five; The mechanism of damage implies inhalation burn from respiration the
superheated air together with the smoke. Inflammation of the airlines, friability with obstruction
, of the bronchi requiring clearance is evidence of severe inhalation harm; ABG demonstrates
hypoxemia as properly
Q: A child got below the kitchen sink consuming a diffusion of caustic sellers, vomiting triggered
right away however chemical burn and sloughing of esophageal lining documented. No gastric
damage obvious. How could you code this harm? - ANS-A: The actual location of the
esophagus injured isn't stated as thorax (below the sternal notch) or to the neck so the default
code is to the neck region. This is an ingestion harm with partial thickness necrosis, the
sloughing of the lining of the esophagus, 340104.Three
Q: A baby is admitted to the ED after gambling on the trampoline wherein another infant landed
on him. X-rays are done and a navicular fracture is diagnosed. How might you code this
damage - ANS-A: This fracture calls for extra facts as to whether or no longer that is a tarsal or
a carpal bone; In an actual medical situation, the physical exam and x-ray would be labeled as
wrist or foot; If that is a tarsal navicular FX then the precise code would be 857451.2 (navicular
bone); if that is a carpal navicular then code 752461.2 (carpal bone).
Q: A guy touched a excessive voltage line with flash burns and injury to the gentle tissue and
muscle of the thumb facet of his R hand requiring serial debridement of necrotic muscle tissues.
Please code this injury - ANS-A: Code 080002.3 the muscle necrosis is indicative of the severity
of the harm.
Q: A motorcyclist crashes and sustains 15 % partial and complete thickness "avenue rash" in
addition to more than one decrease extremity fractures. Following operative remedy of his
fractures he is transferred to the Burn Unit for control of his pores and skin accidents. How have
to the pores and skin accidents be coded? - ANS-A: Although the skin injuries are being
described in terms usually used for burns, the precise codes to use are the abrasion codes. If
you already know the appropriate vicinity of the abrasions, use the Whole Area abrasion codes
in each bankruptcy. The code 910200.1 for more than one abrasions determined inside the
External and Other Trauma chapter is also appropriate.
Q: A affected person arrives after an MVC wherein the car rolled numerous times. CT head -
bad for damage, skull ordinary; CT cervical backbone - occipital condyle fracture, regular
alignment; neurologic exam is everyday- capable of flow all extremities, GCS= 15; there is no
drainage from the ears or nostril, no ecchymosis. - ANS-A: 150202.Three; The occipital
condyles are part of the base of the skull despite the diagnosis frequently appearing on the
cervical CT experiment. As with any basilar skull fracture, an evaluation for CSF leak in addition
to head harm is important. In addition, since the occipital condyles articulate with the primary
cervical vertebrae, assessment for spinal wire harm is likewise important.
Q: A affected person arrives to the ED with a excessive head harm; he's transported to the ICU
in anticipation of organ donation and at the same time as the brain death evaluation is
completed. His final diagnoses consist of the predicted head harm and brain demise. What do
you do whilst coding this chart regarding the brain dying itself? - ANS-A: Brain death is a state
of affairs not an harm. The coder would as it should be code the lesions identified on CT in
addition to any edema. However, brain death is a sequelae of those injuries. If the patient had
no codeable injuries within the mind, the handiest alternative in that scenario might be to
evaluate the chart for a disturbing anoxic event.
Q: A affected person falls down outside all through bloodless weather and cannot get up. They
are brought in with the aid of EMS with a center temp of 32.5 degrees Celsius and a tibia shaft
650217.2, C4 more than one fractures of same vertebra - ANS-
650217.2, C5 a couple of fractures of identical vertebra" - ANS-
650226.2, C1 lateral mass (pedicle) fracture - ANS-
C1 Lateral mass gets coded to the Pedicle" - ANS-
C1 Posterior arch gets coded to the Lamina - ANS-
Coding DAI: HEAD INTERNAL ORGANS (p. 41)
Cerebrum
- 140628.Four: diffuse axonal injury (DAI) NFS [requires coma ?6 hours or, if fatal within 6
hours, diagnosis is made by pathological examination]
- 140625.4: DAI restrained to white rely or basal ganglia
- 140627.Five: DAI involving corpus callosum
- If white count number/basal ganglia and corpus callosum are involved code only the more
intense; do now not code each. If coma exceeds 24 hours and prognosis meets coding
regulations for DAI, use 161011.Five no matter what anatomic description is recorded. Read
"Diffuse Axonal Injury" (page 50) for coding steering. - ANS-Coding DAI: HEAD CONCUSSIVE
INJURY (p. Fifty one)
- Use this class to code a substantiated diagnosis of DAI if no anatomical description is
recorded or if coma exceeds 24 hours and meets the coding regulations for DAI. Read "Diffuse
Axonal Injury" (page 50) for coding steering.
- 161007.4: Diffuse Axonal Injury (extended worrying coma LOC ?6 hours no longer because of
mass lesion) NFS
- 161008.Four: LOC 6-24 hours (mild DAI)
- 161011.5: LOC >24 hours NFS
- 161012.5: without brainstem signs (mild DAI)
- 161013.5: with brainstem symptoms (severe DAI)
Brainstem signs: decerebrate; decorticate
Q: 50 y.O. Male became operating at the roof of a house underneath production whilst he fell at
the least 20?; he is complaining of lower back pain and the CT of the chest reveals a T12
compression FX of fifty% with extra fractures of the T12 pedicle and side at the left. There is not
any verified neurologic deficit. How might you code this harm? - ANS-A: This case demonstrates
the usage of the multiple fracture inside one vertebra code however the essential compression
FX need to be recognized one at a time because of the severity; It of direction, is usually
acceptable to code every fracture for my part is you so pick; Code: 650434.3 and 650417.2; or
650434.3 and 650426.2 and 650422.2
Q: 56 12 months. Antique admitted to the ED with documentation of 15% 2nd and third degree
burns to her chest and bilateral hands. Two days later a Burn specialist files that the affected
person has 30% 2d and third degree burns to equal frame regions. What is the maximum
correct code for this injury - ANS-A: Code 912024.4 30% affected person is older than five
years. Burns can seem much less excessive on the time of incident but can evolve in degree
and quantity so the Burn expert documentation have to be most accurate in this case
,Q: A 24 year vintage male is admitted after a combat. His facial CT demonstrates multiple linear
fractures of the mandible, together with L condyle, L body and R ramus. There is a deep
laceration overlying the left part of his jaw. The fractures are described as minimally displaced.
How might you code those accidents? - ANS-A: The regulations and tips that practice
encompass: Code bilateral mandible fractures as a unmarried damage. Displacement ought to
be giant. With open fractures, do no longer code the overlying pores and skin damage. The fine
preference is to use 250610.2. Open/displaced/comminuted but NFS as to web site. Note that
despite the fact that the displacement is minimal, the code is chosen for the open fracture in
preference to displacement.
Q: A 30 yr antique affected person sustains the subsequent burns: 20% first degree (superficial)
30% second degree (partial thickness) five% 0.33 degree (complete thickness) How are those
burns coded in AIS 2005? - ANS-A: The correct codes are as follows: 912002.1 for the primary
diploma burns; 912024.4 for the second one and third degree burns blended.
Q: A 36 y.O. Lady is running across the motorway and struck by means of a car at high velocity;
she is unresponsive on the scene and has an immediate CT-head which identifies a big bleed
probably on the sagittal sinus. Operative craniotomy reveals a laceration to the sagittal sinus
with a 2000 ml blood loss; the damage is irreparable; How do you code this injury? - ANS-A:
The blood loss, even though big, can't be attached to this injury mainly and laceration is the best
to be had code. Code: 122402.Four
Q: A four y o infant is by chance burned while his pajamas seize fireplace from a candle. His
burns are defined as 15% first, 10% 2nd and nine% third diploma. What is the proper manner to
code this injury? - ANS-A: The burn rule states that in instances defined this manner, the first
diploma burns should be coded one by one from the second one and third. Therefore, the first
degree burns are coded as 912002.1. The 2nd and 0.33 diploma burns collectively total 19 % so
they are coded together as 912014.Three. (Remember that this baby is much less than 5 years
antique.)
Q: A forty five y.O. Male is apneic with GCS of three at scene. Bullet entry is within the occipital
region of the skull with trajectory down and forward with go out on the throat. CT indicates huge
harm of the cerebrum, cerebellum, and brain stem along the bullet pathway Please code the
brain damage. - ANS-A: No matter what number of areas of the brain are worried in a
penetrating harm if the brain stem is concerned you code the harm as 140216.6 and should
have CT, MRI or different proof
Q: A baseball participant turned into by accident struck inside the throat with the aid of a tough
swung bat. He had instant ache and difficulty speakme. In the ED a laryngotracheoscopy was
accomplished with prognosis of nondisplaced fracture of the larynx with vocal twine contusion
and edema. Please code this damage. - ANS-A: Code 340210.4 the vocal cord involvement
increases the severity level of this harm
Q: A burn affected person arrives within the ED after being involved in a house fire where she
was eliminated from the bedroom engulfed in smoke and unresponsive. The initial evaluation
covered intubation, a CO stage and ABG showing pO2 60 mmHg. In addition, a bronchoscopy
turned into done to assess the airlines. The consequences had been positive carbonaceous
deposits requiring lavage to clear the airway and erythema with friable membranes. - ANS-A:
419206.Five; The mechanism of damage implies inhalation burn from respiration the
superheated air together with the smoke. Inflammation of the airlines, friability with obstruction
, of the bronchi requiring clearance is evidence of severe inhalation harm; ABG demonstrates
hypoxemia as properly
Q: A child got below the kitchen sink consuming a diffusion of caustic sellers, vomiting triggered
right away however chemical burn and sloughing of esophageal lining documented. No gastric
damage obvious. How could you code this harm? - ANS-A: The actual location of the
esophagus injured isn't stated as thorax (below the sternal notch) or to the neck so the default
code is to the neck region. This is an ingestion harm with partial thickness necrosis, the
sloughing of the lining of the esophagus, 340104.Three
Q: A baby is admitted to the ED after gambling on the trampoline wherein another infant landed
on him. X-rays are done and a navicular fracture is diagnosed. How might you code this
damage - ANS-A: This fracture calls for extra facts as to whether or no longer that is a tarsal or
a carpal bone; In an actual medical situation, the physical exam and x-ray would be labeled as
wrist or foot; If that is a tarsal navicular FX then the precise code would be 857451.2 (navicular
bone); if that is a carpal navicular then code 752461.2 (carpal bone).
Q: A guy touched a excessive voltage line with flash burns and injury to the gentle tissue and
muscle of the thumb facet of his R hand requiring serial debridement of necrotic muscle tissues.
Please code this injury - ANS-A: Code 080002.3 the muscle necrosis is indicative of the severity
of the harm.
Q: A motorcyclist crashes and sustains 15 % partial and complete thickness "avenue rash" in
addition to more than one decrease extremity fractures. Following operative remedy of his
fractures he is transferred to the Burn Unit for control of his pores and skin accidents. How have
to the pores and skin accidents be coded? - ANS-A: Although the skin injuries are being
described in terms usually used for burns, the precise codes to use are the abrasion codes. If
you already know the appropriate vicinity of the abrasions, use the Whole Area abrasion codes
in each bankruptcy. The code 910200.1 for more than one abrasions determined inside the
External and Other Trauma chapter is also appropriate.
Q: A affected person arrives after an MVC wherein the car rolled numerous times. CT head -
bad for damage, skull ordinary; CT cervical backbone - occipital condyle fracture, regular
alignment; neurologic exam is everyday- capable of flow all extremities, GCS= 15; there is no
drainage from the ears or nostril, no ecchymosis. - ANS-A: 150202.Three; The occipital
condyles are part of the base of the skull despite the diagnosis frequently appearing on the
cervical CT experiment. As with any basilar skull fracture, an evaluation for CSF leak in addition
to head harm is important. In addition, since the occipital condyles articulate with the primary
cervical vertebrae, assessment for spinal wire harm is likewise important.
Q: A affected person arrives to the ED with a excessive head harm; he's transported to the ICU
in anticipation of organ donation and at the same time as the brain death evaluation is
completed. His final diagnoses consist of the predicted head harm and brain demise. What do
you do whilst coding this chart regarding the brain dying itself? - ANS-A: Brain death is a state
of affairs not an harm. The coder would as it should be code the lesions identified on CT in
addition to any edema. However, brain death is a sequelae of those injuries. If the patient had
no codeable injuries within the mind, the handiest alternative in that scenario might be to
evaluate the chart for a disturbing anoxic event.
Q: A affected person falls down outside all through bloodless weather and cannot get up. They
are brought in with the aid of EMS with a center temp of 32.5 degrees Celsius and a tibia shaft
