AIS 2005/2008 Update Dictionary - Clarification Document ...

1 AIS 2005/2008 Update Dictionary - Clarification DocumentUpdated:10/9/2019 15:16We have combined and revised the Clarification documents into an Excel file that has been saved as a PDF for viewing. Although this is a PDF, you are still able to search the would like to take this opportunity to thank the AIS Faculty who worked on the development of the Clarification documents over the years as well as those of you using the coding system for your continued support, questions and suggestions!The first section is this "read me" area followed by: ALL of the combined items; General; Definitions; Rules-Guidelines; Head; Face; Neck; Thorax; Abdomen; Spine; Upper Extremity; Lower Extremity; External; Other; - AIS 2005/2008 Update Dictionary - Clarification Document - Most Current Clarification Date At the Top10/9/2019 15:16 YEARCHAPTERITEMDISCUSSIONREFERENCE/EXAMP LEGENERAL STATEMENT THROUGHOUT DICTIONARYU sing the DictionaryCoding rules and box bold directives have been integrated widely into the Dictionary where they apply to specific organs, structures, body regions or at the beginning of each chapter to assist with accurate coding.

2 Coders should refer to them frequently.( ) "Use one of the following two descriptors when such vague information, including traumatic brain injury or closed head injury, is the only information available. While these descriptors identify the occurrence of a head injury, they do not specify its severity."2019 GENERAL DEFINITIONS uperficial Penetrating InjurySuperficial penetrating injury skin/subcutaneous/muscle only without underlying organ or bony involvement. For penetrating injuries to the extremities that do not involve bone or vascular structures, code as minor DEFINITIONA sphyxiaAsphyxia definition is a condition arising when the body is deprived of oxygen, causing unconsciousness or death.

3 This is a codeable sequela.( )2019 GENERAL DEFINITIONH emarthrosisHemarthrosis is not a codable Hour StatementWithin the first 24 hours post injury, patients with transient signs and symptoms should be coded even if they are resolved within the 24 hour period.( )2019 HEADB lood Along TentoriumSupratentorial codes to Cerebrum; Interpeduncular fossa (cistern) basal cisterns code as injury involving hemorrhage in the brainstem; "Along" the tentorium, code to supratentorial = Cerebrum.( )2019 HEADA mnesiaOne symptom that can exist without a closed head injury, no AIS CondylesOccipital condyles are coded to the skull base.( )2019 HEADC oncussionConcussion must be documented in the medical record by a physician or physician extender.

4 Recorded in PI minutes is ModifiersFor codes with coma modifiers, "not associated with " = means there was documentation of coma, but it was not greater than 6 hours in duration. "Associated with " = means there was documentation of coma, and it was greater than 6 hours in duration. The NFS code should be used when there is no documentation of coma with an injury that has a coma SAH with coma 8 hours = SAH associated with coma > 6 hoursALL - AIS 2005/2008 Update Dictionary - Clarification Document - Most Current Clarification Date At the Top10/9/2019 15:16 YEARCHAPTERITEMDISCUSSIONREFERENCE/EXAMP LE2019 FACELeFort Fractures"LeFort" must be specified in the medical documentation to use the LeFort fracture codes, otherwise, code individual fractured PerforationSoft palate perforation code as laceration; hard palate perforation code as fracture.

5 If palate is not specified as soft or hard, code as Artery InjuryCarotid Artery injury not specified should be coded to Common Carotid Artery.( )2019 NECKJ ugular Vein InjuryJugular Vein injury not specified should be coded to Internal Jugular Vein.( )2019 SPINE24 Hour StatementWithin the first 24 hours post injury, patients with transient signs and symptoms should be coded even if they are resolved within the 24 hour period.( )2019UP EXTREMR otator CuffRotator cuff should be assigned to Shoulder, Glenohumeral Joint, NFS ( )( )2019 EXTERNALSkin TearsSkin tears are coded as a laceration to the appropriate location on the patient and assigned to the ISS body region for calculating an DeathsHanging/Drowning deaths with medical examiner's diagnosis counts as "cardiac arrest documented by medical personnel".

6 ( )Hypothermia is coded in whole number temperature only; do not round up or down. Codes for Fahrenheit are:2016 GENERAL DEFINITIONP uncture WoundPuncture wound is caused by spearing or impalement type injuries. These should be coded as Penetrating NFS or Penetrating minor superficial2016 GENERAL DEFINITIONP alsy/ParesisPalsy/Paresis are coded as nerve DEFINITIONP aralysis/Total Loss of FunctionParalysis or Total Loss of Function is coded as nerve DEFINITIONI ncomplete TransectionIncomplete transection is the same as incomplete circumferential DEFINITIONP seudoaneurysmPseudoaneurysm is coded as a minor artery ( )ALL - AIS 2005/2008 Update Dictionary - Clarification Document - Most Current Clarification Date At the Top10/9/2019 15.

7 16 YEARCHAPTERITEMDISCUSSIONREFERENCE/EXAMP LE2016 GENERAL DEFINITIONA mputationAmputation is defined as "traumatic" not surgical2016 GENERAL DEFINITIONM orel Lavalle LesionMorel Lavalle Lesion, internal shearing or degloving injury of an extremity is coded as a degloving injury in the appropriate extremity DEFINITIONM icro FracturesMicro fractures are not a codeable DEFINITIONBone ContusionsBone contusions are not a codeable DEFINITIONBone EdemaBone edema is not a codeable DEFINITIONE xtra-ArticularExtra-Articular refers to a fracture with NO joint DEFINITIONP artial ArticularPartial Articular (Intra-Articular) refers to at least one fracture through the joint surface and part of the articular surface is still in continuity with the to drawings in the upper and lower extremity chapters2016 GENERAL DEFINITIONC omplete ArticularComplete Articular refers to a fracture where the articular surface is fractured AND there is no continuity with the diaphysis.

8 Refer to drawings in the upper and lower extremity chapters2016 HEADA cute on Chronic BleedsIf the clinician does not differentiate and Document the acute from chronic bleed, code as NFS in the appropriate PlatesPterygoid Plates are part of the sphenoid bone and are coded to the base of the skull if injured in isolation. If the pterygoid plates are part of a LeFort fracture, they are NOT coded additionally as skull base InjuryCaustic injury to the mouth is coded as ( )2016 NECKT hrombosis (Occlusion)Thrombosis (occlusion) secondary to trauma from any lesion but laceration (under carotid artery, internal, and external, and vertebral artery) refers to the sequela of blunt trauma to : seatbelt injury2016 SPINES pinal Cord Injury with Associated Fracture, no deficitSpinal cord injury such as compression, epidural or subdural hemorrhage associated with a fracture AND there is NO neurologic deficit, the coder must choose to either code the cord injury OR the fracture.

9 Current rules prohibit coding InterarticularisPars interarticularis is located between the lamina and the pedicle anatomically and should be coded as pedicle. Previous teaching of coding this to LAMINA has been changed per recent Neurosurgery Air LeakPersistent Air Leak ( ) is described as an air leak in the thorax that lasts for more than 48 hours, which represents a more severe injury than a simple pneumothorax.( )ALL - AIS 2005/2008 Update Dictionary - Clarification Document - Most Current Clarification Date At the Top10/9/2019 15:16 YEARCHAPTERITEMDISCUSSIONREFERENCE/EXAMP LE2016 THORAXI ntracardiac SeptumIntracardiac Septum may also be identified as "intraventricular" septum.

10 ( )2016 THORAXF lail ChestFlail chest with additional but separate rib fractures on the same side is coded to the more severe injury, the flail chest, and the additional rib fractures on the same side are not coded.( )2016 ABDOMENH emoperitoneumHemoperitoneum is a sequela and is not a codeable TearSerosal tear is coded as a partial thickness EXTREMD igital VesselsDigital vessels are included in "other named vessels"2016 LOW EXTREMHip Fracture"Hip Fracture" simply stated with no other description is coded as a proximal femur fracture ( )( )2016 LOW EXTREMS lipped EpiphysisSlipped Epiphysis in children is coded as a femur neck fracture ( )( )2016 OTHERC austic InjuryCaustic injury ( ) is only used if the specific location is not known.