CAISS-AIS FAQs Coding Questions with 100% Verified Correct Answers 2024/2025 Q: How is an aneurysm coded? - Correct Answer 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: - Correct Answer 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 - Correct Answer 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? - Correct Answer 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.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? - Correct Answer 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? - Correct Answer 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? - Correct Answer A: 541828.5; The 1 / 3
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? - Correct Answer 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? - Correct Answer A: The ligament teres hepatis represents the remnant of the fetal left umbilical vein.As such, it is not a codeable injury.Q: How do you code a renal artery psuedoaneurysm? - Correct Answer 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. - Correct Answer 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. - Correct Answer 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? - Correct Answer 2 / 3
Q: A patient sustains a duodenal laceration involving > 75% of D3 (the transverse portion). How is this injury coded in AIS 2005? - Correct Answer 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 to Grade III." AAST) How should multiple Grade II liver lacerations be coded in AIS? - Correct Answer 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? - Correct Answer A: Hemoperitoneum is not codeable in AIS Q: What are the Intraperitoneal organs - Correct Answer 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 - Correct Answer 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. - Correct Answer 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? - Correct Answer 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 areas of the same bone, not to be confused with multiple separate fractures. - Correct Answer A: One fracture line gets only one code. Think of the most severe or important code you want to capture. If the line
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