2000 nass injury coding manual (from docket)
TRANSCRIPT
Editors, 2000 edition: Veridian Engineering P.O. Box 400 Buffalo, New York 14225
Authors, 1990 edition (1996 Update): Association for the Advancement of Automotive Medicine 2340 Des Plaines River Road, Suite 106 Des Plaines. Illinois 60016
Prepared for:
U.S: DEPARTMENT OF TRANSPORTATION NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION
WASHINGTON, D.C. 20590
ACKNOWLEDGMENTS
The editor of the 2000 NASS Injury Coding Manual gratefully acknowledges the cooperation of many individuals and organizations which provided support and technical guidance.
A note of appreciation to Ms. Ruth Ann Isenberg, Mr. Lee N. Franklin, and Mr. Gary R. Toth of the National Highway Traffic Safety Administration and Ms. Elaine Petrucelli of the AAAM injury Scaling Committee for their support and assistance.
Gratitude is expressed to Ms. Connie Volkots of Veridian Engineering (Zone Center 1) and Ms. Paula Pitzer and Mr. Peter Pfeiffer of KLD Associates (Zone Center 2) for their technical review and helpful suggestions.
A particular note of thanks to Ms. Elizabeth S. Bellis who contributed significantly to the publishing of this manual.
Evelyn J. Benton
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TABLE OF CONTENTS
PART I INJURY SCALING - HISTORY, DEVELOPMENT AND PURPOSE Abbreviated Injury Scale (AIS) ...................................... MaximumAIS ................................................... Injury Severity Score (ISS) ......................................... Purpose of Injury Scaling ..........................................
PART II INJURY CODING-AIS DICTIONARY.. Contents and Fonat of the Dictionary Numerical Injury Identifier . . Examples of Injury Coding . Special Instructions for Coding Pediatric and Brain Injuries Special Guidelines for Coding Injury versus Outcome of Injury Final Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .._..... General Nass Injury Coding Rules
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III AIS DICTIONARY LISTING AND CODES ................................. HEAD (Cranium and Brain) ................................................ : GUIDELINES ON WHEN TO USE LOSS OF CONSCIOUSNESS INFORMATION FACE (Includes Ear and Eye) ............................................... NECK ................................................................. THORAX.. ............................................................. ABDOMEN AND PELVIC CONTENTS ........................................ CERVICAL SPINE ........................................................ THORACIC SPINE ....................................................... LUMBARSPINE ......................................................... UPPER EXTREMITY ..................................................... LOWER EXTREMITY ..................................................... EXTERNAL - Skin and Subcutaneous Tissue .................................. BURNS ................................................................ OTHER TRAUMA ........................................................
PART IV DICTIONARY INDEX . . .._........._..........._..._. 169
5 5 6 9
‘11 12 13 15
PART V MEDICAL TERMINOLOGY REFERENCES Glossary of Anatomical & Injury Terms Abbrewatlons
A. 6.1. 0.2. 8.3. C. Cl. c.2. c.3. D. E.
Hospital Symbols ....................... Weights and Measures .................. Deciphering Medical Teninology .......... Prefixes .............................. Roots ................................ Suffixes ............................... Lay Terminology - Nass Injury Synonym List Fractures .............................
SOURCE OF ILLUSTRATIONS ...........
SUGGESTED REFERENCES .............
27 29 43 51 63 71
‘105 07
111 115 121 133 149 153 157
APPENDIX A
APPENDIX B
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LIST OF ANATOMICAL ILLUSTRATIONS
Abdominal Organs ......................
Anatomical Position and Regional Names ...
Sony Skull ............................
BonyPelvis ...........................
Bony Face ...........................
Brain ................................
Distribution of Cranial Nerves .............
Ear .................................
Extremities (Upper) ....................
Extremities (Lower) ....................
Eye .................................
Heart - Intracardiac Structures ............
Layers of the Skin ......................
Major Muscles ........................
Male/Female - Pelvic Organs .............
Mouth ...............................
Nerves, Anterior View ...................
Nerves, Posterior View ..................
Principal Arteries ......................
Principal Veins ........................
Spinal Column ........................
Thoracic Cavity ........................
Throat ...............................
Venous Drainage of the Head ............
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PART I
INJURY SCALING-HISTORY, DEVELOPMENT AND PURPOSE
The overall goals of highway crash research are to reduce fatality, mitigate injury, and decrease economic loss to society. Highway crash reporting and investigation is not a new phenomenon, but only until relatively recently was attention devoted to developing a system of rating the severity of motor vehicle crash related injuries that could be utilized by medical and non-medical researchers alike. Not only would such a system provide uniformity among coders, but also would aid immeasurably in establishing uniform data bases for crash injury statistics, no matter where or by whom they were collected.
Abbreviated lniurv Scale (AIS
Until 1971, no single comprehensive system for rating tissue damage existed that was acceptable to both physicians and others involved in crash research. A number of scales had been developed by universities, independent researchers, safety organizations and the motor vehicle industry, but almost all of the scales had serious shottcomings from the medical standpoint. In 1971, the first Abbreviated Injury Scale (AIS) was published underthe auspices of the joint Committee on Injury Scaling, comprised of representatives of the American Medical Association (AMA), American Association for Automotive Medicine (AAAM), and the Society of Automotive Engineers (SAE). The 1971 AIS was the product of work begun in 1967 when the AMA sponsored an intensive three-day workshop for physicians, engineers and researchers concerned with crash injury tolerance to see if a single injury scale could be developed to serve the needs of all disciplines involved. In addition to developing a single uniform scale, the AIS attempted to standardize the language used to describe injuries to enable valid statistical evaluations among crash researchers anywhere in the world.
Five years later in 1976, the Abbreviated Injury Scale was published in manual format, which included more than two hundred injury descriptions and severity codes as part of the AIS Dictionary. Since 1976, the AIS has been accepted and used by crash researchers in many parts of the world. Based upon the results of this widespread usage, the Abbreviated Injury Scale underwent significant revision during 1978-1979, especially in the area of brain injuries. AIS- retained the original injuty code descriptions which were adopted with slight modification for coding convenience, for NASS. Many of the injury descriptions were redefined in AIS- to meld with current medical terminology and to provide a hierarchy of severity levels for some injuries in the thoracic, abdominal, and vascular areas.
This NASS Injury Coding Manual is based upon AIS- (Update 98), the most recent and up-to-date Abbreviated Injury Scale Dictionary published by the Committee on Injury Scaling. AIS- includes specific rules within the dictionary itself to solve some coding dilemmas such as when there is a choice of descriptions or body regions to which an injury can be assigned, or when clinical diagnosis can be used. Synonyms and parenthetical descriptions are used extensivelyto allow the coder to appropriately match the injuty description in the hospital chart with one in the AIS dictionary. These coding rules, together with coder training, should improve intra- and inter-rater reliability.
The AIS- (Update 98) offers more assistance to coders by providing extensive coding rules and instructions throughout the dictionary. The update also includes the Organ Injury Scale (01s) scores developed by the American Association for the Surgery of Trauma where these scores have appropriate matches to existing injury descriptions in AIS-90. Such matches occur primarily in the THORAX and ABDOMEN AND PELVIC CONTENTS sections.
It is not the purpose of this manual to provide an in-depth histoty of the AIS. Additional information is available upon request from the American Association for Automotive Medicine, Suite 106, 2340 Des Plaines River Road, Des Plaines, IL 60018.
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Maximum AIS
AIS- recommended the use of an Overall AIS (OAIS), which was an assessment of the total effect of multiple injuries on a victim’s body and systems. It was intended not as the sum, median, or average of the individual injury codes, but rather a clinical iudaement or estimate made bv a coder exoerienced in the treatment of trauma, preferably a physician.
AIS- recommended that the highest AIS be used as the surrogate for assessing overall injury severity for victims with multiple injuries.
Field research overthe last several years has shown that the OAIS is too subjective to provide reliable assessments of overall injury severity, especially where medical knowledge or expertise is not available. Experience in using the Maximum AIS (MAIS) [highest single AIS code for a patient with multiple injuries] in place of the OAIS has shown it to be a more objective method that does not require the judgement of the researcher.
In 1981, The Probability of Death Score was introduced. It is mentioned here only to alert the NASS coder that such a system does exist and to provide at least a thumbnail sketch of its purpose should the NASS coder come upon it in other information on injury scaling.
lniurv Severitv Score (ISS)
The Abbreviated Injury Scale is a system for rating the severity of individual injuries. It is recognized, however, that motor vehicle crash victims sustain multiple injuries in more than one body region. As with the aforementioned Maximum AIS, computation of the ISS is not required in NASS.
The Injury Severity Score (ISS) is a mathematically derived code number based on the AIS. It is a sum of the squares of the highest AIS codes in each of the three most severely injured body regions. A detailed discussion of the ISS is contained in the following article: “The Injury Severity Score: A Method for Describing Patients with Multiple Injuries and Evaluating Emergency Care,” Baker, S.P., et al., JOURNAL OF TRAUMA, March 1974.
t.......
This brief introduction is intended to acquaint the NASS injury coder with the major systems currently being used in motor vehicle crash-related injury scaling. It is not intended as a comprehensive background, and the researcher is invited to consult the Suggested References in the Appendix for additional information.
Purpose of lniurv Scalinq
Injurycoding isashort-hand wayof objectively describing the nature and severity of injuries sustained in traffic accidents. Though occasionally confusing to some, the coding of injuries and their sources is one of the more important tasks the injury coder faces in NASS. The types of injuries that can occur and their causes can be analyzedforthe purpose of designing more effective countermeasures to reduce the frequency and severity of injuries in accidents.
NASS is a statistical study of nationwide highway accidents. Statistics rely on accurate and consistent encoding of raw data to produce reliable, useable results. As a step toward this goal, the development of this Injury Coding Manual promotes consistency among coders through the standardization of codes and coding procedures. No manual, however, can feasibly incorporate all injuries and combinations thereof. Hence, the coder must develop a keen sense of judgement and attempt to internalize the logic behind injury coding.
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Since statistics necessarily reflect the data inputted, the statistics that are generated from this data for analysis can only be as good as the data provided by& researcher. It is hoped that all individuals will take personal responsibility to ensure that they collect and code high quality injury data. Only through the collection and coding efforts of ggr& researcher and injury coder can the statistics accurately reflect reality. And only then can the ultimate goal of a safer driving environment for all be attainable.
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PART II
INJURY CODING-AIS DICTIONARY
The AIS Dictionary contained in this NASS Injury Coding Manual is based upon the AIS- (Update 98). The most current and up-to-date Abbreviated Injury Manual was developed by the joint Committee on Injury Scaling. Aithough this manual was developed primarily for NASS and contains information supplementary to what is contained in AIS- (Update 98). it does not deviate in AIS codes and other information essential to the injury system unless noted in the text.
Contents and Format of the Dictionary
The AIS Dictionary is divided into the following sections:
Head (Cranium and Brain) Face Neck Thorax Abdomen and Pelvic Contents Seine
Upper Extremity Lower Extremity External/Skin Burns Other Trauma
Within each section, except the SPINE, EXTERNAL, BURNS, and OTHER TRAUMA, injury descriptions are alphabetized by specific anatomical parts and are categorized in the following order: Whole Area, Vessels, Nerves, Internal Organs, and Skeletal. In addition, the UPPER EXTREMITY and LOWER EXTREMITY sections have a subsection on Muscles, Tendons, and Ligaments. In most cases, the severity level in each anatomical category goes from least severe to most severe. Valid Aspect Codes for each section are listed at the beginning of the particular sections of the Dictionary. Relevant anatomical illustrations are located at the end of speciiic sections. AddRional illustrations can be found at the end of the Part Ill, AIS Dictionary Listing Andy Codes, ,pages 158-167.
The Anatomical Index which follows the Dictionary lists all of the injury descriptions in AIS- (Update 98) in alphabetical order, by the body region in which the injury is located, and the page on which it can be found.
Each injury description has been assigned a unique 7-digit numerical code (see pages 6-8). The single digit to the right of the decimal point is the AIS number, according to the following severity code:
AIS Code Descriotion 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Maximum 7 Injured Unknown Severity
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Signs and symbolsare used throughout the dictionary to help the coder. Examples of each follow:
Brackets [ ] give specific instruction or direction.
Example: Alvaolar ridge (bone) fracture with or without injury to teeth [Do not code teeth separately where these occur simultaneously.]
Parenthesis ( ) give synonyms or further descriptive information.
Example: Pancreas laceration complex (avulsion; massive; rupture: stellate; tissue loss)
Boxed Information gives coding guidelines.
Example: VESSELS
I Descriptions for vessel lacerations distinguish between complete and incompleW transection See footnotes g and h.
The terms ‘laceration,’ ‘puncture’ and ‘perforation’ are oftentimes used interchangeably to describe vessel injuries and are of the same severity. When ‘perforation’ or ‘puncture’ is used. code as laceration. 1
Diaaonal means and/or, i.e., one or more of the descriptors must be present.
Example: Tibia fracture NFS openldisplacedlcomminuted
Numerical lniuw Identifier
AIS- introduced a unique B-digit code for each injury diagnosis to assist in computerization of data. The addition of injury descriptions in AIS-90, especially for the brain and extremities, has required a more flexible numerical system than that used in 1985.
In AIS-90, each injury description is assigned a unique 6-digit numerical code in addition to the AIS severity score. As summarized in the diagram below, the first digit identifies the body region; the second digit identifies the type of anatomic structure; the third and fourth digits identify the specific anatomic structure or, in the case of injuries to the external region, the specific nature of the injury: the fifth and sixth digits identify the level of injury within a specific body region and anatomic structure. The digit to the right of the decimal ooint is the AIS score.
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Body Region -
Type of Anatomic Structure -
Specific Anatomic Structure --
Level --
AIS .-
Aspect -
An additional digit has been added to identity the Aspect. This code measures the location of the injury being reported. It is a refinement of the first number, i.e., a suffix to the body region. It has meanrng only in relationship to the body region to which it is applied. The Aspect Code cannot be used independent of the body region for coding or analysis, Note that while the combination of Body Region codes do not always precisely pinpoint the location of an injury, they do provide additional resolutron.
The following conventions are used in assigning the numerics to specific injury descriptions:
1. Body Region 1 Head 2 Face 3 Neck 4 Thorax 5 Abdomen 6 Spine 7 Upper Extremity 6 Lower Extremity 9 Unspecified
2. Type of Anatomic Structure 1 Whole Area 2 Vessels 3 Nerves 4 Organs (incl. muscles/kg.) 5 Skeletal (incl. joints) 6 Head-LOG 9 Skin
3. Specific Anatomic Structure or Nature (refer to appropriate section below)
Whole Areg (Injury to External Body) 02 Skin - Abrasion 04 - Contusion 06 - Laceration 06 - Avulsion 10 Amputation 20 Burn 30 Crush 40 Degloving 50 Injury - NFS 90 Trauma, other than mechanical
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Head - LOC 02 Length of LOC 04,06.08 Level of Consciousness 10 Concussion
m 02 Cervical 04 Thoracic 06 Lumbar
Vessels. Nerves. Oraans. Sbletal-Bones. Joints are assigned consecutive two-digit numbers beginning with 02.
4. Level
Specific injuries are assigned consecutive two-digit numbers beginning with 02.
To the extent possible, within the organizational framework of the AIS, “00” is assigned to an injury NFS as to severity or where only one injury is given in the dictionary for that anatomic structure. An injury NFS as to lesion or severity is assigned level 99.
5. AIS
AIS Code 1 2 3 4 5 6 7
6. Aspect
1 2 3 4 5 6 7 a 9 0
R L
: A P S
iJ W
Minor ~~~ Moderate Serious Severe Critical Maximum Injured Unknown Severity
Right Left Bilateral Central Anterior/front/ventral Posterior/back/dorsal Superior/upper InferiorAower Unknown/multiple regions Whole region
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Examules of lniurv Codinq
Below are two examples of injury descriptions taken from a medical report. Instructions for coding the injuries follow the descriptions.
Examole 1: The lateral right 4, 5, and 6 ribs are fractured. There was no evidenceof pneumothorax.
A simple method of locating the correct section of the manual is to go to the Dictionary Index and look up the key word “rib.” The coder will find that the rib cage is located under the THORAX section on page 83 (see below).
CODE ASPECT INJURY DESCRIPTION
450299.1
450202.1
450210.2
! Rib cage NFS [Use one line of code - rib fxs]
contusion
+ multiple rib fractures NFS [Use if no other information is available. See footnote before coding in this section.]
450211.3
450212.1
450214.3
450220.2 1
with hemo-/pneumothorax
1 rib
with hemo-/pneumothorax (O/S Grade I)
2-3 ribs any location, or multiple fractures of single rib, with stable chest or NFS (O/S Grade I, /I or 111)
450222.3 with hemo-/pneumothorax
450230.3 > 3 ribs on one side and 5 3 ribs on the other side. stable chest or NFS
450232.4
450240.4
450242.5
450250.3
450252.4
450260.4
with hemo-/pneumothorax
> 3 ribs on each of two sides, with stable chest or NFS
with hemo-/pneumothorax
open/displaced/comminuted (any or combination: t 1 rib)
with hemo-/pneumothorax
flail (unstable chest wall, paradoxical chest movement) unilateral or NFS (O/S Grade 111 or IV)
450262.3 without lung contusion (O/S Grade 111 or IV)
450264.4 with lung contusion (OIS Grade 111 or IV)
450266.5 3 bilateral flail with or without lung contusion (O/S Grade V)
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Under the-Rib cage section, the coder must choose the appropriate code based upon other information in the medical report. In this instance, we know that there are three rib fractures wirhout pneumothorax. This would point to the code 450220.2 (the next code would be chosen if pneumothorax was present). The last decision to be made concerns Aspect - the location of the injury. In this case, we know that the fracture occurred on the right side because the medical report states this. Therefore, the final correct code for this injury is 450220.2,1.
Examole 2: There is a subluxation of the sternoclavicular joint on the right with anterior displacement of the clavicle.
The coder should note the key words “sternoclavicular joint” and go to the Dictionary Index to look up this term. The coder will find that stemoclavicular joint is listed as being under the UPPER EXTREMITY section on page 128 of the manual. If the coder is unfamiliar with the word “subluxation,” he/she should look up the word in Part Ill, The Glossary of Anatomical and Injury Terms. Subluxation is defined as “an incomplete or partial dislocation.” This definition enables the coder to correctly assign the code 751230.2 (see below).
CODE ASPECT INJURY DESCRIPTION
751299.1 + Sternoclavicular joint NFS
751210.1 contusion
751220.1 sprain
751230.2 dislocation
751240.2 laceration into joint
The medical report states that the injury occurred on the right side of the body, so Aspect is coded as “1.” Therefore, the complete code is 751230.2,1.
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Scecial Instructions for Codina Pediatric and Brain lniuries
Pediatric lniurieg
Age can be an important variable in relation to injury severity. It is well documented that an older patient will have a higher probability of unfavorable outcome as compared to a healthy younger person given the same injury seventy. Very young children may be similarly worse off.
AIS- injury descriptions and their AIS severity were reviewed by a group of pediatric trauma surgeons to determine which did not apply to the pediatric population. It was determined that all but a few adequately reflected relative severity of injuries in young children. The exceptions related to the size of brain hematomas, blood loss in severe lacerations, or internal bleeding (by volume), due to abdominal or thoracic injuries. The exceptions were incorporated into AIS- and are in this 2000 NASS Injury Coding Manual.
Analysis of various data bases have indicated that serious brain injuries (AIS L 3) were undercoded when compared to injuries in other body regions.
To correct this inconsistency, the Brain section was expanded in AIS- to include brain contusions with a range from AIS 3 to AIS 5 that accounts for size, location and multiplicity of these injuries. The volume, size and location descriptors for cerebral and cerebellar hematomas have also been revised to more adequately reflect the relative severity of these injuries. The terminology to describe these injuries is clinically more acceptable.
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It should be emphasized that the AIS codes specific individual injuries only (i.e., a single AIS score for each injury for any one person). Also, the AIS clearly distinguishes between an injury, which is coded, and the result(s) of an injury which is not coded. For example, the novice coder may want to code “pain’ in terms of injury coding. It is important to note that pain is a conseouence of trauma. It is the jgjyry (a result of the trauma) that is causing the pain that the coder needs to code. This principle was employed so that the AIS can be used as a measure of the severity of the injury itself and not as a measure of consequences, impairments, or disabilities that result from the injury. Consequences of several injuries have been included in the AIS as part of certain injury descriptions in order to specify injury severity more precisely. For example, in the THORAX section, hemothorex or pneumothorax is not an injury per se, but resufts from fractured ribs or other chest trauma such as lung laceration. It is the fracture or laceration that is coded, but it is acknowledged by increasing the AIS that the existence of hemo-l pneumothorax makes the injury more serious. Another example of deviation from this general philosophy occurs in the HEAD section, which must account for non-anatomic brain injuries (commonly called concussions) because clinical signs and symptoms are the & means by which the severity of certain injuries is measurable.
Outcomes that may be related to injuries but v include:
ache
asphyxia (suffocation) deafness
death drowning
obstruction parn spontaneous abortion swelling’ tenderness
It is acknowledged that research studies conducted for specific purposes may have need for information on various outcomes, including those listed here. Individual data users are urged to develop their own designs for inclusion of such information. The Injury Coding Manual suggests that this type of information may be recorded as data items for ready use in special studies or for future retrieval as needs arise. j&?&r no circumstances, however, should outcome be the basis for assionina the AIS code unless soecificallv listed in the Dictionanl,
Source of further information:
LAY TERMINOLOGY - NASS LESION SYNONYM LIST (Part V, Section D. p. 198)
f “Hemorrhage” and “swelling” are exceptions for the brain and may be coded where indicated in the manual.
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Final Notes
The Injury Coding-AISDictionaryhas beendesigned toeliminateas much guessworkas possibleand to enable even the inexperienced coder to acquire an adequate understanding of injury coding within a short time. The sections entitled DICTIONARY INDEX (Part IV, p.169) and MEDICAL TERMINOLOGY REFERENCES (Part V, p. 179) should be useful tools to improve the coder’s injury coding skills. When a case occurs in which the coder feels the manual is inadequate, other Zone Center and NHTSA personnel will be consulted to devise a uniform code. If the problem requires medical determination, then the Committee on Injury Scaling will be contacted.
A number of new injury codes and descriptions appear in this 2000 Injury Coding Manual. These codes and descriptions represent additions/revisions adopted by the Committee on Injury Scaling and/or approved by NHTSA for use in NASS. Coding rules and instructions have been combined into the section entitled “General NASS Injury Coding Rules.” Coding rules and instructions relevant to specific sections of the Manual are included at the beginning of that section.
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Table of NASS Injury Coding Rules and Pages
lniutv Codina Rules ml!?
1. 2. 3. 4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
22. 23. 24. 25. 26. 27. 20. 29. 30. 31. 32. 33. 34. 35. 36.
37.
Unsubstantiated Injuries ....................................................... 15
DoNotDoubleCount .......................................................... 15
Coding PAR Injury Data ........................................................ 15
Presumption of “No injuv or “Unknown if injured” from PAR. .......................... 15
Injury vs Consequences/Outcomes ............................................... 15
Not Further Specified (NFS) .................................................... 16
AIS Uncertainty Rule .......................................................... 16
CodingAIS-6 ................................................................ 16
Bilateral Injuries .............................................................. 16
Coding Same Type lntegumentary Injuries ......................................... 16
Undetermined Type of Anatomic Structure-Code Skin ............................... 17
SoftTissueTrauma ........................................................... 17
LacerationTypelnjuries ........................................................ 17
DicingTypelnjuries ........................................................... 17
Valid Codes and Aspects for Seat Belt Contusions ................................... 17
Burns ...................................................................... 17
Whiplash ................................................................... 18
StrainvsSprain .............................................................. 18
Crush ...................................................................... 18
OpenFracture ............................................................... 19
SkullFractures ............................................................... 19
Multiple Fractures in a Bone .................................................... 20
Costal Cartilage Fracturenear .................................................. 20
Joint - Ligament Injuries. ....................................................... 20
Coding Brain Injuries ............................................ I ............. 20
InternalOrgans .............................................................. 21
Injuries Involving Skin and Internal Structures ....................................... 21
Blood Loss .................................................................. 21
Transection ................................................................. 22
Tears:AnlnjurySynonym ...................................................... 22
Multiple Vessel or Nerve Injuries ................................................. 22
VesselInjury ................................................................ 23
Side Interior Surface Contacts ................................................... 23
Injuries Produced by Objects, on the Occupant ...................................... 23
Direct vs Indirect Injury ........................................................ 23
Non-Contact Injury Sources -- Codes “fire in vehicle”, “flying glass”, “other noncontact injury source”, and “air bag exhaust gases” .......................... 24
AirBagRelated .............................................................. 25
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GENERAL NASS INJURY CODING RULES
Instructions are included throughout the AIS dictionary to help coders make appropriate decisions concerning injury diagnoses. These are not repeated here. A number of coding principles, however, apply across body regions. The following rules should be learned and applied diligently.
1. Unsubstantiated Injuries
NASS does not code unsubstantiated injuries. If the words, “questionable”, “possible”, or “probable” are used, do not code the injury.
2. Do Not Double Count
The injury coder should take care not to code the same injury twice. When information for the same injury is available from two different sources (e.g., interview and medical report) only the injuries not already coded from medical records should be coded.
3. Coding PAR Injury Data
Data from the PAR are to be coded if specific injury descriptions are detailed and not reported from another source.
If the PAR provides enough specific information to identify an injury description, code that Number of Injuries for This Occupant using the NASS maininjury program.
Example: Minor bleeding, head: 190099.1,9
If the PAR indicates “complaint of pain”, ‘Not injured”, or “Unknown if injured”, or if a “K”, “A”, “B,” or “c” severity rating is the only information available and no injury description is identified, DO NOT open NASS maininjury for this occupant.
Code “Injured, details unknown” in NASSmain (Occupant form/Injury tab/Zone subtab) if the PAR only indicates K, A, or B and no injury description is identified.
4. Presumption of “No injury” or “Unknown if injured” from PAR.
If the PAR is “blank” where the injury severity is assessed and the person was at the scene during the police investigation, code: Not injured. However, ifthe person was not present during the police investigation, code: Unknown if injured.
5. Injury vs Consequences/Outcomes
Excluding “Other Trauma” indicated on page 157. the AIS does not assign codes to consequences of injury (e.g., blindness), but rather to the injury per se (e.g., optic nerve avulsion).
Foreign bodies (e.g., glass, gravel, dirt, etc.) are not injuries and therefore are not coded. However, they may be associated with an injury.
Surgical procedures and other treatment interventions should not be used to determine the severity of an injury. No injury should be upgraded based only on intervention.
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6. Not Further Specified (NFS)
The use of “not further specified” (NFS) allows for coding injuries when detailed intonation is lacking.
Injury unspecified means that an injury has occurred to a specific organ or body part, but the precise injury type is not known. For example, a kidney injury could be a contusion or a laceration, but this information may not be available. In this example, the kidney injury is coded as NFS. Assign the Injury Level ‘99” when NFS is used. [See Numerical Injury Identifier, page 6.1
Sever’@ unspecified means that a specific injury (e.g., laceration) has occurred, but the level of severity is not specifically given or is unclear. In this example, the injury should be coded as laceration NFS. To the extent possible within the organizational framework of the AIS, “00” is assigned to an injury NFS as to severity. [See Numerical Injury Identifier, page 6.1
Use of NFS should not be confused with AIS code “7” which is assigned in those cases where trauma has occurred and no information is available regarding specific organ within a region, For example, “blunt/traumatic abdominal injury” is assigned code 515099.7,O.
7. AIS Uncertainty Rule
If there is any question about the seventy of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
8. Coding AIS-
AIS- is used only for injuries specifically assigned severity level 6 in the AIS. The use of AIS- is not an arbitrary choice simply because the patient died. An AIS- injury is never upgraded to an AIS-6.
9. Bilateral Injuries
Bilateral injuries are coded separately for organs such as the kidneys, eyes, and ears unless the dictionary specifically allows for coding as a single injury (e.g., lung injuries). Maxillae, mandibles, and the rib cage are coded as single structures. Example: Fracture right 6-7 and left 4-6 ribs. Code 450220.2,3 (2-3 ribs any location).
10. Coding Same Type lntegumentary Injuries
Use the following rules when coding “same type” injuries (i.e., abrasions, avulsions. contusions, and lacerations) to a body region.
(a) When the “same type” soft tissue injuries occurs to 1. 2 aspects of a body region due to different contact points, code as separate injuries.
63 Any number of “same type” soft tissue injuries resulting from the same contact point, occurring to a body region, exceot the face, will have one line of code.
(4 If ‘same type” soft tissue injuries resulting from the same contact point occur to the face and involve > 1 and 5 3 different aspects, code each aspect separately. If 2 4 different aspects, enter one line 01 code using aspect “whole region”.
Cd) If any of the words “multiple’. “numerous”, “several”, or the plural of a lesion is used to describe “same type” soft tissue injuries @there are no details of location, enter one line of code from the EXTERNAL - Skin and Subcutaneous Tissue section (e.g., multiple contusions, Code 990400.1,O).
If multiple “same type” soft tissue injuries occur to a specific body region g~9 the aspect is unknown, enter one line of code using the WHOLE AREA section for that body region (e.g., multiple facial abrasions, Code 290202.1 .O).
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11. lJndeterr@ned Type of Anatomic Structure - Code Skin
If the medical or interview information indicates a contused knee, elbow, wrist, ankle, etc., and does not specifically state whether the contusion is to the bone or joint, code the injury as integumentary/skin.
If the contusion is known to be the bone or joint, code using the “Skeletal” or “Skeletal-Joints” Section.
Example: Contused right knee, 890402.1,1 Contused left knee joint, 850802.1.2
12. Soft Tissue Trauma
If the medical indicates “soft tissue trauma” and a specific injury cannot be determined from the medical or some other source (e.g., interview), code the injury as a contusion.
13. Laceration Type Injuries
When an injury is described as a ” type of laceration” (e.g., avulsion type laceration, flap laceration), use the “avulsion” code. For all ambiguous situations, use “laceration” over avulsion.
14. Dicing Type Injuries
When an injury is described as a “dicing type code “abrasion”.
” (e.g., dicing type lacerations, dicing type abrasions)
15. Valid Codes and Aspects for Seat Belt Contusions
For “seat belt bruises” due to a three-point system, code:
Shoulder 790402.1 ,I ,2 (R.L) Chest 490402.1,1,2,4,0 (R,L.C,W) Abdomen 590402.1.1.2,4,7,8,0 (R.L,C.S,I,W)
Code 790402.1 ,1,2, 490402.1,4, and 590402.1,4 if unspecified. [Note: Code only those injuries that are consistent with the type of restraint worn (e.g., do not code 790402.1 or 490402.1 if only a lap belt was used).]
16. Burns
Thermal burn injuries should be coded using the Rule of Nines to assign the AIS severity level for (a) and (b) below. See the Rule of Nines diagram:
(4 If only one body region is burned, use that body region code (e.g., burned upper extremity lo = 792002.1) and the appropriate aspect;
If more than one body region is burned, enter one line of code using the BURNS section (e.g., 2’ burns to chest and upper extremities = 992018.3). Code the aspect as “0” (Whole Region).
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17. Whiplash
Cervical spine strain may, in some cases, still be referred to as “whiplash”. “Whiplash” is not a medical term and is not used in AI.590 (Update 98). If an injury is described as “whiplash”, it should be coded as; cervical spine strain (no fracture or dislocation) 640276.1,6 provided the guidelines below are followed:
(a) Interviewee reports: “Whiplash”. ER reports: “Pain”, ‘stiffness”, or “limited ROM” in neck but does not diagnose strain. Code: Do not code whiplash since ER, in essence, ruled it out.
(b) Interviewee reports: “Whiplash”. ER reports: “Neck supple’ and does not diagnose strain. Code: Do not code whiplash since ER. in essence, ruled it out.
(c) Interviewee reports: “Whiplash”. ER reports: (No medical attention sought.) Code: Do not code whiplash.
(d) interviewee reports: “Whiplash”. ER reports: (No indication that neck was soecifically examined.) Code: Code whiplash, data source “interviewee” (since ER did not rule out its
possibility).
Neck injuries may sometimes be described as “strains” and sometimes as “sprains”. For NASS purposes, neck injuries should be coded as “strains”.
Interviewee allegations of “upper back strain” or “lower back strain” are subject to the same test i.e., (a) through (d) above as an interviewee reported whiplash.
18. Strain vs Sprain
The following definitions have been used traditionally to differentiate “sprain” and “strain” injuries:
&- a ioint injury which causes pain and disability depending on the degree of injury to ligaments and muscle tendons near the joint.
g&l- an injury to a muscle or musculotendinous unit that results from overstretching and may be associated with a sprain or fracture.
In common medical practice, however, physicians often do not adhere strictly to these definitions, and may use the terms interchangeably. Care should be exercised in selection of the proper code: use Sprain for joint injuries and strain for muscle injuries.
Neck injuries may sometimes be described as “strains” and sometimes as “sprains”. For NASS purposes, neck injuries should be coded “strains’ (see above definitions).
19. Crush
“Crush” is a description of etiology, not of injury. However, it is included because it is used in medical charts. “Crush” for coding purposes means destruction of skeletal, vascular and soft tissue systems. The “Crush” injury description is used only when the injury meets the criteria in the dictionary. If the “Crush” code is used. individual injuries are not coded separately.
In order to code “Crush”, the following specific information should be known:
Head (Skull) -. numerous and extensive displaced or comminuted skull fractures accompanied by extrusion or significant displacement of brain matter.
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Thorax (Chest) -
Extremity- -
massive w deformation of chest wall gig internal organs.
massive destruction of bone and internal structures (i.e., muscle and/or vascular system).
20. Open Fracture
An open (compound) fracture, by definition, means that the skin overlaying the fracture is lacerated. The external laceration is implicit in the code for open fracture and is not coded separately.
Exception: open fracture of the skull with lacerated brain matter (code as two injuries).
21. Skull Fractures
The skull bones are divided into two areas of interest (i.e.. vault and base). The entries in the column entitled “Skull Bones” are intended to provide useful anatomical reference points that are often cited in medical records.
Area
Vault
Base
Subarea
Frontal
TemporaU Parietal Occipital
Anterior
Asoect(s)
5 (4
12 (Iv-)
6 (P)
8 (1)
Middle 8 (1)
Posterior 8 (1)
Skull Bones
Frontal bone including frontal sinus and not otherwise specified Temporal bone, including not otherwise specified Parietal bone (entire bone) Occipital bone, including not otherwise specified
Frontal bone, orbital plate--anterior cranial fossa: right and left Ethmoid bone, cribriiorm plate Sphenoid bone, body and lesserwings --forms a portion of anterior cranial fossa Sphenoid bone, sella turcica Sphenoid bone, greater wings _- forms a portion of middle cranial tossa: right and left Temporal bone -- mastoid and squamous portions Temporal bone, petrous portion Occipital bone -- posterior cranial fossa: right and left Occipital bone, including ring area (i.e., foramen magnum)
Code only one fracture per aspect, assigning the code with the higher AIS; Maximum number of codeable skull fractures is five.
Each aspect that was fractured is coded independently of whether the fracture in the aspect originated in the aspect or is a continuation of a fracture line(s) that originated in another aspect. If vault and base are involved record two lines of code.
A skull fracture not otherwise specified as to location is coded: 150400.2,9
“Multiple skull fractures” (or one of its synonyms: several, numerous, etc.) where little specific information is available, are coded: 150400.2,9
Statements such as: “massive skull fracture(s)” or “extensive skull fracture(s)“, where little specific information is available, is coded: 150404.3.?
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22. Multiple F_ractures in a Bone
For multiple fractures to the same bone:
(4 If multiple fractures to the same bone are determined, then code each separately.
(4 If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one comminuted fracture. Assign one line of code with the appropriate AIS.
Exceptions:
mandible - multiple fractures to the mandible are assigned one line of code. Choose the code and AIS for the more specific fracture type. Comminuted must be explicitly stated and is g&t derived from the presence of multiple fractures.
Fractures to the right& left sides are assigned Aspect code “3” (Bilateral).
Fractures to the right side a inferior portion of the mandible (Le., mental protuberance area) are assigned Aspect code “1” (Right).
Fractures to the left side m inferior portion of the mandible (i.e., mental protuberance area) are assigned Aspect code “2” (Left).
Fractures to the right @@ left sides & a fracture to the inferior portion (i.e., mental protuberance area) are assigned Aspect code “3” (Bilateral).
ribs . multiple fractures to the same rib are assigned one line of code. Choose the code and AIS for the more specific fracture type.
pubis - multiple fractures to the pubis (right, left, inferior, and/or superior) are assigned one line of code determined by the particular fracture type.
skull - see rule 21.
23. Costal Cartilage Fracture/Tear
A diagnosed costal cartilage fracture/tear should be coded as a rib fracture.
24. Joint - Ligament Injuries
Joint injuries involving fracture, dislocation, or fracture and dislocation of the extremities and associated ligament/tendon injuries do not require a separate code for the ligament/tendon injuries.
If an injury is described as an avulsion/chip fracture, then treat this injury as a ligament injury and code the injury as a rupture (laceration).
25. Coding Brain Injuries
The brain is divided into the following four suborgans: right hemisphere and left hemisphere (cerebrum), cerebellum, and brain stem.
Code one line of code per injury type per aspect for each brain suborgan. following the guidelines below:
(a) If both edema and swelling are present, code once for presence.
(W If surrounding edema is included for another injury, do not code edema/swelling.
(4 Do not code a brain stem hemorrhage if a contusion or laceration is present.
(d) Do not code a cerebellar or cerebral intracranial hemorrhage if brain stem injury is present (e.g., lacerated).
(4 If contusion & compression or contusion & hematoma are diagnosed code both.
(f) If a crushed brain stem is coded, do not code brain stem contusions or lacerations.
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(9)
04
When a brain lesion is described as an avulsion or transection. use the “laceration” injury description code.
If it is unknown if a diagnosed cortical contusion is to the cerebellum or cerebrum, code to the cerebrum.
(0 Pituitary injury is code 140799.3,8
26. Internal Organs
Where the coding manual assigns a single line of code for multiple same type injuries, use that specific injury code when applicable.
Example: 2 cm laceration right anterior ventricle, 3 cm laceration right atrium. Code multiple myocardium lacerations (441016.64).
For each major specific anatomic structure (organ) in the thorax or abdomen where one line of code does not represent multiple same type injuries, code one row per injury type, choosing the highest AIS for each particular injury type.
Example: The spleen is markedly lacerated, and approximately 50% of it is avulsed and lying free in fragments in the abdomen. Code laceration, complex (544226.5,2).
For multiple internal injuries to an organ of the thorax (except heart) or abdomen, code one row oer iniurvtvue, choosing the highest AIS for each particular type.
Example: Minor contusion spleen, one major laceration spleen, one superficial laceration spleen. Code contusion (544212.2,2) and laceration (544226.4,2).
The following terms may be used as a guide in differentiating between superficial, major, or complex lacerations or perforations to internal organs of the neck, thorax. and abdomen. However, the final choice of whether or not to use the “superficial” or ‘major” AIS levels depends on the term within the COntext of the & injury description.
Superficial - minor, partial thickness, small Major _ deep, full thickness, large, severe Complex - massive, tissue loss, segmental loss, stellate (abdomen)
NOTE: When organs are lacera&!pedorated and the medical report indicates massive, extensive, or significant blood loss, code the higher AIS.
27. Injuries Involving Skin and Internal Structures
If a deep laceration or puncture penetrates the soft tissue and it can be determined that it is associated with a similar lesion to a related internal structure, onlythe injury with the higher AIS (the internal injury) should be coded. If in doubt that the external and~intemal lesions are related, then code both.
28. Blood Loss
A number of injuries to the skin, vessel lacerations, brain lesions. and internal organs are described in terms of blood loss by volume. The following table should help in assessing blood loss when information in the hospital chart is not specific, and in coding these injuries in children.
21
As a rule of thumb, 1,000 cc of blood = 20% blood loss in an average adult.
Blood loss -- Consider all blood loss regardless of Cavity when estimating total blood loss
When blood loss is ~20% and more than one injury qualifies for the blood loss, choose the most severe associated injury.
Pounds x .4536 = Kilograms weight in Kilograms x 15 = 20% blood loss threshold
29. Transection
When a vessel injury is described as “transection” without additional data, code as complete transection (total severance). If “incomplete” transection is indicated, one AIS code less severe than “transection” should be used.
Examples: Aortic transection (abdominal) - code: 520208.5. Aortic laceration with incomolete transection - code: 520206.4
30. Tears: An Injury Synonym
If the injury description states only “tear”, then code as follows:
(a) If involving internal organs, use the ‘“laceration” code.
(b) If involving the external integumentary system, use the “laceration” or “avulsion” code as appropriate. If unknown which to select, then choose the “laceration” code.
31. Multiple Vessel or Nerve Injuries
For multiple injuries to a vessel or nerve located in the same body region or the same region of the spinal cord (e.g.. cervical), code onlv one line of code, choosing the injury with the highest AIS among all the injuries present.
Example: Laceration aorta (thoracic). severance aorta. Code only one injury, 420210.5 severance (laceration-major).
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32. Vessel Injury
Code a vessel injury separately if:
(4 there is-no accompanying, documented organ injury or
(b) accompanying organ injury does not include vessel injury in its description or
(c) Named vessel injury occurs with organ injury S@ is higher in severity than descriptor for organ injury.
INJURY SOURCE GUIDELINES
33. Side Interior Surface Contacts
If a side interior surface contact (left or right) occurs and it is uncertain whether the side hardware or armrest was involved, then code “Left side interior surface, excluding hardware or armrests” or “Right side interior surface, excluding hardware or armrests”, respectively.
34. Injuries Produced by Objects on the Occupant
If an object on the occupant (e.g., eyeglasses, pen, pencil, etc.) produces an injury due to contact, consider the object as a medium through which force is transmitted rather than the injury source itself. Determine and code the mechanism that contacted the object on the occupant.
Example: Driver’s face strikes steering wheel rim causing eyeglasses to lacerate right eyebrow.
Code Injury Source as “Steering wheel rim”.
35. Direct vs Indirect Injury
Definitions and procedures for coding InjurySourcefordirect, indirect, induced, noncontact, and airbag related injuries are listed below:
Injury Source is defined as the vehicte component or object that directly caused the injury (direct injury) or initiated the injury mechanism (indirect injury).
Direct iniury - an injury to a particular Body Region caused by the traumatic contact of that Body Region with a vehicle component or other object. The vehicle component or other object is coded as the injury source for that injury. Brain injuries, anatomic or non-anatomic, and skull injuries may be caused by the face or head striking a component or object. For these cases, consider the brain or skull injury as a direct injury.
Indirect or induced iniury - an injury to a particular Body Region caused by a blow or a traumatic contact in some other Body Region (e.g., head/neck). In the case of the lower or upper extremities, an injury to a particular body member caused by a blow or traumatic contact to a different body member within the same body region (e.g. knee/acetabulum). The injury source for an indirect injury would be the vehicle component contacted bytheother Body Region or member (i.e., the occupant contact that initiates the injury mechanism).
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36. Non-Con+t Injury Sources - Codes “fire in vehicle”, “flying glass”, “other noncontact injury source”, and “air bag exhaust gases”
These noncontact injury sources are to be usad only for the following specific types of injuries:
(4 head or neck injuries in which the torso is supported (e.g., by seat back or belt) and head or neck experiences traumatic forces due to inertial motion -- code “other noncontact injury source’:
(b) flying glass injuries -- code “flying glass”;
(4 burns due to chemicals or gaseous inhalation -- code “other noncontact injury source”;
Cd) burns due to flame -- code “fire in vehicle”; and
(6 burns due to air bag exhaust gases -- code “air bag exhaust gases”.
The following examples illustrates the above definitions.
Injury Mechanism Determined
Example 1 Neck strain 640276.1
a. b.
C. d.
e.
f.
9.
Example 2 Hip Dislocation 850610.2
Examole 3 Shoulder-elbow- wrist fracture/ dislocation 75-30.1
EXamDIe 4 Acute lumbar strain 640676.1
From Crash Evidence lniurv Source
head strikes windshield forehead hits roof of convertible top head strikes steering wheel rim back hits seatback, no head restraint, head rolls back over seat neck forced into lateral flexion by impact forces torso restrained by belt, head and neck inertia causes neck injury back hits seat back, head hits head restraint, neck is injured
Knee strikes knee bolster forces transmitted along femur forcing femoral head out of the acetabulum
Occupant braced hands on instrument panel, transmitting forces to wrist, elbow, and shoulder
Jackknife over seat belt, rotation about seat belt stretches back muscles
a. windshield b. roof or convertible top
c. steering wheel rim d. other noncontact injury source
e. other noncontact injury source
f. other noncontact injury source
g, head restraint
knee bolster
instrument panel
belt restraint
24
37. Air Bag Related
Air bag related is coded when a body part set in motion by a deploying air bag contacts a component which produces an injury.
Example: Deploying aitiag flings an into A-pillar which produces a fracture. Code Injury Source as “A-pillar” and Direct/Indirect Injury as air bag related.
DO NOT use air bag related if the air bag produced the injury
25
PART III
AIS DICTIONARY LISTING AND CODES
Codina Rules
HEAD (Cranium and Brain)
AIS Uncertainty Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e.. the lowest AIS code in that injury’s category).
Skull Fractures
The skull bones are divided into two areas of interest (i.e., vault and base). The entries in the column entitled “Skull Bones” are intended to provide useful anatomical reference points that are often cited in medical records.
Area Vault
Base
Subarea Frontal
Temporat/ Parietal Occipita
Anterior
Asoechs) 5 (4
12 (RN
6 (P)
8 (0
Middle 8 (1)
Posterior a (1)
Skull Bones Frontal bone including frontal sinus and not otherwise specified Temporal bone, including not otherwise specified Parietal bone (entire bone) Occipital bone, including not otherwise specified
Frontal bone, orbital plate--anterior cranial fossa: right and left Ethmoid bone, cribriform plate Sphenoid bone, body and lesserwings --forms a portion of anterior cranial fossa Sphenoid bone, sella turcica Sphenoid bone, greater wings --forms a portion of middle cranial fossa: right and left Temporal bone -- mastoid and squamous portions Temporal bone, petrous portion Occipital bone -- posterior cranial fossa: right and left Occipital bone, including ring area (i.e., foramen magnum)
Code only one fracture per aspect, assigning the code with the higher AIS; Maximum number of codeable skull fractures is five.
Each aspect that was fractured is coded independently of whether the fracture in the aspect originated in the aspect or is a continuation of a fracture line(s) that originated in another aspect. If vault and base are involved record two lines of code.
A skull fracture not otherwise specified as to location is coded: 150400.2,9
“Multiple skull fractures’ (or one of its synonyms: several, numerous, etc.) where little specific information is available, are coded: 150400.2,9
Statements such as: “massive skull fracture(s)” or “extensive skull fracture(s)“, where linle specific information is available, is coded: 150404.3,?
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~,-,-
1
Multiple Fracturee in a Bone
For multiple fractures to-the same bone:
(a) If multiple fractures to the same bone are determined, then code each separately.
(4 If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as gne cornminute fracture. Assign one line of code with the appropriate AIS.
Exceptions:
skull - skull fractures
Coding Brain Injuries
The brain is divided into the following four suborgans: right hemisphere and left hemisphere (cerebrum), cerebellum, and brain stem.
Code one line of code per injury type per aspect for each brain suborgan, following the guidelines below:
(a) If both edema and swelling are present, code once for presence.
W If surrounding edema is included for another injury, do not code edema/swelling.
(0) Do not code a brain stem hemorrhage if a contusion or laceration is present.
W Do not code a cerebellar or cerebral intracranial hemorrhage if brain stem injury is present (e.g., lacerated).
W If contusion a compression or contusion and hematoma are diagnosed code both.
0) If a crushed brain stem is coded, do not code brain stem contusions or lacerations.
(9) When a brain lesion is described as an avulsion or transection, use the “laceration” injury description code.
(W Pituitary injury is code 140799.3.8
See page 40 for guidelines on when to use Loss of Consciousness information.
Valid Asoect Codes: 1,2,3,5.6.8,9,0 (Fl,L,B.A,P,I.U,W)
@ - 1,2,5,6,,9,0 (R,L,A.P.U,W)
+ - 1,2,9 (R.L,U)
? - 1,2.5,6,9 (R.L,A,P,U)
! - 1.2,3,9 (R,L,B,U)
w &g&j
Frontal 5 (4 Parietal 1,2.9 (RLJJ) Temporal 1,2.8,9 (R,L,I,U)
Occipital Sphenoid Cerebrum Cerebellum Brainstem
6 P) 1,2,8.9 (R.L,I,U) 1,2.3,9 6 8
Remarks
Aspect “8” covers; Mastoid Process, Svoid Process, Petrous portion.
Aspect “8” is for Sella turcica.
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I ‘Closed head init@ or Yrsumatic brain injury” are not specitic diagnosis and, depending on local usage, may mean almosf any type 01 head injury. Therefore, if this vague information is the only description available. the brain injury should be coded under ‘Whole Area’ and assigned Ihe code 7. These descriptors should never be used when more specific information is available. I
CODE ASPECT INJURY DESCRIPTION
115099.7 0 I I
Closed head injury/blunt head trauma/traumatic brain injury NFS
115999.7 died without further evaluation; no autopsy
113000.6 0 (Crush) Massive destruction of both cranium (skull) and brain
190099.1 @ Scalp NFS
190202.1 abrasion
190402.1 contusiotisubgaleal hematoma
190600.1 laceration NFS
190602.1 minor (superficial)
190604.2 maior’ (> 1Ocm long and into subcutaneous tissue)
190606.3 blood loss > 20% by volume
190800.1 avulsion NFS
190802.1 superficial’ (minor: 5 lOOcm*)
190804.2 major’ (> 100cm’ but blood loss < 20% by volume)
190806.3 blood loss > 20% by volume
190808.3 total scalp loss
* See page 151 for diagram of actual injury size.
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I Vessel injuries should be coded separate from the injuries to the brain. If specific vessel is not known, cods as intracranial vessel NFS. code 121299.3.9.
Thrombosis includes any injury to the vessel resulting in its occlusion (e.g., intimal tear. dissection). ‘Open lacsrstion’ mesns the vessel is bleeding out of the body (externally).
CODE ASPECT INJURY DESCRIPTION
120299.3
120202.5
120204.3
120206.3
120499.5
120402.5
120404.5
120406.5
120602.4
120899.3
120802.4
120804.5
120806.3
121099.3
121002.5
121004.4
121006.3
121299.3
5 Anterior cerebral artery NFS
laceration
thrombosis (occlusion)
traumatic aneurysm
8 Basilar artery NFS
laceration
thrombosis (occlusion)
traumatic aneurysm
5 Carotid-cavernous fistula
8 Cavernous sinus NFS
laceration
open laceration or segmental loss (“open” means vessel is bleeding outside the body externally)
thrombosis (occlusion)
+ Internal carotid artery NFS
laceration
thrombosis (occlusion)
traumatic aneurysm
9 Intracranial vessel NFS [Use this description if specific vessel is not
121202.4 laceration
121204.3 thrombosis (occlusion)
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CODE - ASPECT INJURY DESCRIPTION
gmental loss (“open” means vessel
122606.4 thrombosis (occlusion)
33
CODE - ASPECT INJURY DESCRIPTION
122899.3 + Vertebral artery NFS
122802.5 laceration
122804.3 thrombosis (occlusion)
122806.3 traumatic aneurysm
34
Because of limitations in diagnostic capabilities. it is often impossible lo assign specific injury descriptors to cranial nerve injuries. Therefore, many cranial nerve injuries may be described only by the type of dysfunction that exists in normal nerve function. Unless contusion or laceration is specified, code as laceration if total loss of nerve function (paralysis) is described. Code as contusion if subtotal loss of function (paresis) is documented. Do not increase the severity for bilateral or multiple injuries of the same nerve. Nerve injuries should be coded separate from the injuries to the brain. If specific nerve is not known. code as cranial nerve NFS. code 130299.2,9.
CODE ASPECT INJURY DESCRIPTION
35
CODE -ASPECT INJURY DESCRIPTION
131899.2
132204.2 laceration
132499.2 + XI (Spinal accessory nerve) NFS
132402.2 contusion
132404.2 laceration
132699.2 8 XII (Hypoglossal nerve) NFS
132602.2 contusion
132604.2 laceration
36
1 The injuries in this section should be coded only if verified by CT scan, MRI. surgery. x-ray. angiography qr autopsy. Clinical diagnosis alone is not an adequate determination for establishing the e&fence of an anatomic lesion for coding purposes. I
CODE ASPECT INJURY DESCRIPTION
140299.5
140202.5
140204.5
140206.5
140208.5
140210.5
140212.6
140214.6
140216.6
140218.6
8 Brain stem (hypothalmus. medulla, midbrain, pons) NFS
compression (includes transtentorial (uncal) or cerebellar tonsillar hernial
contusion
diffuse axonal injury (white matter shearing) [Use this code only if medical indicates “white matter shearing” or diagnosis is “diffuse axonal injuv (DAI).]
infarction
injury involving hemorrhage
laceration
massive destruction (crush)
penetrating injury
transection
140499.3 6 Cerebellum NFS [Use this section only if cerebellum, infratentorial or posterior fossa are named. Otherwise, code as Cerebrum.]
140402.3
140403.3
140404.4
contusion, single or multiple, NFS [include surrounding edema for size]
small (superficial); (ZZ 15cc; 3 3cm diameter)
large (15-30~~; > 3cm diameter)
140405.5 extensive (massive; total volume > 3Occ) I I
140406.5 6 diffuse axonal injury (white matter shearing) [Use this code only if medical indicates “white matter shearing” or diagnosis is “diffuse axonal injun/’ (DAI).]
140410.4 6 hematomaihemorrhage NFS [Use this code for “extra axial unless further described as epidural or subdural, includes surrounding edema]
140414.4 epidural or extradural NFS [include surrounding edema
37
CODE ASPECT INJURY DESCRIPTION
Cerebellum (continued)
140418.4 6 small (s 3Occ in adults;’ 5 2cm thick; smear; tiny; moderate)
140422.5 large (> 3Occ in adultq” > 2cm thick; massive; extensive)
140426.4 6 intracerebellar including petechial and subcortical NFS [include surrounding edema for size]
140430.4
140434.5
140438.4
140442.4
6
small (5 15~; < 3cm diameter)
large (> 15cc: > 3cm diameter)
subdural NFS
small (I 3Occ in adults;’ i 2cm thick; smear: tiny; moderate)
140446.5 large (> 3Occ in adults;- > Zcm thick; massive: extensive)
Injury involving any of the following but not further specified anatomically other than cerebellum, infratentorial or posterior fossa: [Use this category even in the presence of anatomically described substantiated injuries.]
140450.3 6 brain swelling/edema not including surrounding edema NFS [Code one or other, i.e., swelling or edema, but not both. DO NOT code if result of anoxia or other nontraumatic cause.]
140458.3 infarction (acute due to traumatic vascular occlusion) I I
140482.3 ischemia
140466.3 subarachnoid hemorrhage
140470.3 subpial hemorrhage
140474.4 6 laceration
P s 15cc or s lcm diameter/thick if s 10 years old
aa t 15cc or L lcm diameter/thick if i 10 years old
Note: Adult means > 10 years old
. See Rule 25
38
CODE -ASPECT INJURY DESCRIPTION
140699.3 + Cerebrum NFS [Use if described as “brain” injury]
140602.3 contusion NFS [include surrounding edema for size]
140604.3
140606.3
140608.4
140610.5
single NFS
small (superficial; < 30~~;’ < 4cm diameter; midline shift < 5mm)
large (deep; 30-50~~; > 4cm diameter;- midline shift > 5mm)
extensive (massive; > 5OcP)
140611.3 I 9 I multiple NFS I I
140812.3
140614.3
140616.4
140618.5
140820.3
multiple, on same side but NFS
small (superficial; total volume ~3Occ;’ midline shift s 5mm)
large (total volume 30-50cc;“a midline shift > 5mm)
extensive (massive; total volume > 5Occ)“”
multiple, at least one on each side but NFS
140822.3 small (superficial: total volume 5 30~~)~ I ,
140624.4 large (total volume 30-5Occ)’ I I
140626.5 extensive (massive; total volume > 5Occ)”
140628.5 diffuse axonal injury (white matter shearing) [Use this code only if medical indicates “white matter shearing” or diagnosis is “diffuse axonal injuw (DAI).]
140629.4 + hematomtiemorrhage NFS [Use this code for “extra axial” unless further described as epidural or subdural]
140630.4 epidural or extradural NFS [include surrounding hematoma for size)
140632.4 small (5 5Occ adult: 5 2%~ if I 10 years old; zz lcm thick; smear; tiny; moderate)
140634.5 3 bilateral
a < 15cc or 5 2cm diameter if i 10 years old
” 15-30~~ or 2-4cm diameter if zc 10 years old
> 3Occ or > 4cm diameter if s 10 years old
Note: Adult means > 10 years old
39
CODE ASPECT INJURY DESCRIPTION
140638.4 +
140640.4
140642.4
140644.4
140646.5 3
140648.5 +
140650.4 +
140652.4
140654.5 3
140656.5 +
140660.3
I
140666.5 I
large (> 5Occ adult; > 2%~ if s 10 years old; > lcm thick; massive: extensive)
intracerebral NFS [include surrounding edema for size)
small (s 3Occ; < 4cm diameter’)
petechial hemorrhage(s)
subcortical hemorrhage
bilateral
large (> 3Occ; >4cm diameter”)
subdural NFS
small (5 5Occ adult; s 25cc if i 10 years old; s lcm thick; smear: tiny; moderate)
bilateral
large (> 5Occ adult; > 2%~ if i 10 years old; > lcm thick: massive; extensive)
Injury involving any of the following but not further specified anatomically other than cerebrum, supratentorial. anterior cranial fossa or middle cranial fossa: [Use this category even in the presence of anatomically described substantiated injuries.)
brain swelling/edema NFS’ (not including surrounding edema) [Code one or other, i.e., swelling or edema, but not both. DO NOT code if result of anoxia or other nontraumatic cause.]
mild (compressed ventricle(s) w/o compressed brain stem cisterns)
moderate (compressed ventricle(s) and brain stem cisterns)
severe (absent/obliterated ventrfcle(s) or brain
P i: 15cc or i 2cm diameter if d 10 years old
” > 15cc or > 2cm diameter if i 10 years old
Note: Adult means > 10 years old
* See Rule 25
40
CODE -ASPECT INJURY DESCRIPTION
lar hemortiagelintracerebral hematoma in
41
-I Code all skull fractures under vault unless specified as base. Code associated brain or cranial nerve injuries separately under Nerves. Vessels. or Organs. Code nasc-ethmoidal fracture as basilar. In these cases, do not code facial fractures separately. I
CODE ASPECT INJURY DESCRIPTION
150200.3 8 Base (basilar) fracture NFS (may involve ethmoid, orbital roof, sphenoid, temporal-including petrous, squamous or mastoid portions - or occiptal bones)
150202.3 without CSF leak
150204.3 with CSF leak
150206.4 complex (oper? with torn, exposed or loss of brain tissue; comminuted.w ring. hingebM) 1 1
Any of the following clinical signs may be indicators of basilar skull fracture: hemotympanum; perforated tympanic membrane with blood in canal: mastoid hematoma (battle signs); CSF otorrhea; rhinorrhea; periorbiial ecchymosis (racoon’s eyes).
150400.2 ? Vault fracture NFS (may involve frontal, occipital, parietal, or temporal bones not otherwise specified) [Use this code if unknown if base or vault is fractured.]
150402.2
150404.3
closed (simple; undisplaced; diastatic; linear)
comminuted (compoundb, open but dura intact; depressed < 2cm; displaced)
150406.4 complex (oper? with tom, exposed or loss of brain tissue) I I
150408.4 massively depressed (large areas of skull depressed > 2cm)
The term “compund” is uniquely applied to skull fracture; it means open fracture. “Open” skull fracture means a compound fracture plus torn dura, exposed or loss of brain tissue.
” If extensive fractures occur to a single basilar fossa or if two or more of the three basilar fossa (anterior, middle, and posterior) are fractured, then code as a basilar fracture.
A hinge fracture extends from the left to the right temporal bones. The fracture may extend across (1) the middle cranial fossa. often involving the sella turcica; (2) the posterior cranial fossa. from one petrous portion to the opposite petrous portion; or (3) both the middle and posterior cranial fossae.
42
GUIDELINES ON WHEN TO USE LOSS OF CONSCIOUSNESS INFORMATION
Injuries coded under this section are based on leveliloss of consciousness data. A non- anatomical injury is coded in addition to substantiated anatomic iniuries and when there are no substantiated anatomic iniurfes. Onlyg9g non-anatomic injury is coded per individual.
Loss of consciousness codes cannot be used if: (1) death occurs within 24 hours and patient has not regained consciousness or (2) the patient survives and the diagnosis is “closed head injur)r with no information about LOC or length of unconsciousness except for descriptors 160820.4. 160822.5 or 160824.5.
The Glascow Coma Score is included under the ‘Level of Consciousness’ section as one indicator of neurologic status that needs corroboration for the presence of brain injury. The presence of alcohol or other drugs will oftentimes confound the assessment of brain injury based upon neurologic status. Similarly, intubation of patients following injury limits the application of GCS to assess the presence or absence of brain injury. For these reasons GCS should never be used as the sole indicator of brain injury based on level of consciousness. Use code 115099.7 if the patient has been intubated and/or only GCS data is available, unless a brain injury is substantiated in the medical record.
Anatomical iniuries
For coding head injuries other than those to the skull, the coder may know the anatomical injury, the level of consciousness, or the duration of unconsciousness. If an anatomical injury is substantiated by autopsy, CT scan, MRI (magnetic resonance imaging), surgery, x-ray, or angiography, it should be coded using the section titled Internal Organs. (Recall that clinical diagnosis alone is not an adequate determination for establishing the existence of an anatomical injury for coding purposes.)
Where LOC accompanies a documented anatomical lesion, the LOG should be considered only if it reflects a more serious injury than is described by the anatomical lesion alone. In these cases, code the higher AIS non-anatomical lesion gncJ the documented anatomical lesion.
Non-Anatomical iniuly
In the absence of a documented anatomic injury, only information on status of consciousness may be available to the coder. In these cases, the following sections on length of unconsciousness or level of consciousness should be used.
Self-reported LOC or reports of bystanders with no corroboration by EMS or medical personnel and no evidence of head trauma should be disregarded. Abrasions, contusions, pr lacerations to the scalp are coded under Whole Area and are not automaticallv oresumed to have an associated brain injury.
Neurological deficit
One or more of the following sequela that was not present pre-injury constitute a neurological deficit if it lasts for more than a transient period (i.e., minutes): hemiparesis: hemiplegia; weakness; sensory loss; hypesthesia; visual field defect: asphasia; dysphasia; seizure; central (not peripheral) facial weakness or palsy; deviation of both eyes to the same side; unequal pupils (anisocoria): pupils fixed or not reactive. The latter three must be due to head, not eye or orbital, injury.
Add an AIS of 1 (where indicated in the manual) if the injury involves a neurological deficit for more than a transient period. The deficit assessment must be made by a medically qualified observer and must be contained on an official record of a medical facility or an E.M.T. service.
43
Length of Unconsciousness
This section may be used only within the immediately preceding guidelines. This section should always be used in preference to the one that follows, called the Level of Consciousness. The necessity to use this section in preference to the one titled Internal Organs (pages 37-41) oftentimes reflects inadequate data sources.
The length of unconsciousness must be recorded by emergency (i.e., EMS) or medical personnel (i.e., ER), and must be related to head injury. If length of unconsciousness is unknown, proceed to the level of consciousness section.
CODE ASPECT INJURY DESCRIPTION
180202.2
160204.3
160206.3
160208.4
160210.4
160212.5
0
Unconsciousness known to be
c 1 hr.
with neurological deficit
1-6 hn.
with neurological deficit
6-24 hrs. (includes 1 calendar day when hours cannot be estimated)
with neurological deficit
44
Level of Consckusness
This section is used only ii an injury cannot be coded by the internal Organs (pages 37-41) or Length of Unconsciousness (page 44) sections. The level of consciousness and its duration must be obsewed by emergency (i.e., EMS) or medical personnel (i.e., ER), and must be related to head injury. The necessity to use this section in preference to the one titled Internal Organs oftentimes reflects inadequate data sources.
CODE ASPECT INJURY DESCRIPTION
160499.1
160614.3 I 1-6 hrs. unconsciousness I
45
CODE -ASPECT INJURY DESCRIPTION
Level of Consciousness
160824.5
46
VENOUS DRAINAGE OF HEAD
SAG II SUI’FRIOR \
SINUS
PI’TROSAI. SINUS
STRAIGIII’ SIN115
; ; , \\ - CAVERNOIlS SINUS
Adapted from: Source (5). p. 383 Additional illustrations: Jacob. et al.. p. 402
47
/ ! I
\
Facial m"SCleS Submandibular Sublingual TOllg"e Soft palate
Stcrnocleidomasloid Trapezius
Adapted irom: *ourcc (7). ,'. 261
40
-
Arachnoid
Svbarachnoid
Pia mater
BWJNSTM: nla1amus
neninges of the brain (cross section)
Adapted from: source (8). P. 314 - top source (3,. P. 195 - bottom
Additional ill”Stratio”s: ,acob. et al., P. 237, 247
49
Parfetal bone
Fronral bone
Ethmoid bone Sphenoid
Ethnoid bone: crista galli Cribiform place
Parietal bone
Foramen magnum
Occinical bone
Adapted fmm: Source (5). p.98-top Source (a), p. 141-botrom
Addxrional Illustrations: Jacob. et al.. pP.99. 108-S
50
Codina Rules
FACE (Includes Ear and Eye)
AIS Uncertainty Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
Bilateral Injuries
Bilateral injuries are coded separately for organs such as the eyes, and ears unless the dictionary specifically allows for coding as a single injury. Maxillae and mandibles are coded as single structures.
Coding Same Type htegumentary Injuries
Use the following rules when coding ‘same type” injuries (i.e., abrasions, avulsions. contusions, and lacerations) to a body region.
(9 When the “same type” soft tissue injuries occurs to 2 2 aspects of a body region due to different contact points, code as separate injuries.
(b) Any number of “same type” soft tissue injuries resulting from the same contact point, occurring to a body region, exceot the face, will have one line of code.
Cc) If “same type” soft tissue injuries resulting from the same contact point occur to the face and involve z 1 and 5 3 diierent aspects, code each aspect separately. If 2 4 diierent aspects, enter one line of code using aspect “whole region”.
(d) If any of the words “multiple”, “numerous * “several”, or the plural of a lesion is used to , describe ‘&same type” soft tissue injuries ggg there are no details of location, enter one line of code from the EXTERNAL - Skin and Subcutaneous Tissue section (e.g., multiple contusions, Code 990400.1.0).
If multiple “same type” soft tissue injuries occur to a specific body region &@ the aspect is unknown, enter one line of code using the WHOLE AREA section for that body region (e.g., multiple facial abrasions, Code 290202.1 ,O).
Laceration Type injuries
When an injury is described as a ’ type of laceration’ (e.g., avulsion type laceration, flap laceration), use the “avulsion” code. For all ambiguous situations, use “laceration” over avulsion.
Dicing Type Injuries
When an injuryisdescribed as a ‘dicingtype code ‘“abrasion”.
” (e.g., dicing type lacerations, dicing type abrasions)
51
Multiple Fractures in a Bone
For multiple fractures to.the same bone:
(a) If multiple fractures to the same bone are determined, then code each separately.
W If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one comminutecf fracture. Assign one line of code with the appropriate AIS.
Exceptions:
mandible - multiple fractures to the mandible are assigned one line of code. Choose the code and AIS for the more specific fracture type. Comminuted must be explicitly stated and is goJ derived from the presence of multiple fractures.
Fractures to the right g9g left sides are assigned Aspect code “3” (Bilateral).
Fractures to the right side anrJ inferior portion of the mandible (Le., mental protuberance area) are assigned Aspect code “1” (Right).
Fractures to the left side and inferior portion of the mandible (i.e., mental protuberance area) are assigned Aspect code “2” (Left).
Fractures to the right& left sides and a fracture to the inferior portion (i.e., mental protuberance area) are assigned Aspect code “3” (Bilateral).
Valid ASDeCt Codes: 1,2,3,4,7,8,9,0 (R.L.B.C,S.I,U,W)
* - 1,2,4.7,8,9,0 (R,L,C,S,I,U,W)
+ - 1,2,9 (R,L.U)
% - 1,2.3,8,9 (R,L.B,I.U)
! - 1.2,3,9 (R,L,B.U)
@gi$J
Cheek Chin
Ear Eye
Eyebrow
Forehead Lips Nasal Spine Nose
52
CODE ASPECT INJURY DESCRIPTION
215099.7
215999.7
290099.1
290202.1
290402.1
290600.1
290602.1
290604.2
290606.3
290800.1
290602.1
290804.2
290806.3
Bluntfhumatic facial injury NFS
died without further evaluation: no autopsy
Skin/Subcutaneous tissuehluscle [Including lip, external ear (pinna/auricle), forehead, eyebrow -- for eyelid or orbit (soft tissue) - see Eye-Skin] NFS
abrasion
contusion
laceration NFS
minor (superficial)
major’ (> 1Ocm long and into subcutaneous tissue)
blood loss > 20% by volume
avulsion NFS
superficial’ (minor; 5 25cm*)
major’ (> 25cm’ but blood loss < 20% by volume)
blood loss > 20% by volume
f See page 151 for diagram of actual injury size.
53
[also see NECK]
CODE
220200.1
220202.1
220204.3
ASPECT INJURY DESCRIPTION
+ External cartoid artety branch(es) including facial and internal maxillary laceration NFS
minor
major (blood loss > 20% by volume)
m [also see CRANIAL NERVES under HEAD]
CODE ASPECT INJURY DESCRlPTfON
230299.1
230202.2
, 230204.2
230206.2
+ Optic nerve injury NFS [Intraorbital portion only; for intracranial portion or location unknown, code under cranial nerves in HEAD section.]
contusion
laceration
avulsion
54
CODE ASPkT INJURY DESCRIPTION
241002.2 with retinal detachment
241200.1 + Sclera laceration
241202.2 involving globe (includes rupture)
297099.1 + Skin-Eyelid or orbit (soft tissue) NFS
297202.1 abrasion
297402.1 contusion
297602.1 laceration
297602.1 avulsion
241499.1 + Uvea injury
241699.1 + Vitreous iniurv
55
CODE -ASPECT INJURY DESCRIPTION
243099.1 8 Mouth injury NFS
243299.1 a Gingiva (gum) NFS
243202.1 contusion
243204.1 laceration
243206.1 avulsion
243400.1 a Tongue laceration NFS
243402.1 superficial
56
CODE ASPECT INJURY DESCRIPTION
to teeth [Do not code
as singe
250610.2 mminuted (any or combination) but
d LeFort I - horizontal segmented fracture of the alveolar process of the maxilla in which the teeth are usually contained in the detached portion of the bone.
e LeFort II - unilateral or bilateral fracture of the maxilla in which the body of the maxilla is separated from the facial skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline of the hard palate, through the floor of the orbit and into the nasal cavity.
LeFort III - a fracture in which the entire maxilla and one or more facial bones are completely separated from the base of the skull.
57
CODE ASPECT INJURY DESCRIPTION
251200.2
58
Condyle
Ramvs
Alveolar ridge
Angle Body
-.
Adapted from: source (3). p. 72 - tap source (5). p. 106 - t.otrom
Addi~io”al,illus~ra~io”: Jacob. et al.. p. 97
59
MOUTH
Lip (pulled outward)
mngiva (gum)
MIDDLE EAR (ossicular chain): mihs. I”c”~, stapes
EXTERNAL LAP.:
Pinna (auricle)
Tympanic membrane (eardrum)
External auditory meatus (ear canal)
INNER EAR:
Adapted from: Source (8). p. 542 and (3). p. 255 Additlonal illustrations: Jacob, et al.. pp. 320-l
60
con,unct*va
61
NECK
Coding Rules
AI.5 Uncertainty Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
Internal Organs
The following terms may be used as a guide in differentiating between superficial, major, or complex lacerations or perforations to internal organs of the neck. However, the final choice of whether or not to use the “superficial” or “major” AIS levels depends on the term within the m of the m injury description.
Superficial - minor, partial thickness, small Major - deep, full thickness, large, severe Complex - massive, tissue loss, segmental loss, stellate (abdomen)
NOTE: When organs are lacerated/perforated and the medical report indicates massive, extensive. or significant blood loss, code the higher AIS.
Valid Aspect Codes: 1,2,5,6,9,0 (R,L.A.P,U,W)
*- 1,2,5,6,9,0 (R,L,A,P,U,W)
+ - 1,2,9 (R.L,U)
63
CODE ASPECT INJURY DESCRIPTION
315099.7 0 BkuWTrsumetic neck/throat injury NFS
315999.7 died without further evaluation; no autopsy
311000.6 0 Decapitation
390099.1 * Skin/Subcutaneous tissue/Muscle NFS
390202.1 abrasion
390402.1 contusion (hematoma)
390600.1 laceration NFS
390602.1 minor (superficial)
390604.2 major’ (> 20cm long and into subcutaneous tissue)
390606.3 blood loss > 20% by volume
390600.1 avulsion NFS
390802.1 superficial’ (minor: < 100cm’)
390804.2 major’ (z- 1OOcm’ but blood loss < 20% by volume)
390806.3 blood loss > 20% by volume
* See page 151 for diagram of actual injury size.
Descriptions for vessel lacerations distinguish between complete and incomplete transection. See foctnotes g and h.
The terms ‘laceration,’ ‘puncture.’ and ‘perforation’ are oftentimes used interchangeably to describe vessel injuries and are of the same severity. When ‘perforation’ or ‘puncture’ is used, code as laceration.
Thrombosis includes any injury to the vessel resulting in its occlusion (e.g., intimal tear, dissection)
CODE ASPECT INJURY DESCRIPTION
320210.4
320214.5 with neurological deficit (stroke) not head injury
320410.2 with thrombosis (occlusion) secondary to trauma
320412.2 thrombosis (occlusion) secondary to trauma
g (superficial: incomplete transection; incomplete circumferential involvement; blood loss s 20% by volume)
(rupture; complete transection: segmental loss: complete circumferential involvement; blood loss > 20% by volume)
65
CODE ASPECT INJURY DESCRIPTION
320606.3
wtth neurological deficit (stroke) not head injury
321016.3 with thrombosis (occlusion) secondary to trauma
321018.3 thrombosis (occlusion) secondan, to trauma
321020.4 with neurological deficit (stroke) not head injury related
p (superficial; incomplete transection; incomplete circumferential involvement; blood loss s 20% by volume)
(rupture; complete transection; segmental loss: complete circumferential involvement; blood loss > 20% by volume)
66
CODE ASPECT INJURY DESCRIPTION
Brachial plexus [see SPINE]
330299.2
330499.1
Cervical spinal cord or nerve root [see SPINE]
+ Phrenic injury
+ Vagus nerve injury [see also THORAX and ABDOMEN]
67
CODE ASPECT INJURY DESCRIPTION
341002.3
341499.1
341402.1
341404.2
341899.2
341802.2
with ductal involvement or transection
5 Thyroid gland NFS
contusion (hematoma)
laceration
Trachea [see THORAX]
5 Vocal cord NFS (not due to intubation)
unilateral
68
CODE
350200.2
ASP&X INJURY DESCRIPTION
Cervical spine [see SPINE]
5 Hyoid fracture
69
Pharynx
Larynx
Esophagus Trachea
Carotid artery
70
THORAX
Codina Rules
Specific Rules for Thoracic lnjuty To be used when coding injuries that involve “results”(i.e., hemo/pneumothorax, hemo/pneumomediastinum)
a When L two thoracic injuries occur in the same patient, only one thoracic injury description code and AIS can account forthe presence of (any mixture of) results (i.e., hemo-l pneumothorax and/or hemo- lpneumomediastinum -- unilateral or bilateral.
0 If tension pneumothorax is diagnosed with rib fractures but without a documented lung injury, use the thoracic injury description to code the tension pneumothorax (442210.5) and code the rib fracture(s) without pneumothorax.
0 If an occupant has a pleural laceration & rib fractures & hemothorax and/or pneumothorax -- unilateral or bilateral but no luna lacerations or vessel iniuries. then incorporate the results into the rib fracture code.
cl If an occupant has a flail chest with unilateral or bilateral lung contusion(s). then the lung contusion(s) is/are a coded separately.
Code: 4 5 02 60.4,+ -- is used for unilateral flail chest when it is unknown if any lung contusion occurred
Code: 4 5 02 62.3,+ -- is used for unilateral flail chest when it is known that no lung contusion occurred
Code: 4 5 02 64.4,+ _- is used for unilateral flail chest when it is known that unilateral or bilateral lung contusion occurred
Code: 4 5 02 66.5,3 -- indicates bilateral flail chest with or without lung contusion (unilateral or bilateral)
3 If a hemo-/pneumothorax (unilateral or bilateral) is present with flail chest and lung contusion, then do m code the results separately. However, if a lung laceration is present, then incorporate the results into the appropriate lung laceration injury description.
cl Where a specific anatomical injury description is lacking and only hemothorsx, pneumothorax, hemomediastinum, or pneumomediastinum are given, use the injury description “Thoracic Cavity Injury NFS”.
AIS Uncertainty Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
Bilateral Injuries
Bilateral injuries are coded separately for organs such as the kidneys, eyes, and ears unless the dictionary specifically allows for coding as a single injury (e.g., lung injuries). The rib cage is coded as a single structure. Example: Fracture right 6-7 and left 4-6 ribs. Code 450220.2,3 (2-3 ribs any location).
71
Multiple Fracture0 in a Bone
For multiple fractures tothe same bone:
(a) If multiple fractures to the same bone are determined, then code each separately.
(b) If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one comminuted fracture. Assign one line of code with the appropriate AIS.
Exception:
ribs - multiple fractures to the same rib are assigned one line of code. Choose the code and AIS for the more specific fracture type.
Internal Organs
Where the coding manual assigns a single line of code for multiple same type injuries, use that specific injury code when applicable.
Example: 2 cm laceration right anterior ventricle, 3 cm laceration right atrium. Code multiple myocardium lacerations (441016.6,4).
For each major specific anatomic structure (organ) in the thorax where one line of code does not represent multiple same type injuries, code one row per injury type, choosing the highest AIS for each particular injury type.
Example: The spleen is markedly lacerated, and approximately 50% of it is avulsed and lying free in fragments in the abdomen. Code laceration, complex (544228.5,2).
For multiple internal injuries to an organ of the thorax (except heart), code one row oer iniurv tvoe, choosing the highest AIS for each particular type.
Example: Minor contusion spleen, one major laceration spleen, one superficial laceration spleen. Code contusion (544212.2.2) and laceration (544226.42).
The following terms may be used as a guide in differentiating between superficial, major, or complex lacerations or perforations to internal organs of the thorax. However, the final choice of whether or not to use the “superficial” or “major” AIS levels depends on the term within the gg&+@ of the entile injury description.
Superficial - minor, partial thickness, small
Major - deep, full thickness, large, severe
Complex - massive, tissue loss. segmental loss, stellate (abdomen)
NOTE: When organs are lacerated/perforated and the medical report indicates massive, extensive. or significant blood loss, code the higher AIS.
Transection
When a vessel injury is described as “transection” without additional data, code as complete transection (total severance). If “incomplete” transection is indicated, one AIS code less severe than “transection” should be used.
Examples: Aortic transection (abdominal) _ code: 520208.5.
Aortic laceration with incomplete transection - code: 520206.4
72
Costal Cartilage Fracture/Tear
A diagnosed costal cartilage fracturehear should be coded as a rib fracture.
Valid Codes and Aspects for Seat Belt Contusions
For “seat belt bruises” due to a three-point system, code:
Shoulder 790402.1 ,1,2 (R,L) Chest 490402.1,1.2,4,0 (R,L,C,W) Abdomen 590402.1,1,2,4,7,8,0 (R,L.C,S.I,W)
Code 790402.1 ,1,2, 490402.1,4, and 590402.1,4 if unspecified. [Note: Code only those injuries that are consistent with the type of restraint worn (e.g., do not code 790402.1 or 490402.1 if only a lap belt was used).]
Valid AsDect Codes: 1,2,3,4,9,0 (R.L.B,C,U.W)
# - 1.2,3.4.9,0 (R.L,B.C,tJ,W)
+ - 1,2.9 (R,L,U)
! - 1,2.3,9 (R,L,B,U)
\ - 1,2,3.4,9 (R,L.B,C,U)
& - 1,2,4,9,0 (R.L.C,U,W)
73
I ‘Blunt chest injury’ is not a specific diagnosis and. depending on local usage, may mean almost any type of chest injury. Therefore. if it is the only information available. B should be coded under ‘Whole Area’ and assigned the code 7. This descriptor should never be used when more specific information is available.
CODE ASPECT INJURY DESCRIPTION
415099.7 0 Bluntrrraumatic chest (thoracic) injury NFS I I
415999.7
411000.2
413000.6
died without further evaluation; no autopsy
+ Breast avulsion, female
0 (Crush) bilateral destruction/obliteration by external forces of a substantial portion of the chest cavity including skeletal, vascular, internal organs, and tissue systems.
490099.1 # Skin/Subcutaneous tissue/Muscle/Chest wall NFS
490202.1 abrasion
490402.1 contusion (hematoma) (O/S Grade I)
490600.1 laceration NFS
490602.1 minor (superficial) (O/S Grade I, 11)
490604.2 major’ (> 20cm long and into subcutaneous tissue)
490606.3 blood loss > 20% by volume
490800.1 avulsion NFS
490802.1 superficial’ (minor 5 lOOcm*)
490804.2 major’ (z= 100cm’ but blood loss s 20% by volume)
490806.3 blood loss > 20% by volume
’ See page 151 for diagram of actual injury size.
74
Descriptions for vessel lacerations distinguish behveen complete and incomplete transection. See fcotnotes g and h.
The terms %ceration.’ ‘puncture’ and ‘perforation’ are oftentimes used interchangeably to describe vessel injuries and are of the same severity. When ‘perforation’ or ‘puncture’ is used, code as laceration.
CODE ASPECT INJURY DESCRIPTION
420216.6
420606.4 majo?
g (superficial: incomplete transection; incomplete circumferential involvement; blood loss 5 20% by volume)
(rupture; complete transection: segmental loss; complete circumferential involvement; blood loss > 20% by volume)
75
CODE ASPECT INJURY DESCRIPTION
421408.4
421699.3
421602.3
421604.3
421606.4
421899.3
421602.3
421804.3
421806.4
majo?
+ Subclavian vein NFS (a// O/S Grade 11)
laceration (perforation, puncture) NFS
minoP
mafoP
4 Vena Cava, superior and thoracic portion of inferior NFS (a// OIS Grades IV and Vj
laceration (perforation, puncture) NFS
minor with or without thrombosis@
maioS
Q (superficial; incomplete transection; incomplete circumferential involvement: blood loss < 20% by volume)
(rupture: complete transection; segmental loss; complete circumferential involvement; blood loss > 20% by volume)
76
CODE -ASPECT INJURY DESCRIPTION
422299.2
422206.3
Other named arteries NFS (e.g., bronchial, esophageal, intercostal, internal mammary) (a// O/S Grade 1)
intimal tear, no disruption
laceration (perforation. puncture) NFS
mine?
majo?
Other named veins NFS (e.g., azygos, bronchial, cardiac, intercostal, hemiazygos, internal mammary, internal jugular) (a// O/S Grades I except azygos, Grade II)
laceration (perforation, puncture) NFS
mine?
major”
Q (superficial; incomplete transection: incomplete circumferential involvement; blood loss < 20% by volume)
(rupture; complete transection; segmental loss; complete circumferential involvement; blood loss > 20% by volume)
77
CODE ASPECT INJURY DESCRIPTION
Spinal cord [see SPINE]
430499.1
Phrenic nerve [see NECKJ
4 Vagus nerve injury [see also NECK and ABDOMEN]
70
CODE ASPECT INJURY DESCRIPTION
440808.4
79
-.
CODE ASPECT INJURY DESCRIPTION
441099.1
441002.1
441004.1
441006.4
441008.3
441010.3
441012.5
441014.6
441016.6
441016.6
441200.5
441300.5
441499.3
441402.3
441406.3
441410.4
441414.3
441416.3
441418.4
441420.4
441422.5
441424.5
441426.5
Heart (Myocardium) NFS
contusion (hematoma) NFS
minor [patients presenting with dysrrhthmia, wall motion abnormality, other ECG changes not related to CAD]
major [this diagnosis must be substantiated e.g., by surgery, autopsy, EF < 25% absent CAD]
laceration NFS
no perforation, no chamber involvement
perforation (ventricular or atrial with or without tamponade)
complex or ventricular rupture
multiple lacerations: > 50% tissue loss of a chamber
avulsion
Intracardiac valve laceration (rupture)
lntraventricular or inter-atria1 septum laceration (rupture)
Lung NFS
contusion NFS with or without hemo-/pneumothorax [This diagnosis should be coded m there is a history of chest trauma g@ a physician’s diagnosis is documented by x-ray, CT, MRI, surgery or autopsy. Clinical pulmonary dysfunction is insufficient evidence of a codeable injury.]
unilateral with or without hemo-/pneumothorax [If associated with flail chest, see Rib cage _ Flail. page 83.1
bilateral with or without hemo-/pneumothorax
laceration’ [See footnote’ before coding in this section.] NFS with or without hemo-/pneumothorax unless described as follows:
with pneumomediastinum
with hemomediastinum
with blood loss > 20% by volume
with tension pneumothorax
with parenchymal laceration with massive air leak
with systemic air embolus
80
CODE - ASPECT INJURY DESCRIPTION
unilateral with or without hemo-/pneumothorax unless
441456.5
81
CODE ASPECT INJURY DESCRIPTION
Thoracic cavity injury NFS [Use this section Q& when there is no
82
.--
CODE ASPtiCT INJURY DESCRIPTION
450230.3 > 3 ribs on one side and 3 ribs on the other side
450264.4
450266.5
with lung contusion (O/S Grade 111 or IV)
bilateral flail with or without lung contusion (O/S Grade V)
450899.1 4 Sternum NFS
450802.1 contusion
450804.2 fracture (O/S Grade /I or I//)
’ If rib fracture(s) coexists with lung laceration(s) dare associated with hemo-/pneumothorax, consider the hemo-l pneumothorax under the lung laceration only. Code the rib %acture(s) as if no hemo-/pneumothorax was present. Do not code the hemo-/pneumothorax separately.
83
Pericardium
Epicardium
Aorta (arch)
Pulmonary artery & "d"S
Atrium (right b left)
Ventricles (right b left)
SepWl
Hyocardim (muscle)
Endocarditm
Adapfed from: Source (6). p. 22 - cop source (3). p. 3117 - h"ti"Cl
Additional illustrations: .,ncc,l,, 11,~ n, , pp. 345. 348
84
85
ABDOMEN AND PELVIC CONTENTS
Codina Rules
AIS Uncertainty Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
Duct Involvement Injuries to the Gallbladder, Liver and Pancreas
If there is one ductal injury involving more than one organ sharing the same duct, assign the injuryto the organ with the higher AIS. If the AIS is the same, then choose and code only- of the involved organs.
If a separate ductal injury occurs to more than one organ (e.g., right hepatic duct and pancreatic duct), code each involved organ.
Internal Organs
Where the coding manual assigns a single line of code for multiple same type injuries, use that specific injury code when applicable.
Example: 2 cm laceration right anterior ventricle, 3 cm laceration right atrium. Code multiple myocardium lacerations (441016.6,4).
For each major specific anatomic structure (organ) in the abdomen where one line of code does not represent multiple same type injuries, code one row per injury type, choosing the highest AIS for each particular injury type.
Example: The spleen is markedly lacerated, and approximately 50% of it is avulsed and lying free in fragments in the abdomen. Code laceration, complex (544228.52).
For multiple internal injuries to an organ of the abdomen, code one row oer iniurv tvoe, choosing the highest AIS for each particular type.
Example: Minor contusion spleen, one major laceration spleen, one superficial laceration spleen. Code contusion (544212.22) and laceration (544226.4,2).
The following terms may be used as a guide in dffferentiating between superficial, major, or complex lacerations or perforations to internal organs of the abdomen. However, the final choice of whether or not to use the “superficial” or “major” AIS levels depends on the term within the context of the g&e injury description.
Superficial - minor, partial thickness, small Major - deep, full thickness, large, severe Complex - massive, tissue loss, segmental loss, stellate (abdomen)
NOTE: When organs are lacerated/perforated and the medical report indicates massive, extensive, or significant blood loss, code the higher AIS.
07
Transection -
When a vessel injury is described as ‘transection” without additional data, code as complete transection (total severance). If “incomplete” transection is indicated, one AIS code less severe than “transection” should be used.
Examples: Aortic transection (abdominal) - code: 520208.5. Aortic laceration with incomolete transection - code: 520206.4
Valid Codes and Aspects for Seat Se/t Contusions
For “seat belt bruises” due to a three-point system, code:
Shoulder 790402.1 ,1,2 (R,L) Chest 490402.1.1,2.4,0 (R,L,C.W) Abdomen 590402.1.1,2,4,7,8,0(R,L,C,S.I,W)
Injuries Involving Skin and Internal Structures
If a deep laceration or puncture penetrates the soft tissue and it can be determined that it is associated with a similar lesion to a related internal structure, only the injury with the higher AIS (the internal injury) should be coded. If in doubt that the external and internal lesions are related, then code both.
Valid AsDeCt Codes: 1.2.4,7,8,9,0 (R,L,C,S,I,U.W)
l - 1,2,4,7,8,9,0 (R,L,C,S,I,U,W)
+ - 1,2,9 (R,L,U)
= - 7,8,9 (S.I,U)
‘Blunt abdominal injuv is not a specific diagnosis and, depending on local usage. may mean any type of abdominal injury. Therefore, if it is the only information available, it should be coded under ‘Whole Area’ and assigned the code 7. This descriptor should never be used when fnOre soecific information is available.
CODE ASPECT INJURY DESCRIPTION
515099.7 0 Sluntrrraumatic abdominal injury NFS
515999.7 died without further evaluation: no autopsy
590099.1 t SkinlSubcutaneous tissuehhscle NFS
590202.1 abrasion
590402.1 contusion (hematoma)
590600.1 laceration NFS
590602.1 minor (superficial)
590604.2 major* (> 2Ocm long and into subcutaneous tissue)
590606.3 blood loss > 20% by volume
,590600.1 avulsion NFS
590602.1 superficial* (minor; < IObcm’)
590804.2 major’ (> IOOcm’ but blood loss 5 20% by volume)
590806.3 blood loss > 20% by volume
* See page 151 for diagram of actual injury Size.
69
Descriptions for several vessel lacerations distinguish between complete and incomplete transection. See footnotes g and h.
The terms ‘laceration,’ ‘puncture.’ and ‘perfarstion’ are oftentimes used interchangeably to descdhs vssssl injuries, and are of the same sevedty. When ‘perforation’ or ‘puncture’ is used. code as laceration.
CODE ASPECT INJURY DESCRIPTION
4 Aorta, abdominal NFS
Q (superficial; incomplete transection; incomplete circumferential involvement; blood loss s 20% by volume)
h (rupture; complete transection; segmental loss; complete circumferential involvement; blood loss > 20% by volume)
90
CODE -ASPECT INJURY DESCRIPTION
521604.3 mine? with or without thrombosis
Q (superficial: incomplete transection: incomplete circumferential involvement; blood loss i 20% by volume)
(rupture; complete transection; segmental loss; complete circumferential involvement; blood loss > 20% by volume)
91
CODE ASPECT INJURY DESCRIPTION
530499.1
Lumbar spinal cord [see SPINE]
Cauda aquina [see SPINE]
= Vagus nerve injury [also see NECK 8 THORAX]
92
CODE ASPECT INJURY DESCRIPTION
540620.2
540622.3
540624.4
laceration NFS
no perforation (partial thickness) (O/S Grade /j
perforation (full thickness but not complete transection) (O/S Grades I/, 111, IV)
540626.4 massive (avulsion; complex; tissue loss) (O/S Grades II, /I/, Iv)
540640.3 rupture NFS [Use this code only when a more detailed description is not available1
93
CODE - ASPECT INJURY DESCRIPTION
540822.2
540826.4
disruption -Z 50% of circumference; no perforation
541023.3
541024.4
enteric contamination; devascularization; massive odenopancreatic complex)
I I Cystic duct iniuw Lode as for Gallbladder1
Dl = superior or first part; D2 = descending or second part; D3 = horizontal or third part; D4 = ascending or fourth part
“Duct involvement” applies only to gallbladder, liver and pancreas. Injuries to these organs, which really share the same duct system, not infrequently involve injuries to the duct systems of each organ. When there is one ductal injury, it should be assigned to either (not both) of the two involved organs. On the other hand, when separate ductal injuries (e.g., to the right hepatic duct and the pancreatic duct) occur, they should be assigned to both organs,
94
CODE - ASPECT INJURY DESCRIPTION
541299.2
541210.2
541220.2
541222.2
541224.3
7 Gallbladder NFS
contusion (hematoma) (O/S Grade 1)
laceration (perforation) NFS (O/S Grade l/j
minor (superficial; no cystic duct involvement)
massive (avulsion; complex; rupture: tissue loss; cystic duct; laceration or transection) (O/S Grade 111)
541226.4 with common bile or hepatic duct “laceration” or transection (O/S Grades Wand V)
541499.2
541410.2
541420.2
541422.2
a Jejunum-ileum (small bowel) NFS
contusion (hematoma) (O/S Grade I)
laceration NFS
no perforation (partial thickness: < 50% of circumference) (O/S Grade I or I/)
541424.3 perforation (full thickness; 250 % of circumference without transection) (01.9 Grade 1//j
541426.4 massive (avulsion; complex; rupture: tissue loss: transection: devascularization) (O/S Grades War V)
541699.2
541610.2
541612.2
+ Kidney NFS
contusion (hematoma) NFS
minor (superficial: subcapsular, nonexpanding, confined to renal retroperiioneum or without parenchymal laceration) (O/S Grade I or II)
541614.3 major (large; subcapsular, > 50% surface area or expanding)
541620.2
541622.2
541624.3
laceration NFS
minor (superficial; < lcm parenchymal depth of renal cortex without urinary extravasation) (O/S Grade I!,
moderate (> lcm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation) (O/S Grade 111)
541626.4 major (extending through renal cortex, medulla and collecting system: main renal vessel involvement with contained hemorrhage) (O/S Grade IV)
541628.5 hilum avulsion; total destruction of organ and its vascular system (O/S Grade V)
541640.4 rupture NFS [Use this code onJ when a more detailed injury description is not available.]
95
CODE - ASPECT INJURY DESCRIPTION
541899.2
541810.2
541612.2
1 Liver NFS
contusion (hematoma) NFS
minor (superficial: subcapsular, 5 50% surface area, nonexpanding; intraparenchymal 5 1Ocm in diameter) (O/S Grade I or /I)
541614.3 major (ruptured subcapsular or parenchymal, > 50% surface area or expanding; intraparenchymal > 10cm or expanding; subcapsular; blood loss > 20% by volume) (O/S Grade 111)
541820.2
541822.2
laceration NFS
minor (superficial; i 3cm parenchymal depth, ZG IOcm in length, simple capsular tears; blood loss < 20% by volume) (O/S Grade I or 11)
541824.3 moderate (> 3cm parenchymal depth, with major duct involvement; blood loss > 20% by volume) (O/S Grade /I/)
541626.4
541820.5
major (parenchymal disruption of 5 75% of hepatic lobe or 1-3 Couinard’s segments within a single lobe; multiple lacerations > 3cm deep; burst injury) (O/S Grade /V)
complex (parenchymal disruption of > 75% of hepatic lobe or involving > 3 Couinard’s segments within a single lobe or involving retrohepatic vena cavakentral hepatic veitiepatic artery/portal vein) pulpefication (O/S Grade V)
541830.6 hepatic avulsion (total separation of all vascular attachments) (O/S Grade V/)
541840.4
542099.2
542010.2
542020.2
542022.2
542024.3
542026.4
rupture NFS [Use this code g& when a more detailed injury description is not available.]
8 Mesentety NFS
contusion (hematoma)
laceration NFS
minor (superficial
major (blood loss > 20% by volume)
complex (avulsion; massive; rupture; stellate; tissue
96
CODE - ASPECT INJURY DESCRIPTION
542820.2
542822.2
rnvo vemen (O/S Grade I or II)
laceration NFS
minor (superficial; no evidence of duct involvement) (O/S Grade I)
542824.3
542826.4
542820.4
542830.4
542832.5
moderate (with major vessel or major duct involvement) (O/S Grade II/)
if involving ampulla (O/S Grade IV)
major (multiple lacerations)
if involving ampulla (O/S Grade IV)
complex (avulsion; massive; rupture; stellate; tissue loss: massive disruption of pancreatic head)
97
CODE - ASPECT INJURY DESCRIPTION
543099.1
543010.1
543020.1
543022.1
543024.2
543026.3
543299.1
543210.1
543220.1
543222.1
543224.2
543226.3
543400.3
543402.4
543699.2
543610.2
543620.2
543622.2
543624.3
543625.4
543626.5
543800.3
- 0
0
8
a
6
-
Penis NFS
contusion (hematoma)
laceration (perforation) NFS
minor (superficial)
major
complex (amputation; avulsion: massive: rupture)
Perineum NFS
contusion (hematoma)
laceration (perforation) NFS
minor (superficial)
major
complex (avulsion; massive: rupture)
Placenta abruption NFS
blood loss > 20% by volume
Rectum NFS
contusion (hematoma) (O/S Grade I)
laceration NFS
no perforation (partial thickness; < 50% of circumference) (O/S Grades I and II)
perforation (full thickness: 2 50% of circumference) (O/S Grade //I)
perforation (full thickness: extending into perineum) (O/S Grade IV)
massive (avulsion; complex; rupture: tissue loss: devascularization; gross fecal contamination of pelvic space) (O/S Grade V)
Retroperitoneum hemorrhage or hematoma [If this injury occurs in combination with other abdominal injury, code it separately using this description o& if it can be determined that it is unrelated to the other injury. This description may also be used when no anatomical injury has been documented.]
The following organs or structures, when injured, may cause retroperitoneal hemorrhage: pancreas, duodenum, kidney, aorta, vena cava, mesenterlc vessel: also pelvic or vertebral fractures.
98
CODE -ASPECT INJURY DESCRIPTION
544099.1
544010.1
544020.1
544022.1
544024.2
544299.2
544210.2
544212.2
544214.3
544220.2
544222.2
544224.3
544226.4
544226.5
544240.3
544499.2
544410.2
544420.2
544422.2
544424.3
544426.4
a Scrotum NFS
contusion (hematoma)
laceration (perforation) NFS
minor (superficial)
major (amputation: avulsion; complex)
2 Spleen NFS
contusion (hematoma) NFS
minor (superficial; subcapsular 5 50% surface area; intraparenchymal, nonexpanding 5 5cm in diameter) (O/S Grade I or /I)
major (subcapsular > 50% surface area or expanding; ruptured subcapsular or parenchymal; intraparenchymal > 5cm in diameter or expanding) (O/S Grade III)
laceration NFS (rupture)
minor (superficial: simple capsular tear i 3cm parenchymal depth: no major (i.e., trabecular) vessel involvement) (O/S Grade I or I/)
moderate (no hilar or segmental parenchymal disruption or destruction: > 3cm parenchymal depth or involving major (i.e., trabecular) vessels) (O/S Grade 111)
major (involving segmental or hilar vessels producing major devascularization of > 25% of spleen with no hilar injury) (0I.S Grade IV)
complex (with hilar disruption producing total devascularization; tissue loss; avulsion; stellate; pulpefication) (06’ Grade V)
rupture (“fracture”) NFS [Use this code gg!y when a more detailed injury description is not available.]
7 Stomach NFS
contusion (hematoma) (O/S Grade I)
laceration NFS
no perforation (partial thickness) (O/S Grade /.J
perforation (full thickness) (O/S Grades /I and Ill)
massive (avulsion; complex; rupture: tissue loss: with major vessel involvement) (O/S Grades IV and V)
99
CODE ASPECT INJURY DESCRIPTION
544826.3
545026.3 massive (avulsion; complex; rupture: tissue loss) (O/S Grade A’)
545028.4 with posterior tissue loss (O/S Grade V)
100
-.-
CODE -ASPECT INJURY DESCRIPTION
545240.3 complex (awlsion; massive; rupture; involving uterine artery; placental abruption > 50%)
545424.2
545426.3
major (deep) (O/S Grade 111)
complex (avulsion; massive: rupture) (O/S Grades /V and V)
545699.1
545610.1
545620.1
545622.1
545624.2
545626.3
0 Vulva NFS
contusion (hematoma) (O/S Grade 1)
laceration (perforation) NFS
minor (superficial) (O/S Grade II)
major (deep) (O/S Grade /I/)
complex (avulsion; massive; rupture) (O/S Grades IV and V)
101
CODE ASPECT INJURY DESCRIPTION
Lumbar spinal [see SPINE]
Pelvis [see LOWER EXTREMITY for bony pelvis]
102
- Gallbladder - Pancreas
I +---- Duodenum
Diaphrqm
Diapnragm
Spleen Adrenal gland
Kidney Abdominal aorta
Ureter
Bladder
‘Jrt?rhra
Xectum
Adopted from: Source (Z), Fig. 2-26 - tap Source (61, p. 90 - bottom I ;:;-y-jj,#y+;..~.,,:::
Additional illuscrncions: Jacob. et al.. pp. 453. 460, 463. 494. 496
103
la--- Ovarian (Fallopian) cube
Bladder
Adapted from: source (5). p. 567. 572 Additional illusrrarione: Jacob, et .al..
pp. 508, 567-a. 573-4
Mid-saggital SeCtiOn of male pe1v1s
104
Codina Rules
CERVICAL SPINE
AIS Uncertainfy Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injurys category).
Whiplash
Cervical spine strain may, in some cases, still be referred to as “whiplash”. “Whiplash” is not a medical term and is not used in A&SO. If an injury is described as ‘whiplash”, it should be coded as; cervical spine strain (no fracture or dislocation) 640276.1,6 provided the guidelines below are followed:
(a) Interviewee reports: “Whiplash”. ER reports: “Pain”, “stiffness”, or”limited ROM” in neck but does not diagnose strain. Code: Do not code whiplash since ER, in essence, ruled it out.
(b) Interviewee reports: “Whiplash”. ER reports: “Neck supple” and does not diagnose strain. Code: Do not code whiplash since ER, in essence, ruled it out.
(c) Interviewee reports: “Whiplash”. El3 reports: (No medical attention sought.) Code: Do not code whiplash.
(d) Interviewee reports: “Whiplash”. ER reports: (No indication that neck was specifically examined.) Code: Code whiplash, data source “interviewee” (since ER did not rule out its
possibility).
Neck injuries may sometimes be described as “strains” and sometimes as “sprains”. For NASS purposes, neck injuries should be coded as “strains”.
Interviewee allegations of “upper back strain” or “lower back strain” are subject to the same test i.e., (a) through (d) above as an interviewee reported whiplash.
Strain vs Sprain
The following definitions have been used traditionally to differentiate “sprain” and “strain” injuries:
& - a j&t injury which causes pain and disability depending on the degree of injury to ligaments and muscle tendons near the joint.
&&- an injury to a muscle or musculotendinous unit that results from overstretching and may be associated with a sprain or fracture.
In common medical practice, however, physicians often do not adhere strictly to these definitions, and may use the terms interchangeably. Care should be exercised in selection of the proper code; use Sprain for joint injuries and strain for muscle injuries.
Neck injuries may sometimes be described as “strains” and sometimes as “sprains”. For NASS purposes, neck injuries should be coded “strains” (see above definitions).
105
Non-Contactlnjucy Sources - Codes “firein vehicle”, “flying glass “, “othernoncontactinjury source”, and “air bag exhaust gases”
These noncontact injury’sources are to be used only for the following specific types of injuries:
(a) head or neck injuries in which the torso is supported (e.g., by seat back or belt) and head or neck experiences traumatic forces due to inertial motion -- code ‘other noncontact injury source”;
(b) flying glass injuries -- code ‘flying glass”;
Cc) burns due to chemicals or gaseous inhalation -- code “other noncontact injury source’;
W burns due to flame -- code “fire in vehicle”; and
W burns due to air bag exhaust gases -- code “air bag exhaust gases”.
The following example illustrates the above definitions.
Injury Mechanism Determined
InJulJ From Crash Evidence lniuw Source
Examole 1 Neck strain a. head strikes windshield a. windshield 640278.1 b. forehead hits roof of convertible b. roof or convertible top
top c. head strikes steering wheel rim c. steering wheel rim d. back hits seatback, no head restraint, d. other noncontact injury source
head rolls back over seat e. neck forced into lateral flexion by e. other noncontact injury source
impact forces f. torso restrained by belt, head and 1. other noncontact injury source
neck inertia causes neck injury g. back hits seat back, head hits head g. head restraint
restraint, neck is injured
Valid AsDect Codg: 6 (P) Not coded: Kyphosis. lordosis, scoliosis’
’ kyphosis = abnormal increase in anterior convexity, thoracic spine (lateral view) lordosis = abnormal increase in anterior concavity, cervical and lumbar spine (laieral view) scoliosis = appreciable lateral deviation in the normal straight vertical line of the spine
-
CODE - ASPECT INJURY DESCRIPTION
615099.7 6 Blunt/traumatic cervical spine injury NFS (includes unspecified cord injury)
615999.7 died without further evaluation. no autoosv
ragnosis of compression or epidural or
640212.4
640214.4
640216.4
640218.4
640220.5
(Brown-Sequard) syndromes) but NFS as to fracture/dislocation
with no fracture or dislocation
with fracture
with dislocation
with fracture and dislocation
complete cord syndrome NFS (quadriplegia or paraplegia with no
107
CODE - ASPECT INJURY DESCRIPTION
640221.5 C-4 or below NFS as to fracture/dislocation, of NFS as to
640264.5 with fracture
640266.5 with dislocation
640268.5 with fracture and dislocation
640269.6 C-3 or above NFS as to fracture/dislocation
640270.6 with no fracture or dislocation
640272.6 with fracture
640274.6 with dislocation
CODE -ASPECT INJURY DESCRIPTION
THORACIC SPINE
Codina Rules
AIS Uncertainty Rule
If there is any question about the severii of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
Valid Aspect Codes: 1,2.4.7.8,9.0 (R.L,C,S,I,U,W,)
7 (3
l - 1.2,4,7.8,9.0 (R.L.C,S,I,U,W)
111
CODE ASPECT INJURY DESCRIPTION
616099.7 7 Blunt/traumatic thorecic spine injury NFS (includes unspecified cord injury)
616999.7 died without further evaluation, no autopsy
690099.1 * Skin/subcutaneous tissue/muscle NFS
690202.1 abrasion
690402.1 contusion (hematoma)
690600.1 laceration NFS
690602.1 minor (superficial)
690604.2 mafor’ (5 1Ocm long and into subcutaneous tissue)
690606.3 blood loss > 20% by volume
690600.1 avulsion NFS
690802.1 superficial* (minor: s 100cm’)
690804.2 major” (> 1OOcm’ but blood loss 5 20% by volume)
690806.3 blood loss > 20% by volume
* See page 151 for diagram of actual injury size.
112
CODE - ASPECT INJURY DESCRIPTION
r motor function; includes lateral
640440.5
640442.5
640444.5
640446.5
640448.5
640450.5
640460.5
640462.5
640464.5
640466.5
640468.5
incomplete cord syndrome NFS as to fracture/dislocation (preservation of some sensation or motor function)
with no fracture or dislocation
with fracture
with dislocation
with fracture and dislocation
complete cord syndrome NFS as to fracture/dislocation (paraplegia with no sensation or motor function)
with no fracture or dislocation
with fracture
with dislocation
with fracture and dislocation
113
CODE - ASPECT INJURY DESCRIPTION
650499.2 7 Disc injury NFS
650400.2 herniation NFS
650402.2 without nerve root damage (radiculopathy)
650416.2
114
LUMBAR SPINE
Codina Rules
AIS Uncertainty Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injurys category).
Valid Asmct Code: 8 (I)
WHOLE AREA [See THORACIC SPINE]
115
CODE -ASPECT INJURY DESCRIPTION
630602.3
116
CODE - ASPECT INJURY DESCRIPTION
Cord contusion NFS (includes the diagnosis of compression or epidural or
640610.4
CODE ASPECT INJURY DESCRIPTION
650604.2
Fracture without cord contusion or laceration with or without dislocation
650634.3 major compression (> 20% loss of height)
650684.1 0 lnterspinous ligament laceration (disruption)
630699.2 8 Nerve root or eacral plexus, single or multiple, NFS
630660.2 contusion (stretch iniury)
630662.2 laceration NFS
630664.2 single
630666.3 multiple
630668.2 avulsion (rupture) NFS
630670.2 single
640678.1 8 Strain, acute with no fracture or dislocation
118
Pedicle
\\ \
TRORACIC (DORSAL)
Lu?mAR
SACRAL
COCCYcFAL
II \
Addirional i11"srracio"s: Jacob. et al.. PP. 112-3, 248. 252. 256-7
119
Codina Rules
UPPER EXTREMITY
AIS Uncertainty Rule
If there is any question about the seventy of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
Undetermined Type of Anatomic Structure - Coda Skin
If the medical or interview information indicates a contused knee, elbow, wrist, ankle, etc., and does not specifically state whether the contusion is to the bone or joint, code the injury as integumentarylskin.
If the contusion is known to be the bone or joint, code using the “Skeletal” or “Skeletal-Joints” Section.
Example: Contused right elbow, 790402.1 ,l Contused left knee elbow, 750610.1,2
Joint - Ligament Injuries
Joint injuries involving fracture, dislocation, or fracture and dislocation of the extremities and associated ligament/tendon injuries do 6gt require a separate code for the ligament/tendon injuries.
If an injury is described as an avulsiotichip fracture, then treat this injury as a ligament injury and code the injury as a rupture (laceration).
Valid Codes and Aspects for Seat Belt Contusions
For “seat belt bruises” due to a three-point system, code:
Shoulder 790402.1,1,2 (R,L) Chest 490402.1,1.2.4,0 (R,L,C,W) Abdomen 590402.1,1,2,4,7,&O (R,L,C.S,I,W)
Code 790402.1 ,1,2, 490402.1,4, and 590402.1.4 if unspecified. [Note: Code only those injuries that are consistent with the type of restraint worn (e.g., do not code 790402.1 or 490402.1 if only a lap belt was used).]
Crush
“Crush” is a description of etiology, not of injury. However, it is included because it is used in medical charts. “Crush” for coding purposes means destruction of skeletal, vascular and soft tissue systems. The “Crush” injury description is used only when the injury meets the criteria in the dictionary. If the “Crush” code is used, individual injuries are not coded separately.
In order to code ‘Crush*, the following specific information should be known:
Extremity - massive destruction of bone and internal structures (i.e., muscle and/or vascular system).
Open Fracture
An open (compound) fracture, by definition, means that the skin overlaying the fracture is lacerated. The external laceration is implicit in the code for open fracture and is not coded separately.
121
Multiple Fractures in a Bone
For multiple fractures tothe same bone:
(4 If multiple fractures to the same bone are determined, then code each separately.
(b) If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one cornminuted fracture. Assign one line of code with the appropriate AIS.
Air Bag Related
Air bag related is coded when a body part set in motion by a deploying air bag contacts a component which produces an injury.
Example: Deploying airbag flings arm into A-pillar which produces a fracture. Code Injury Source as “A-pillal” and Direct/indirect Injury as air bag related.
DO NOT use air bag related if the air bag produced the injury.
Valid AsDect Codes: 1,2,3,9 (R,L,B,U)
+ - I,29 (R,L,U)
! - 1,2.3.9 (R.L.B,U)
122
CODE ASPECT INJURY DESCRIPTION
715000.2
790604.2
790606.3
790600.1
790802.1
790604.2
major’ (5 IOcm long on hand or 20cm on entire
blood loss > 20% by volume
awlsion NFS
superficial’ (5 25cm’ on hand or 5 lOOcm* on entire extremity)
major’ (> 25cm’ on hand or > 1OOcm’ on entire extremity)
I
* See page 151 for diagram of actual injury size.
** Increased pressure in a confined anatomical space adversely affects the circulation and threatens the function and viability of the tissue.
123
DeSCriptiOnS for savaral vassal lacerations distinguish between complete and incomplete transection. See footnotes g and h.
The terms ‘laceration: ‘punctura.’ and ‘perforation’ are oftentimes used in!erchangeably to describe vessel injuries. and are of the same severity. When “perforation’ or ‘puncture’ is used. coda as laceration.
CODE ASPECT INJURY DESCRIPTION
g (superficial; incomplete transection: incomplete circumferential involvement; blood loss < 20% by volume)
h (rupture: complete transection: segmental loss; complete circumferential involveAent; blood loss > 20% by volume)
124
CODE -ASPECT INJURY DESCRIPTION
721099.1 + Other named arteries NFS (e.g., distal to elbow or small arteries of extremities)
721002.1
721004.1
721006.1
721008.3
721299.1
721202.1
721204.1
intimal tear, no disruption
laceration (perforation. puncture) NFS
minoP
major
+ Other named veins NFS (e.g.. distal to elbow or small veins of extremities)
laceration NFS
mine+
g (superficial; incomplete transection; incomplete circumferential involvement; blood loss 5 20% by volume)
(rupture; complete transection; segmental loss; complete circumferential involvement; blood loss > 20% by volume)
125
CODE ASPECT INJURY DESCRIPTION
730299.1
730202.1
730204.1
730499.1
730410.1
730420.1
730430.2
730440.2
Brachial Plexus [see SPINE]
+ Digital nerve NFS
contusion [Use for diagnosis of “palsy”]
laceration
+ Median, radial, or ulnar nerve NFS
contusion [Use for diagnosis of “palsy”]
laceration NFS
single nerve
multiple nerves
126
CODE ASPECT INJURY DESCRIPTION
740200.1 + Tendon laceration (rupture, tear, avulsion) NFS
740210.1 multiple tendons (in hand)
740220.1 multiple tendons (other than hand)
740400.2 Muscle laceration (rupture, tear, avulsion)
740402.1 Muscle strain or contusion
740600.2 Joint capsule laceration (rupture, tear, avulsion)
127
CODE ASPECT INJURY DESCRIPTION
751099.1 + Shoulder (glenohumerel joint) NFS
751010.1 contusion
751020.1 sprain
751030.2 dislocation
751040.2 laceration into joint
751050.3 massive destruction of bone and cartilage (crush)
751299.1 + Sternoclavicular joint NFS
751210.1 contusion
751230.2 dislocation
751240.2 laceration into joint
128
CODE ASPECT INJURY DESCRIPTION
751499.1 + Wrist (carpus) joint NFS (capitate, hamate, lunate, pisifon, scaphoid [navicular), trapezium, trapezoid, triquetrum)
751410.1 contusion
751420.1 sprain
751430.2 dislocation at radiocarpal. intercarpal or pericarpal articulations
751440.2 laceration into joint
751450.3 massive deStructiOn of bone and cartilage (crush)
129
CODE ASPECT INJURY DESCRIPTION
orearm fracture NFS [Use only if more specific anatomic information is
130
Radius : Head Neck fuberosity Sryloid process 4i 7
1 Ill
Adapted rrorn: source (8). P. 162 Additional illustrations: .Incob, et al.. pp. 118-21
Ulna:
01ecranon process Coronoid process
I Head
131
Carpal* : capitate, hamare, lunate, pisiform;
Lateral 6 medial epicondyles
Radial head
Radial nerve
(radial!
(ulnar)
01ecranon
Ulnar nerve
Adapted from: Source (8). p. I68 - top source (a). p. 166 - left 8ource (7). p. 206-7 - right
Additional illustration: Jacob. et al., p. 132
132
LOWER EXTREMITY
Codina Rules
AIS Uncertainty Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
Undetermined Type of Anatomic Structure - Code Skin
If the medical or interview information indicates a contused knee, elbow, wrist, ankle, etc., and does not specifically state whether the contusion is to the bone or joint, code the injury as integumentary/skin.
If the contusion is known to be the bone or joint, code using the “Skeletal” or “Skeletal-Joints” Section,
Example: Contused right knee, 890402.1 .l
Contused left knee joint, 850802.1,2
Multiple Fractures in a Bone
For multiple fractures to the same bone:
(a) If multiple fractures to the same bone are determined, then code each separately.
W If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one comminuted fracture. Assign one line of code with the appropriate AIS.
Exceptions:
pubis - multiple fractures to the pubis (right, left, inferior, and/or superior) are assigned one line of code determined by the particular fracture type.
Joint - Ligament Injuries
Joint injuries involving fracture, dislocation, or fracture and dislocation of the extremities and associated ligament/tendon injuries do g&t require a separate code for the ligament/tendon injuries.
If an injury is described as an avulsionJchip fracture, then treat this injury as a ligament injury and code the injury as a rupture (laceration).
‘“Crush” is a description of etiology, not of injury. However, it is included because it is used in medical charts. “Crush” for coding purposes means destruction of skeletal, vascular and soft tissue systems. The “Crush” injury description is used only when the injury meets the criteria in the dictionary. If the “Crush” code is used, individual injuries are not coded separately.
In order to code “Crush”, the following specific information should be known:
Extremity - massive destruction of bone and internal structures (i.e., muscle and/or vascular system).
133
Open Fracture -
An open (compound) fracture, by definition, means that the skin overlaying the fracture is lacerated. The external laceration is implicit in the code for open fracture and is not coded separately.
Valid Aspect Codes: 1,2,3,5,6,9.0 (R,L.B,A,P,U,W)
+ - 1,2,9 (R,L,U)
? - 1,2,5,6,9 (R,L.A.P,U)
! - 1,2,3,9 (R,L,B,U)
Valid Aspect Codes for Pelvis:
Acetabulum 129 Coccyx and/or Sacrum 6 Ilium and/or lschium 1.23 Pubic ramus 5
RLSJ) 03 O=i,L,U) (4
134
CODE ASP&T INJURY DESCRIPTION
tern but NFS as to sit
890600.1 laceration NFS
890602.1 minor (superficial)
890604.2 maior* (> 20cm long and into subcutaneous tissue)
890806.3 blood loss > 20% by volume
890800.1 avulsion NFS
890802.1 superficial* (minor: < 100cmz)
890804.2 major’ (> lOOcm*)
890806.3 blood loss > 20% by volume
* See page 151 for diagram of actual injury size.
Increased pressure in a confined anatomical space adversely affects the circulation and threatens the function and viability of the tissue.
135
1 Descriptions for several vessel lacerations distinguish between complete and incomplete transection. See footnotes g and h.
I The terms ‘laceration; ‘pun&e.’ and ‘perforation are oftentimes used interchangeably to describe vessel injuries, and are of the same severity When ‘perforation’ or ‘puncture’ is used, code as laceration.
CODE ASPECT INJURY DESCRIPTION
820806.3 , I
4 ~;;;cial; incomplete transection; incomplete circumferential involvement; blood loss i 20% by
(rupture; complete transection; segmental loss; complete circumferential involvement; blood loss > 20% by volume)
136
CODE -ASPECT INJURY DESCRIPTION
821099.1
621002.1
621004.1
821006.1
621008.3
821299.1
621202.1
821204.1
+ Other named arteries NFS (e.g., distal to knee or small lower extremity arteries)
intimal tear, no disruption
laceration (perforation, puncture) NFS
minoP
majo?
+ Other named veins NFS (e.g., distal to knee or small lower earemity veins)
laceration (perforation, puncture) NFS
minoP
g (superficial; incomplete transection; incomplete circumferential involvement; blood loss 5 20% by volume)
h (rupture; complete transection; segmental loss; complete circumferential involverhent; blood loss > 20% by volume)
ma- CODE ASPECT INJURY DESCRIPTION
830299.1 + Digital nerve NFS
830202.1 contusion
830204.1 laceration
830499.2 + Sciatic nerve NFS
830402.2 contusion (neuropraxia)
830404.3 laceration NFS
830406.3 incomplete
830408.3 complete
830699.2 + Femoral, tiblsl, peroneal nerve NFS
830602.2 contusion
830604.2 laceration, avulsion NFS
830606.2 single nerve
830608.2 multiple nerves
138
CODE ASPiCT INJURY DESCRIPTION
139
I
CODE ASPECT INJURY DESCRIPTION
Ankle (Tarsus) Joint NFS (calcaneus. cuboid. cuneifons (medial, intermediate, and lateral), navicular {scaphoid), talus (talar)) [Use this category only if specific anatomy is unknown. If fibula, tibia or talus is
850699.1
CODE -ASPECT INJURY DESCRIPTION
851610.2 open/displacectkomminuted (any or
651614.3 oDenldisDlaced/comminuted (anv or
141
CODE ASPECT INJURY DESCRIPTION
851800.3
851801.3
651804.3
851808.3
851810.3
+ Femur’ fracture but NFS as to site [See Pelvis for Hip fracture.]
open/displaced/comminuted (any or combination) but NFS as to site
condyfar
head
intertrochanterfc
651814.3 shaft
851818.3 subtrochanteric
851822.3 supracondyfar
852000.2 + Foot fracture NFS [Use only if more specific anatomic infonation is I 1 unknown.]
I 852002.2
852200.2
852400.2
+ Leg or Ankle fracture NFS [Use only if more specific anatomic information is unknown.]
Malleous fracture [see Fibula]
+ Metatarsal or Tarsal fracture
+ Patella fracture
852600.2 ? Pelvis fracture NFS, with or without dislocation, of any or one combination: acetabulum, ilium, ischium, coccyx, sacrum, pubis and/or pubic ramus [Enter one line of code per aspect. Simple closed fractures of superior and inferior right or leff rami are not coded as comminuted fractures, but as closed fracture. Use this code for diagnosed “hip fracture” not further described anatomical1y.l
852602.2 closed
852604.3 openldisplacedlcomminuted (any or combination)
852606.4 0 substantial deformation and displacement with associated vascular disruotion or with maior retrooeritoneal hematoma: “ooen book” fracture: NFS as to blood loss (crush)
blood loss 5 20% by volume
blood loss > 20% by volume
6 Sscroilium fracture with or without dislocation
5 Symphysis pubis separation (fracture)
852608.4
852610.5
852800.3
853000.3
. Femur bone order: head, neck, greater trochanter, intertrochanteric, lesser trochanter, shaft, medial condyle, lateral condyle. The proximal portion of the shaft is subtrochanteric; the distal part of the shaft is supracondylar.
CODE - ASPECT INJURY DESCRIPTION
853602.1
853604.2 amputation I I
Tibia bone order: condyles, intercondyioid spine, shaft, malleoli.
143
h Femur: [ Head
Posterior
Adapted from: Source (8). p. 173 Additional illustration: Jocob, et al.. p. 122
144
Lateral h medial meniscus (semil"nar)
Fibular collateral ligamenr
Anterior (~parella pulled CX.4
Posterior
Tibia1 COllater?Al ligament
Tibia1 collateral 1igWJXllt
1 . .
I
c
Pacellar ligament
Patella
Knee joint
Sciatic nerve
Adapted from: source (5). p. 138-9 - lefr source (3). p. 203 - right
Addirional illuscrnCione: 3acob. et al.. PP. l'+O. 262
145
Digits/Phalanges- UMlE
Tarsals: calcaneus (heel), cuhoid. cuneiforms, navicu1ar, ra1vs
Fibular coverage Tibia1 caverage
Fibula
Tibia
Lateral malleolus
Medial malleolus
Digits/ MetaCarSalS Tarsals Phalanges
Adapted from: Source (8). p. 177 Additional illustrations: Jacob, et al., pp. 125-6
146
Ilium
Sacroiliac joint
Symphysis pubis
Pubic ramus (su,erior) Pubic ramus (inferior)
lschium
S*Cr”TO coccyx
Femur : Head Neck
Greater trochanrer Intercrochanferic
line
Acerabulum
Female
Adapted from: source (6). p. 57 Additional illustrations: Jacob, et al.. pp. 123-4
147
-
EXTERNAL - Skin and Subcutaneous Tissue
Codina Rules
AIS Uncertainty Rule
If there is any question about the severity of an injuly based upon all available documented infonation. code conservatively (i.e., the lowest AIS code in that injury’s category).
Valid AsDect Codes: 9,0 (U,W)
> - 9,0 (U,W)
I This section should be used only if no information is available on a specific body part or area. Multiple minor external injudes to one or more body regions should be coded as one injury (AIS 1) using this section, e.g., coverall abrasions’ = 990200.1 or ‘multiple lacerations’ = 990600.1. I
CODE ASPECT INJURY DESCRIPTION
990200.1 > Abrasion
990400.1 5 Contusion (hematoma)
990600.1 > Laceration
990600.2 > Avulsion
149
Sweat gland
Oil gland
Hair shaft
Adapted from: Source (a), p.105 Additional illustrations: Jacob. et al.. p.77
EPIDERMIS
DERMIS
SUSCUTANEOUS TISSUE
150
DIAGRAM OF ACTUAL INJURY SIZE
lOcm/3.9 in.
20cm/7,8 in.
100cm2/15.5 in.?
25cm2/3.9 in.2
151
Codina Rules
BURNS
AIS Uncsrtainiy Rule
If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injury’s category).
Varying Bum Degrees
When burns occur in varying degrees, code the most serious burn.
Bodv Reaion: (-) Any Region (l-9)
Valid Aspect Code: $ (Any valid aspect for Body Region coded)
153
The following bum injury descriptions are not a substitute for a comprehensive bum scale. but only intended as gross estimates of the severity. If a bum amputation occurs, code as amputation in bcdy region. If ampuiation is required sometime after the event, code the bum, not the amputation.
CODE ASPECT DEGREE TOTAL BODY SURFACE*
-92008.2
992028.5 0 face/hand/genitalia involvement
992030.5 0 2’ or 3’ (or full thickness) 40-89%
992032.8 0 2’ or 3” (or charring to head or trunk or t 90%
Total body surface (TSS) is assessed by using the diagram of “nines” that follows. For example, one entire upper extremity (all sides) is 9% of the TBS.
154
RULE OF NINES
\ :I \ Reprinted with permi
American Fqn Associ American College of
,ssion 0: ation al SUrgeOn,
OTHER TRAUMA
CODE ASPECT INJURY DESCRIPTION
919200.2 0
919201.2
=F 919202.3 0
919204.4
919206.5
919208.6 I
Inhalation injury NFS including nonintentional carbon monoxide exposure
Absence of carbonaceous deposits, erythema, edema, bronchorrhea or ObStNCtiOn
minor or patchy areas of erythema, carbonaceous deposits in proximal or distal bronchi (below 20mg% carboxyhemoglobin) [any or combination]
moderate degree of erythema, carbonaceous deposits, bronchorrhea with or without compromise of the bronchi (20-40mg% carboxyhemoglobin) [any or combination]
severe inflammation with friability copious carbonaceous deposits, bronchorrhea, bronchial obstruction (5 40mg% carboxyhemoglobin) [any or combination]
Evidence of mucosal sloughing, necrosis, endoluminal obliteration [any or combination1
157
_-
Anatomical Position and Regional Names
Adapted from: SCUI-C~ (8). P.20
158
Principal Arteries
Superficial temporal Posterior auricular
Exrernal carotid Vertebral
Rrachiocephalic (innominate)
Common carotid
Left subclavian
Arch of aorta
Thoracic aorta
Ahdominal aorta Inferior mesent Common iliac Internal ili
External iliac
TcsticularlOvarian
Deep palmar arch Superficial palmar arch
Anterior tibia1
l’osterior tibia1
Dorsalis pedis
Dorsal arch
Anterior View
Adapted from: source (8). p. 471
159
Principal Veins
External jugular Internal jugular
Brachiocephalic Subclavian Cephalic
Superior vena cava I Anterior cardiac
Superior mesenteric
Inferior Venb cava
Iiiac :
Falmar digitals
Axillaty
Great cardiac Rrachial Basilic
Splenic
Renal Inferior mesenteric
it--- Posterior tibia1
Adapted from: SourCe I?,), p. 478
160
NERVES
Brachial plexus
Lumbar plexus
sacra1 plexus
Common peroneal (Lateral Poplit Common peroneal
Superficial pel
(Medial Popliteal)
Deep peroTlea
Anterior View
Adapted from: Source (I), p. 140
161
l’lllNC1l’Al. PLEXUSES amI NERVES
Lumbar plexus
Cauda equina
Sacra1 plexus
Coccygeal plexus Pudendal
;,Sciatic
Adapted from: Source (7). p. 20s
162
Quadriceps:
- Triceps l.arissim”s dOTSi
auteus maximus
>c
NiiJ ::_
“HLlCX~i”gS! - Biceps femoris - Semirendinosus
t-
Semimembranor”s
Adapted from: Source (61, p.113 Additional illustrations: Jacob, et al., pp.lST-201
163
Internal jugular Y. tomnon cararid a.
Lobes of right lung
Inferior vena cava
Adrenal gland
crura of diaphragm Kidney
-
Penis (cut) I
Epididymis Tesris scrorum
,. +- Pulmonary Y.
,&+ yjy
Heart
i Esophagus
I! ,,.. ; Celiac trunk
I Spleen
Adapted from: Source (5). P. 17
164
Ascending colon
tlesenrery (cut)
Appendix Urerine tube Broad ligament Round ligament of
“Ler”S
- Lung
t Descending aorra Esophagus Prriocardial cavj
Transverse colon Jejunum (cut)
A-Descending colon
L& Aorta tomon iliac
artery and vein Sigmaid colon
-Rectum - ouary
uterus
Adapted from: source (5). P. 16
165
Right brachiocepha: Wi”
Subclavian vein Cephalic vein Axi11iary vein Delmid muscle
upper, middle & lover lobes Of right lung
Brachial vein
Ascending colon
cecum lipperdix
spermatic cord
Adapted from: source (5). p. 15
166
Gallbladder
crearer omenturn Ascending colon
cecum
- Pectoralis minor muscle (cut head)
- Cephalic vein Lhillary vein
- killary artery l.efr. lung
-PPericardial sac
Sromach
Transverse colon
Descending calm,
Adapted from: source (5)) P. 14
167
PART IV
DICTIONARY INDEX
Page Anatomical Description Section
89
36 142
139 36
128 130
93 57
140 93
90 75 75 75
130 109 109 36
124 124
32 93
124 107 124
75 75 37 74
79 79
Abdomen, whole area [use for Abdominal injury NFS, Penetrating or Skin]
Abducens nerve Acetabulum
[see Pelvis] Achilles tendon Acoustic nerve Acromioclavicular joint Acromion Adrenal Gland Alveolar ridge
[see also Teeth in Face, Page SE] Ankle Anus Aorta
abdominal thoracic
Aortic root Aortic valve Arm NFS Atlanta-axial Atlanta-occipital Auditory nerve
[see Acoustic nerve] Axillary artery Axillary vein Basilar artery Bladder (urinary) Brachial artery Brachial plexus Brachial vein Brachiocephaiic artery Brachiocephalic vein Brain stem Breast Bronchus
distal to main stem main stem
Abdomen & Pelvic Contents
Head Lower Extremity
Lower Extremity Head Upper Extremity Upper Extremity Abdomen 8 Pelvic Contents Face
Lower Extremity Abdomen & Pelvic Contents
Abdomen & Pelvic Contents Thorax Thorax Thorax Upper Extremity Spine (cervical) Spine (cervical) Head
Upper Extremity Upper Extremity Head Abdomen & Pelvic Contents Upper Extremity Spine (cervical) Upper Extremity Thorax Thorax Head Thorax
Thorax Thorax
169
Page Anatomical Description Sectlon
141 55
65 54 65 32 65 32
129
128 129 116
32 90 37
32 33 33 39 71
79 55
130 142
139 94 55 55 76 35 68
139
94 64
135 123 149
Calcaneus Canaliculus (tear duct) Carotid artery
common external external internal internal
Carotid - cavernous sinus Carpal joint
[see Wrist] Carpal - metacarpal joint Carpus Cauda equina Cavernous sinus Celiac artery Cerebellum Cerebral artery
anterior middle posterior
Cerebrum Chest
[see Thorax] Chordae tendinae Choroid Clavicle coccyx
[see Pelvis] Collateral ligament Colon (large bowel) Conjunctiva Cornea Coronary artery Cranial nerve NFS Cricoid cartilage
[see Larynx] Cruciate ligament
[see Collateral ligament] Cystic duct Decapitation Degloving injury Degloving injury Degloving injury
Lower Extremity Face
Neck Face Neck Head Neck Head Upper Extremity
Upper Extremity Upper Extremity Spine (lumbar) Head Abdomen 8 Pelvic Contents Head
Head Head Head Head Thorax
Thorax Face Upper Extremity Lower Extremity
Lower Extremity Abdomen & Pelvic Contents Face Face Thorax Head Neck
Lower Extremity
Abdomen & Pelvic Contents Neck Lower Extremity Upper Extremity - External
170
Page Anatomical Description Section
79 138 126
109 118 112
94 55 55
128 79 42
55 53
57 36 97
136 138 136 142 141 130
140 142 130
42
95 56
128
36 130
31
80
Diaphragm Digital Nerve Digital Nerve Disc
cervical lumbar thoracic
Duodenum Ear canal Ear NFS Elbow joint Esophagus Ethmoid bone
[see Skull, base] Eye, whole organ or NFS Face, whole area
[use for Penetrating or Skin] Facial bone(s) NFS Facial nerve Fallopian tube
[see Ovarian tube] Femoral artery Femoral nerve Femoral vein Femur Fibula Finger Foot
joint NFS bone NFS
Forearm NFS Frontal bone
[see Skull, vault] Gallbladder Gingiva (gum) Glenohumeral joint
[see Shoulder] Glossopharyngeal nerve Hand NFS Head, whole area
[use for Penetrating, Scalp, Head/ Brain injury NFS, Crush]
Heart
Thorax Lower Extremity Upper Extremity
Spine Spine Spine Abdomen & Pelvic Contents Face Face Upper Extremity Thorax Head
Face Face
Face Head Abdomen & Pelvic Contents
Lower Extremity Lower Extremity Lower Extremity Lower Extremity Lower Extremity Upper Extremity
Lower Extremity Lower Extremity Upper Extremity Head
Abdomen 8 Pelvic COntentS
Face Upper Extremity
Head Upper Extremity Head
Thorax
_.
Page Anatomical Description Section
140 130
69 36 37
95
90 90
142
55 75
75
128 141
109 114 118
80
80 32 80 55
142
95 127
66 66 95
140 94
68
Hip Humerus Hyoid bone Hypoglossal nerve Hypothalamus
[see Brain stem] Ileum (small bowel)
[see Jejunum] Iliac artery (common, internal, external) Iliac vein (common, internal, external) Ilium
[see Pelvis] Inner ear Innominate artery
[see Brachiocephalic artery] Innominate vein
[see Brachiocephalic vein] lnterphalangeal joint lnterphalangeal joint
[see Metatarsal, Phalangeal or lnterphalangeal joint]
lnterspinous ligament cervical lumbar thoracic
Intra-atrial septum [see lntraventricular septum]
Intracardiac valve Intracranial vessel NFS lntraventricular septum Iris lschium
[see Pelvis] Jejunum (small bowel) Joint capsule NFS Jugular vein
external internal
Kidney Knee Large bowel
[see Colon] Larynx
Lower Extremity Upper Extremity Neck Head Head
Abdomen & Pelvic Contents
Abdomen & Pelvic Contents Abdomen & Pelvic Contents Lower Extremity
Face Thorax
Thorax
Upper Extremity Lower Extremity
Spine Spine Spine Thorax
Thorax Head Thorax Face Lower Extremity
Abdomen & Pelvic Contents Upper Extremity
Neck Neck Abdomen B Pelvic Contents Lower Extremity Abdomen & Pelvic Contents
Neck r
172
-
Page Anatomical Description Section
141
96 142 135
80 a2
58
142 57 57 57
143
126 37
96 128
130
141 142
37
55
56 127 139
80
64
Lateral malleolus [see Fibula]
Liver Leg NFS Lower extremity, whole area
[use for Penetrating, Skin, Degloving, Amputation, Crush, Compartment syndrome]
Lung Main stem bronchus
[see Trachea] Malar
[see Zygoma] Malleous Mandible Maxilla Maxillary sinus
[see Maxilla] Medial malleous
[see Tibia] Median nerve Medulla
[see Brain stem] Mesentery Metacarpal - phalangeal joint
[see Carpal-Metacarpal] Metacarpus
[see Carpus] Metatarsus
joint bone
Midbrain [see Brain stem]
Middle ear [see Inner ear]
Mouth NFS Muscle NFS Muscle NFS Myocardium
[see Heart] Neck, whole area
[use for Penetrating or Skin]
Lower Extremity
Abdomen & Pelvic Contents Lower Extremity Lower Extremity
Thorax Thorax
Face
Lower Extremity Face Face Face
Lower Extremity
Upper Extremity Head
Abdomen & Pelvic Contents Upper Extremity
Upper Extremity
Lower Extremity Lower Extremity Head
Face
Face Upper Extremity Lower Extremity Thorax
Neck
173
Page Anatomical Description Section
105 ii8 114
58 42
35 109 35 97
35 35 54 57
42
55 97 97 97 42
142 139
109 ii8 114 142
98 ai 98
138
141
68 67 41
NeNe root cervical lumbar thoracic
Nose Occipital bone
[see Skull, base or vault] Oculomotor nerve Odontoid Olfactory nerve Omentum Optic nerve
intracranial segment intracananicular segment intraorbital segment
Orbit [see also Optic nerve. intraorbital segment in Face, Page 541
Orbital roof [see SkulLbase]
Ossicular chain (ear bone) Ovarian tube Ovary Pancreas Parietal bone
[see Skull, vault] Patella Patellar tendon Pedicle
cervical lumbar thoracic
Pelvis Penis Pericardium Perineum Peroneal nerve
[see Femoral, tibia& peroneal nerve] Phalangeal joint
[see Metatarsal, Phalangeal or lnterphalangeal joint]
Pharynx Phrenic nerve Pituitary gland
Spine Spine Spine Face Head
Head Spine (cervical) Head Abdomen & Pelvic Contents
Head Head Face Face
Head
Face Abdomen 8 Pelvic Contents Abdomen 8 Pelvic Contents Abdomen & Pelvic Contents Head
Lower Extremity Lower Extremity
Spine Spine Spine Lower Extremity Abdomen & Pelvic Contents Thorax Abdomen & Pelvic Contents Lower Extremity
Lower Extremity
Neck Neck Head
174
Page -Anatomical Description Section
98
al
37
136
136
142
76
al
76
126
130
98
55
98
68
a3
ii8
142
142
33
68
31 130 138
55
99
128
33
33
149
42
42
42
36
Placenta Pleura Pons
[see Brain stem] Popliteal artery Popliteal vein Pubic ramus
[see Pelvis] Pulmonary artery Pulmonary region
[see lung] Pulmonary vein Radial nerve
[see Median, radial or ulnar nerve] Radius Rectum Retina Retroperiioneum Retropharyngeal area
[see Pharynx] Rib cage Sacral plexus
[See NeNe root] Sacroilium Sacrum
[see Pelvis] Saggital sinus
[see Superior longitudinal sinus] Salivary gland Scalp Scapula Sciatic nerve Sclera Scrotum Shoulder Sigmoid sinus Sinus NFS Skin NFS as to body region Skull
base vault
Sphenoid bone [see Skull, base or vault]
Spinal accessory nerve
175
Abdomen & Pelvic Contents Thorax Head
Lower Extremity Lower Extremity Lower Extremity
Thorax Thorax
Thorax Upper Extremity
Upper extremity Abdomen B Pelvic Contents Face Abdomen B Pelvic Contents Neck
Thorax Spine (lumbar)
Lower Extremity Lower Extremity
Head
Neck Head Upper Extremity Lower Extremity Face Abdomen B Pelvic Contents Upper Extremity Head Head External
Head Head Head
Head
Page Anatomical Description Section
107 116 112
109 ii8 114
99 128 a3 99 76 76
141 33
142 142 142
58
42
58 129 139 100 a2
a2 74
68
68 143 138
143 56 a2
Spinal cord cervical lumbar thoracic
Spinous process cervical lumbar thoracic
Spleen Sternoclavicular joint Sternum Stomach Subclavian Artery Subclavian vein Subtalar joint Superior longitudinal sinus Symphysis pubis Talus Tarsus
[see Metatarsal or Tarsal] Teeth
[see also Alveolar ridge in face, Page 571 Temporal bone
[see Skull, base or vault] Temporomandibular joint Tendon NFS Tendon NFS Testes Thoracic cavity
[see also Thorax, whole area] Thoracic duct Thorax, whole area
[use for chest injury NFS. Penetrating or Skin] [see also Thoracic cavity]
Thyroid cartilage [see Larynx]
Thyroid gland Tibia Tibia1 nerve
[see Femoral, tibial, peroneal nerve] Toe Tongue Trachea
Spine Spine Spine
Spine Spine Spine Abdomen 8 Pelvic Contents Upper Extremity Thorax Abdomen & Pelvic Contents Thorax Thorax Lower Extremity Head Lower Extremity Lower Extremity Lower Extremity
Head
Face Upper Extremity Lower Extremity Abdomen & Pelvic~ Contents Thorax
Thorax Thorax
Neck
Neck Lower Extremity Lower Extremity
Lower extremity Face Thorax
176
Page Anatomical Description Section
141
141
109 ii8 114
33 36 35 55
130 126
123
100 100
93
101 55
101 67 78 92
91 76
109 ii8 114
34 66
109 ii8 114
Transmetatarsal joint [see Subtalar, transtarsal or transmetatarsal joint]
Transtarsal joint [see Subtalar, transtarsal or transmetatarsal joint]
Transverse process cervical lumbar thoracic
Transverse sinus Trigeminal nerve Trochlear nerve Tympanic membrane (ear drum) Ulna Ulnar nerve
[see Median, radial or ulnar nerve] Upper extremity, whole area
[use for Penetrating, Skin, Degloving, Amputation, Crush]
Ureter Urethra Urinary bladder
[see Bladder] Uterus Uvea Vagina Vagus nerve Vagus nerve Vagus nerve Vena Cava
inferior superior
Vertebra [see dislocation or fracture] cervical lumbar thoracic
Vertebral artery Vertebral artery Vertebral body
cervical lumbar thoracic
Lower Extremity
Lower Extremity
Spine Spine Spine Head Head Head Face Upper Extremity Upper Extremity
Upper Extremity
Abdomen 8 Pelvic Contents Abdomen & Pelvic Contents Abdomen 8 Pelvic Contents
Abdomen 8 Pelvic Contents Face Abdomen 8 Pelvic Contents Neck Thorax Abdomen 8. Pelvic Contents
Abdomen & Pelvic Contents Thorax
Spine Spine Spine Head Neck
Spine Spine Spine
1-n
Page Anatomical Description Section
Vessels Each body region, except the SPINE and EXTERNAL has a section titled Vessels. In addition to listing specific arteries and veins, a nonspecific description is included to code vessel injuries when precise information is lacking. The coder is urged to become acquainted with these default codes by body region.
55 Vestibular apparatus Face
/ [see also Acoustic nerve in Head] 36 Vestibular nerve Head
[see Acoustic nerve] 55 Vitreous Face 68 Vocal cord Neck
101 Vulva Abdomen & Pelvic Contents
129 wrist Upper Extremity 58 Zygoma Face
The following traumatic events to the whole body or an entire body region are listed as follows:
154 a2
157 43
a2
Bums Hemothorax NFS
[see Thoracic cavity NFS] Inhalation Loss of Consciousness
(including concussion) Pneumothorax NFS
[see Thoracic cavity NFS]
Bums Thorax
Other Trauma Head
Thorax
178
PART V
MEDICAL TERMINOLOGY REFERENCES
This section consists of four parts:
A. Glossarv of Anatomical and lniurv Terms
Thisalphabetical listdefinestermsas used inthis manual withthepurposeof expediting injurycoding. Refer to your medical dictionary and/or anatomy textbook for additional information.
9. Abbreviations, Svmbols, Weiahts and Measures
This section includes commonly used abbreviations, symbols, and weights/measures found in hospital records. It will aid the injury coder in interpreting and coding injury information. If you encounter an abbreviation, etc., not included here, consult a medical abbreviations dictionary.
C. p
This part is comprised of three lists of common medical prefixes, roots, and suffixes. By recognizing the parts of a word, its definition may be extracted quickly without the assistance of a medical dictionary, thus building your vocabulary.
D. Lav Terminoloav - NASS Lesion Svnonvm List
This list attempts to translate laytermsfrequentlyencountered (particularly in interviews) into injuries codeable in NASS.
E. Fractures
This section includes fractures frequently encountered in NASS CDS. Refer to the Glossary or a medical dictionary for additional information.
179
A. GLOSSARY OF ANATOMICAL & INJURY TERMS
abrasion wearing or rubbing away by friction of cells or tissues from an area of skin or membrane.
amputation, traumatic cutting off of a body part, such as a limb, as a result of an injury
angiography, cerebra/ radiographic visualization of the blood vessels supplying the brain, including the extracranial portions, after the introduction of contrast material
aphasia loss or impairment of speech (due to trauma)
autopsy an examination of the internal organs of a body after death for the purpose of determining the cause of death or studying the pathological changes present
awlsion tearing away of a part of a body structure in which a portion is separated from underlying tissues and adjacent parts, and left hanging as a flap
awlsion, major a tearing away of 95 cm2 of skin but blood loss 40% by volume on the face or hand, or z-1 00 cm’ on the body; see page 151 for diagram of actual injury&e
avulsion, superficial a tearing away of 525 cm’ of skin on the face or hand, or z-1 00 cm’ on the body; see page 151 for diagram .of actual injury size
Babinski’s syndrome condition in which when the sole of the foot is stroked, the great toe turns upward instead of downward, indicating an organic lesion in the brain or spinal cord
bilateral involving both organs or body parts where they exist in pairs (e.g.. eyes, ears, lungs, upper or lower exiremities)
cauda equina collection of spinal nerve roots descending from the lower part of the spinal cord; their appearance resembles a horse’s tail
a bony surface in the posterior skull formed by a portion of the basilar part of the occipital bone and the upper part by a part of the sphenoid bone
coma a state of unconsciousness with inability to respond, either verbally or through other recognized body motions, even to painful stimuli
computerized tomography (CT scan) the gathering of anatomical information from a cross-sectional plane of the body by using pencil-like x-ray beams to scan the section of the body being studied; it combines the speed of a computer with the sensitivity of x-ray detectors
180
concussion (of the brain) clinical syndrome characterized by immediateand transient impairment of neural function such as alteration of consciousness, disturbance of vision, etc., due to mechanical forces
conjugate deviation deflection of two similar body parts (e.g., the eyes) in the same direction at the same time
contrecoup occurring to a body part opposite the area of impact (e.g., a contrecoup injury to the shoulder is a direct result of trauma to the elbow)
contusion (of the brain) structural alteration of the brain, usually involving the surface, characterized by brain tissue death, and due to mechanical forces
contusion (integumentary) bruise characterized by hematoma without a break in the skin; commonly referred to as “black and blue”
CT scan - see computerized tomography
decerebrate a type of movement, spontaneous or induced, characterized by extensor rigidity of one or both upper extremities and indicative of brain stem dysfunction
decorticate atype of movement, spontaneous or induced, characterized by abnormal, inappropriate flexion of the upper extremity and extension of the lower extremity
detachment separation of an anatomic structure from its support; most common example is detached retina of the eye, in which retina separates from choroid
diastasis form of dislocation in which there is a separation of two bones normally attached to each other without existence of a true joint (e.g., symphysis pubis)
dislocation displacement of a bone at a joint from its nonal anatomical position
distal a comparative ten indicating a point, structure or location further from the root or attachment point (e.g., the knee joint is distal to the hip)
dura (also dura mater) outermost, toughest and most fibrous of the three membranes covering the brain and spinal cord
edema presence of abnormally large amounts of fluid in the body tissue
electroencephalogram (EEG) a diagnostic procedure used to detect brain disorders; it records underlying cerebral activity through a montage of externally applied scalp electrodes
epidural situated upon or outside the outermost and most fibrous of the three membrane (dura) covering the brain and spinal cord
181
flail chest term used to d&cribe an abnormal ability for the chest to contract and protract (i.e., respiratory embarrassment) as a result of significant injuries to any one or more of the structures in the thoracic cavity (e.g., multiple rib fractures)
flank the part of the body below the ribs and above the ilium
footdrop dropping of foot due to paralysis of anterior leg muscles
fracture break in a bone - see specific fracture for more precise definition
fracture, avulsion or chip an indirect fracture caused by avulsion or pull of a ligament occurring at a joint
fracture, basilar skull break in the base of the cranium
fracture, blowout a break in the orbital floor forcing the orbital contents into the maxillary sinus: the eye muscles may be injured
fracture, closed break in a bone that does not produce an open wound in the skin; commonly called a simple fracture
fracture, cornminuted break in a bone in which the bone is splintered or fragmented
fracture, compound- see fracture, open
fracture, depressed skull break in the skull in which a fragment(s) is pushed inward, causing a change in the normal skull contour
fracrure, displaced break in a bone that causes one segment to be moved out of its normal anatomical relation with the remainder of the bone
fracture, linear a break in a bone extending lengthwise
fracture, open break in a bone in which there is an external wound leading to the break: commonly called compound except in the head where ‘open” implies exposure of dura or brain surface (do not code any accompanying laceration unless the laceration was not caused by the fracture)
fracture, ring a break in the base of the skull area surrounding foramen magnum (where spinal cord passes into skull): also referred to as “annular basal fracture”
fracture, simp/e - see fracture, closed
fracture, transverse break in a bone at right angles to the long axis of the bone
fracture, undisplaced break in a bone that does not cause the bone to be moved out of its normal anatomical position
fracfure, (of the liver) sometimes used to describe laceration of the liver
friction bums brush bums: bums caused by rubbing
hematoma collection of blood within a confined area
hemiparesis a slight paralysis on one side of the body
hemiplegia paralysis on one side of the body
hemomediasfinum a collection of blood around the structures (heart, esophagus, etc.) between the two pleural sacs that tine the thoracic cavity and encase the lungs
hemorrhage blood flowing profuselyina relatively non-confined space, such as bleeding resulting from adeep laceration
hemothorax a collection of blood in the pleural portions of the thoracic (chest) cavity
hernia an abnormal protrusion of an organ or other body part structure through a membrane or wall in which it is normally encased
hygroma accumulation of cerebrospinal fluid in a specified part of the brain
hypesthesia condition of decreased pain sensation
lower portion of the small intestine, extending from the jejunum to the large intestine
incus one of three small bones in the tympanic (ear) cavity
infarction, cerebra/ an ischemic condition of the brain, producing a persistent focal neurological deficit in the area of one of the cerebral arteries
inhalation bum a burn in the respiratory system caused by breathing of smoke or hot air
ischemia localized decrease in the flow of blood usually due to an arterial obstruction
jejunum the upper portion of the large intestine extending between the duodenum and the ileum
laceration, complex a term sometimes used to describe a rupture to an internal organ
133
laceration, major (use this definition Q& for external integumentary (skin) injury] a cut or incision into subcutaneous tissue & >20 cm on the body, or >lO cm (4 in.) on the head, face or hand; see page 151 for diagram of actual Injury Size
laceration, superficial a cut or incision not into subcutaneous tissue, regardless of length&r into subcutaneous tissue but 5 10 cm on the face, head or hand, or 520 cm on the body; see page 151 for diagram of actual Injury Size
Le Fori I fracture a horizontal segmented fracture of the alveolar process of the maxilla (the supporting bone of the upper teeth), in which the teeth are usually contained in the detached portion of the bone
Le Fort /I fracfure unilateral or bilateral fracture of the maxilla, in which the body of the maxilla is separated from the facial skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline of the hard palate, through the floor of the orbit, and into the nasal cavity
Le Fort /I/ fracture a fracture in which the entire maxilla and one or more facial bones are completely separated from the brain case
magnetic resonance imaging (MR/) a diagnostic device which produces pictures of the body’s internal tissues that are similar to the computerized, cross-sectional x-rays made by CT scanners; the MRI method uses electromagnets instead of x-ray tubes
malleus one of the three small bones in the tympanic (ear) cavity
mediastinum a body cavity occupying the space bordered by the lungs on either side, diaphragm below, thoracic inlet above, sternum in front, and vertebrae behind: contains the heart, esophagus, trachea, etc.
MRI - see magnetic resonance imaging
muscle be//y the fleshy, contractile part of a muscle
necrosis death of a cell or group of cells that is in contact with living tissue
neurological deficit visible or measurable effects of trauma, such as confusion, restlessness, visual field defects (blurred/doubWtunneI vision), amnesia, paralysis, loss of speech, seizure
obstruction a blockage or clogging, such as in the esophagus or airway
ossicular chain ear bone comprised of three small bones (malleus, incus, and stapes) between the outer ear (pinna) and Inner ear
papilledema excessive accumulation of fluid in the optic nerve
paraplegia paralysis of the lower part of the body
104
paresthesia sensation of prickling. tingling or creeping on the skin having no identiiiable cause, sometimes associated with injury or irritation of a sensory nerve or nerve root
paresis partial paralysis
._, perforation a hole through an organ or other body structure resulting from contact with an external force or object
petechial a rounded spot of hemorrhage on the surface of the skin or a membrane
pia innermost covering of the brain and spinal cord
plexus a network of nerves
pneumocephalus presence of air or gas in the intracranial cavity
pneumomediastinum an accumulation of air in the space between the two pleural sacs (the lining of the thoracic cavity)
pneumothorax an accumulation of air or gas in the thoracic (chest) cavity
pneumothorax, tension closed pneumothorax in which the tissues surrounding the opening into the pleural cavity act as valves, allowing air to enter but not escape. The resultant positive pressure in the cavity displaces the mediastinum to the opposite side, with consequent embarrassment of respiration. Called also pressure pneumothorax.
proximal a comparative term indicating a point, structure or location closer to the root of the limb (e.g., the hip joint is proximal to the knee)
puncture a wound made by a pointed object - see also perforation
puncture. deep [use this definition &for external integumentary (skin) injury] a perforation into subcutaneous tissue & >20 cm on the body, or ~-10 cm on the head, face or hand; see page 151 for diagram of actual Injury Size
puncture, superficial a perforation not into subcutaneous tissue, regardless,of length a into subcutaneous tissue but 510 cm on the face, head or hand, or 520 cm on the body: see page 151 for diagram of actual Injury Size
quadriplegia paralysis of all four,extremities simultaneously; also called tetraplegia
remarkable a term used to describe an organ or other body pan or feature that is substantially different from the nom? opposite of unremarkable
respiratory embarrassment medical term used to describe a condition resulting from a thoracic or throat injury that restricts one’s ability to breathe normally
185
rib, “cracked” - a partial fracture, one that does not break the bone through and through
rupture forcible tearing or breaking of a body structure (i.e., membrane, organ, tendon, etc.)
segmental loss a term used to indicate that a section of a vessel is gone (indicative of two lacerations): segmental loss and transection are equivalent in severity
Severance - see transection
spondylolisthesis forward displacement of one vertebra over another
sprain bending of a joint beyond its normal range of motion with partial rupture or other injury to its soft tissue attachments, but without luxation (dislocation) of bones: characterized by rapid swelling, heat, pain and disablement of the joint
stapes one of the three small bones in the tympanic (ear) cavity
strain an overstretching of a muscle
subarachnoid situated beneath the middle membrane covering the brain and spinal cord
s&cortical situated beneath the gray matter of the brain
subdural situated beneath the outermost and most fibrous of the three membranes (dura) covering the brain and spinal cord
subgaleal beneath the scalp
subluxation an incomplete or partial dislocation
subpial situated or occurring beneath the innermost membrane covering the brain and spinal cord
tamponade, cardiac acute compression of the heart due to effusion of fluid into the outer layer (pericardium) of the heart or collection of blood in pericardium due to heart rupture or penetration
tear a shearing injury - see also laceration, rupture
tetraplegia see quadriplegia
thorax the bony cage consisting of the ribs which give it shape, muscles which cover the ribs and vital organs located within the cage, such as the heart and lungs; commonly called chest cavity ’
transection, severance a cut made across the long axis
unilateral involving only one pair of organs or body parts (e.g., eyes, ears, lungs, upper or lower extremities)
unremarkable a term used to describe an organ or other body part or feature that is considered within the norm; opposfte of remarkable
“whiplash” a popular term for hyperextensiotiyperfiexion injuries of the neck (cervical spine): the term should not be used to imply any specific resultant pathologic condition or syndrome
wound, closed an injury to the body caused by an outside force in which the skin is not broken
wound, open an injury to the body caused by an outside force in which the skin is broken
187
6.1. ABBREVIATIONS
Abbrev.
aa
A4
Abd
AC
ad
A.D.
ad lib
Adm
AE
AU
AM
AMA
Amb.
ante
ant
AXOX
AOB
A&P
AP
AP & Lat
AS
AU
Meaning
of each
auto accident
abdomen, abdominal
acute
to
right ear
at liberty
admit
above elbow
above knee
before noon
against medical advice
ambulatory
before
anterior
alert & oriented x three
alcohol on breath
antero-posterior, auscultation and palpation, auscultation and percussion
arterial pressure
anterior, posterior and lateral (projection of x-ray)
left ear
both ears
Abbrev.
AV
BAC
BE
bil
BK
B.M.R
BP.
F3S
c CAD
CAT
G
cc
CBC
ecu
chr
CN II-XII
CNS
cl0
Meaning
atrioventricular or auriculoventticular
blood alcohol concentration
below elbow
below knee
basal metabolic rate
blood pressure
breath sounds, bowel sounds, blood sugar
coronary artery disease
computerized axial tomography
_ cervical vertebra
chief complaint
complete blood count
coronary care unit
second (2”‘) to twelfth (12’“) cranial nerves
central nervous system
complaints of
compound
188
Abbrev.
CPR
CR
CSF
CTA
CVA
w-r
CXR
D
D,
D/C
DL
DOA
DOB
DT
D.T.R.
DX
Meaning
cardiopulmonary resuscitation
cardiac rate
cerebrospinal fluid
clear to auscultation
cardiovascular accident
central vertebra tenderness
chest x-ray
dorsal
_ dorsal (thoracic) vertebra
discontinue
danger list
dead on arrival
date of birth
delirium tremens
deep tendon reflexes
diagnosis
ECG (also EKG) electrocardiogram
ED emergency department
EEG electroencephalogram
E.E.N.T eyes, ears, nose, and throat
e.g. example
EKG (also ECG) electrocardiogram
EMG electromyograph, electromyogram
EOM extraocular movement
ER emergency room
Abbrev.
Etiol
ETOH
exam
exi
FB
FFP
FH
FRC
FROM
ft
F/U
FUO
fx
G.B.
Gen A
G.I.
GM
G.U.
GW.
h. H
HA
hb, hgb
HBP
HCO,
HCT
HEENT
Meaning
etiology
alcohol
examination
extremities
foreign body
fresh frozen plasma
family history
frozen red cells
full range of motion
foot
follow up
fever unknown origin
fracture
gall bladder
general anesthesia
gastrointestinal
grand mal
genito-urinary
Gynecology
hour
headache
hemoglobin
high blood pressure
bicarbonate
hematocrft
head, ears, eyes, nose, and throat
189
Abbrev.
HR
Hosp
H&P
HPI
ht
HX
ICP
ICU
I&D
i.e.
IMP
inf
IOP
IQ
I.V.
K.U.B,
L
L, It
L
LE
kl.
LL
LLE
LLL
LLQ
LOC
Meaning
heart rate
hospital
history and physical
history of physical illness
heart, height
history
intracranial pressure
intensive care unit
incision and drainage
that is
impression
inferior
intraocular pressure
intelligence quotient
intravenous
kidney, ureter, bladder
lumbar
left
_ lumbar vertebra
lower extremity
large
lower lobe
left, lower extremity
left lower lobe of lung
lower left quadrant
loss of consciousness
Abbrev.
LOM
LPN
LRQ
LS
LSK
LS
LUE
LUQ
M m
MAE
mand
max
MD
MD
MP
mod
MRI
MS
M. T
MVA
N
NAD
N.C.
Neuro
N/F
Meaning
loss of motion
licensed practical nurse
lower right quadrant
lumbosacral. liver and spleen
liver. spleen, kidney
lumbosacral
left upper extremity
left upper quadrant
murmur
moves all extremities
mandible
maxilla
Doctor of Medicine
muscular dystrophy
metaphalangeal
moderate
magnetic resonance imaging
musculoskeletal
masses, tenderness
motor vehicle accident
Negro, normal
no acute distress
no complaints
Neurology
Negro woman
190
Abbrev.
NKA
NL
N/M
NSR
NN
08
O.D.
OPD
Ophth
OR
Ortho
OS.
ou
F
P.
PA
P&A
Path
P.E.
_ Meaninq
no known allergies
normal
Negro male
normal sinus rhythm (heart)
nausea, vomiting
obstetrics
right eye
out patient department
Ophthalmology
operating room
Orthopedics
lefl eye
both eyes
post, after
pulse
pulmonary aorta
palpation and auscultation, percussion and auscultation
Pathology
physical exam
through or by
by mouth
pupils equal, round, react to light, accommodate
past history
petit mal
post mortem
per
per 0s
PERRLA
PH
PM
PM
PM
PMD
PMH
PO
post
post-op
PR
PRBC
pre-op
orn
prog
Pt
PTA
PTR
PtX
PX
qd
qh qih
qt
R.
RBC
R. rt
RLE
RLL
RLQ
Meaninq
afternoon
private medical doctor
past medical history
by mouth
posterior
postoperative
pulse rate
packed red blood cells
preoperative
according to circumstances as needed
prognosis
patient
prior to admission
pulse, temperature, respiration
pneumothorax
prognosis
every day
every hour
quiet
respiration
red blood cells
right
right lower extremity
right lower lobe
right lower quadrant
191
Abbrev. - Meaninq
FVO n&out
ROM range of motion
RR regular rhythm (heart)
RUE right upper extremity
RUL right upper lobe
RUQ right upper quadrant
Rx prescription, treatment
s without
S
SB
SC.
semi
Sm
SOB
SIP
spont
ss. ss
stat.
sacral vertebra
small bowel
subcutaneous
half
small
shortness of breath
status post
spontaneous
half
at once
subcutaneous
temperature
total lung capacity
tympanic membrane
temporomandibular joint
_ thoracic vertebra
subcu
temp. T.
TLC
TM
TMJ
T”
Abbrev.
T.P.R.
TX
TX
UE
UGI
U&L
ULQ
unil
URD
URI
URQ
vs
vs
VT
WBC
WD
W/F
WIM
WN
WNL
WI
w/o
YO
Meaning
temperature, pulse, respiration
treatment
traction
upper extremity
upper gastrointestinal
upper and lower
upper left quadrant
unilateral
upper respiratory disease
upper respiratory infection
upper right quadrant
versus
vital signs
ventricular tachycardia
white blood count
well developed
white female
white male
well nourished
within normal limits
weight
without
years old
192
a”
0
t
1
<
>
C
S - ss
+
x
0
89 HOSPITAL SYMBOLS
Meaning
female
male
degree
increase
decrease
less than
greater than
with
without
half
plus
times (multiplication)
no, none
minus
negative; no murmurs
equal
approximately
primary, first degree
secondary second degree
tertiary, third degree
pounds; fracture
193
cc
cm
cm2
F
fl
9, gm
in
in2
kg
I
lb, #
m
mg
mm
OZ
vd
8.3. WEIGHTS AND MEASURES
Celsius or Centigrade (temperature): C + 5/9 (F - 32)
cubic centimeter (volume): cm3; 1 ml = 1 cc
centimeter (length): l/100 of a meter: cm = in x 2.54
square centimeters (area): cm2 = in2 x 6.4516
Fahrenheit (temperature): F = 9/5 (C) + 32
foot (length): 12 inches
gram (weight)
inch (length)
square inches (area)
kilogram (weight): 1000 grams: kg = lb x 0.4536
liter (volume): 1000 cm3 or 1000 ml
pound (weight): 16 ounces
meter (length): m = ft x 0.3046
milligram (weight): 111000 of a gram
millimeter (length): l/1000 of a meter
ounce (weight): i/16 of a pound
yard (length): 3 feet
194
Prefix
a-, an-
ad-
ambi-
ante-
anti-
auto-
bi-
circum-
contra-
di-
dys-
ecto-
endo-
epi-
ex-, e-
MO-
extra-
hemi-
hyper-
in-
C. DECIPHERING MEDICAL TERMINOLOGY
Meaning
absence of
to; toward; near
both
before; forward
against
self
tW0
around
against: opposed
against
tW0
painful; difficult
outside
within
over; upon
from: without
outside
C.l. PREFIXES
Prefix
infra-
inter-
intra-
iso-
lumbo-
macro-
mal-
mego-
micro-
para-
peri-
PolY-
post-
pre-; pro-
retro-
semi-
sub-
Meaning
below: under
between
within
equal
loin
large
disordered: bad
great
small
beside; near
around
many
after: behind
before; in front of
backward
hatf
under: below outside of; beyond; in addition to
half
above; excessive; more than normal
below; deficient; less than normal
in; not
super-, supra- above
sym-8 syn with, together
tachy- fast
trans- across; beyond
tri- three
uni- one
195
Root
acro-
adeno-
angio-
arterio-
arthro-
audio-
bio-
brachio-
cardio-
cephalo-
celio-
cerebro-
choleo-
chondro-
costo-
cranro-
cysto-
dent-
derma-
duodeno-
encephalo-
entero-
gastro-
glyco-
hem-, hemato-
J&&g
extremities
gland
tube; blood vessels
arteries
joint
hearing
life
upper arm
heart
head
abdomen
cerebrum
bile
cartilage
rib
skull
sac
teeth
skin
first part of small intestine
brain
intestine
stomach
sugar
blood
C.2. ROOTS
&&t
hepato-
hetero-
histo-
home-, homeo.
hydro-
hystero-
laparo-
mammo-
meningo-
myleo-
myo-
nephro-
neuro-
olig-
OS-, osteo-
phleb-
pneumo-
pseudo-
puimono-
pyelo-
reno-
rhino-
schlero-
toxo-
vaso-
Meaninq
liver
other; different
tissue
same
water
uterus
abdominal wall
breast
membranes
marrow; spinal cord
muscle
kidney
nerve
little: few
bone
vein
air; lung
false
lung
pelvis; kidney
kidney
nose
hard
poison
vessel
196
m
-al
-algia
-asthenia
-cele
-centesis
-cyte
-duct
-ectomy
-emia
-esthesia
-genie
-grade
-gram
-mW
-ia
-IC
-itis
-metry
Meaning
pertaining to
pain
weakness
tumor
tapping
cell
to lead or draw
surgical removal
blood
feeling; sensation
causing
trend; current; progression
visual record
visualization
state; condition
pertaining to
inflammation
measurement
C.3. SUFFIXES
Sunix
-aid
-0logist
-0logy
-0ma
-0sis
-0tomy
-pathy
-penia
-plasty
-pnea
-ptosis
--rrhag (e) -rrhag (ia)
-rrhea
-rrhexis
-scopy
-uria
Meaning
resemble: like
specialist
science of
tumor
abnormal condition
formation of opening
cutting into
disease
insufficiency
surgical repair
breathing
falling; downward displacement
to burst forth
discharge
rupture
see
urine
197
D. LAY TERMINOLOGY - NASS INJURY SYNONYM LIST
This list is intended as a “best fit” mapping between commonly encountered laytens and NASS injuries. The mapping presented here does not preclude the use of a dlfferent injury. The ultimate choice of injury is based upon the gg&tt in which the lay term is used. If the context dictates the use of an injury other than those presented below, then use that injury. Some layterms (e.g., bumped, jarred, jolted, etc.) are nebulous in their meaning and further insight as to their meaning should be explored during an interview.
Lav Term NASS lniurv
abortion (aborted) result’ ache result
black and blue black eye blacked out bleeding blister (blistered) bloody bored broke bruise (bruised) brush burn bump bumped burst bust (busted)
carpet bum chaff (chaffed) chipped collapsed lung complaint of pain cracked cramp crick cut cut in half
cut through
contusion contusion concussion result burn result puncture fracture contusion abrasion contusion resutt rupture fracture or laceration
abrasion abrasion fracture result result fracture result strain laceration transection or severance transection or severance
. In NASS “results” are not considered injuries and therefore are not coded. In this list the word “result implies that the lay term is not a codeable injury.
199
Lav Term
decapitated denudation disconnected dismembered
ecchymosis embedded erythema excoriated exposed
foreign body
gash goose egg
hematoma hemorrhage hurt (hurting) hyperextended
infection irritation
jammed (e.g.,jammed finger) jar (jarred) jolt (jolted)
knocked out (head) knocked out (teeth) knot
NASS lnlunf
amputation avulsion separated amputation
contusion result’ result abrasion avulsion
laceration contusion
contusion’ result result strain
result result
sprain result result
concussion avulsion contusion
maimed mash (mashed) miscarriage
obstruction ooze (oozed)
pain parched penetrate (penetrated) perforation pinched nerve
unknown injury crush result
result result
result bum puncture laceration strain
‘Exception: if not anatomic injury of brain.
Results are not codeable in NASS
199
Lav Term
popped out pricked pulled
“P (ripped) ;:z;;;; (integumentaty)
roasted rubbed
saw tooth scorched scrape (scraped) scratch (scratched) scrunch separated shifted shook up singed skinned slashed slit snapped sore (soreness) spasm speared spiked splinter (splintered) split
squash (squashed) squirted stiffness strawberry stretch (stretched) stuck suffocation swelling
NASS lniury
fracture, laceration or rupture dislocation puncture strain or sprain
laceration avulsion abrasion burn abrasion
laceration burn abrasion laceration crush dislocation dislocation result bum abrasion laceration laceration strafn result result puncture puncture fracture dislocation or laceration strain or dislocation crush result result abrasion strain puncture result result2
‘Exception: code if anatomic injury of brain.
Results are not codeable in NASS
200
-bv
tear (tom)
tenderness turn (turned) twisted
weakness welt whiplash (to the neck) wrench (wrenched)
NASS lniury
laceration (internal organ) laceration, avulsion (integumentary) result’ strain or sprain strain or sprain
concussion
result3 unknown injury strain
strain
3Exception: if neurological deficit due to head injury, AIS may be upgraded for its presence.
201
E. FRACTURES
A fracture is a partial or complete interruption in the continuity of a bone. Definitions of the fractures more frequently encountered in NASS are listed below.
Twes of Fractures
Articular
Avulsion
Bennett’s
Blow-out
Burst
Butterfly
Chance
Clay-shoveler
Closed
Colles’
Fracture of the joint surface of a bone; also called “joint fracture”.
Fracture that occurs when a joint capsule, ligament, or muscle insertion of origin is pulled from the bone as a result of a sprain dislocation or strong contracture of the muscle against resistance: as the soft tissue is pulled away from the bone, a fragment or fragments of the bone may come away with it.
Oblique fracture of the base of the first metacarpal.
Fracture of the floor of the orbit, without a fracture of the rim, produced by a blow on the globe with the force being transmitted via the globe to the orbital floor.
Fracture of the body of vertebra.
Comminuted fracture in which there are two fragments on each side of a main fragment resembling the wings of a butterfly.
Transverse fracture usually in the thoracic or lumbar spine, through the body of the vertebra extending posteriorly through the pedicles and the spinous process.
Fracture of one or more spinous processes of the lower cervical or upper thoracic vertebrae.
Fracture which does not produce an open wound in the skin: also called simple fracture.
Fracture of the lower end of the radius at the wrist with displacement of the distal fragment dorsally: sometimes called reversed Colles’ or Smith Fracture when volar displacement of the distal fragment occurs in the same location.
Fracture of radius a) Cokes fracture, b) Smith Fracture
202
Comminuted Crushing fracture in which the fragments are splintered to pieces. _
Compound
Compression
Depressed
Hangman’s
Fracture in which the skin is perforated and there is an open wound down to the fracture.
Fracture caused by compression and usually involving the spine.
Fracture of the skull in which a fragment is depressed.
Fracture through the pedicles of the axis (C2) with or without subluxation of the second cervical vertebra on the third.
Le Fort’s
Le Fort I
Bilateral horizontal fracture of the maxilla.
Horizontal segmented fracture of the alveolar process of the maxilla, in which the teeth are usually contained in the detached portion of the bone. Also called Guerin’s and horizontal maxillary fracture.
Le Fort II
Le Fort Ill
Unilateral or bilateral fracture of the maxilla, in which the maxilla is separated from the facial skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline of the hard palate, through the floor of the orbit, and into the nasal cavity. Also called pyramidal fracture.
Fracture in which the entire maxilla and one or more facial bones are completely separated from thecraniofacial skeleton: such fractures are almost always accompanied by multiple fractures of the facial bones. Also called craniofacial disjunction and transverse facial fracture.
i
Le Fort Fractures
Lisfranc’s Fracture-dislocation through the tarsometatarsal.
203
Monteggia’s - Fracture in the proximal half of the shaft of the ulna, with dislocation of the head of the radius. Sometimes called ‘parry fracture’ because it is often caused by attempts to fend off blows with the forean.
Open
Pilon
P0ttk
1, wggia Fractures Y$ ‘, !
Same as Compound fracture.
Fracture of the distal metaphysis of the tibia extending into the ankle joint.
Fracture of the lower part of the fibula and of the malleolus of the tibia, with outward displacement of the foot.
Teardrop Fracture-dislocation of the cervical spine; compression fracture of the body of the cervical vertebra.
Trimalleolar
Tripod
Fracture of the medial and lateral malleoli and the posterior tip of the tibia,
Facial fracture involving the three supports of the malar prominence, the arch of the zygomatic bone, the zygomatic process of the frontal bone, and the zygomatic process of the maxillary bone.
204
APPENDIX A
SOURCE OF ILLUSTRATIONS
(1)
(2)
(3)
(4)
(5)
(‘3)
Anatomv & Phvsioloav. Vol. 2 (2”d Ed.. 2nd Rev.). New York: Barnes & Noble, 1984.
Anderson, J.E. Grant’s Atlas of Anatomy (p Ed.). Baltimore: William 8 Wilkins, 1978.
Anthony, C.P., and Kolthoff, N.J. Textbook of Anatomv and Phvsiolooy (8’” Ed.). St. Louis: C.V. Mosby, 1971.
Dorland’s Illustrated Medical Dictionary (26’” Ed.). Philadelphia: W.B. Saunders, 1981
Dorland’s Illustrated Medical Dictionary (28n Ed.). Philadelphia: W.B. Saunders, 1994.
Jacob, SW., Francone, C.A., and Lossow, W.J. Structure and Function in Man (4’” Ed.). Philadelphia: W.B. Saunders, 1978.
(7)
(8)
(9)
PDR Medical Dictionaw (l” Ed.). Baltimore: Williams &Wilkins, 1995.
Smith, G.L., and Davis, P.E. Medical Terminology (4’ Ed.). New York: John Wiley, 1981.
Tortora, G.J., and Anagnostakos, N.P. Princioles of Anatomv & Phvsiolooy (1” Ed.). San Francisco: Canfield Press, 1975.
(10) Tortora, G.J.. and Anagnostakos, N.P. Principles of Anatomv 8 Phvsiolooy (2”4 Ed.). San Francisco: Canfield Press, 1978.
,
205
APPENDIX B
SUGGESTED REFERENCES
This Injury Coding Manual has been designed to provide the nonmedically-oriented NASS injury coder with the “tools” currently identified and available to extrapolate and interpret injury data, and to assign codes accurately. After this manual has been mastered, the following references provide an opportunity for in-depth reading for coders who are eager to learn more about the history and background of injury coding. This list is not all inclusive, but does represent some of the major contributions to the field.
The Abbreviated Injury Scale (AIS) 1976 Revision, including Dictionary, American Association for Automotive Medicine (now Association for the Advancement of Automotive Medicine), Des Plaines, IL.
The Abbreviated Injury Scale (AIS) 1980 Revision, American Association for Automotive Medicine (now Association for the Advancement of Automotive Medicine), Des Plaines, IL.
The Abbreviated Injury Scale (AIS) 1965 Revision, American Association for Automotive Medicine (now Association for the Advancement of Automotive Medicine), Des Plaines. IL.
Baker, S. P., O’Neill, B., Haddon, W.. and Long, W. B.: “Injury Severity Score: A Method for Describing PatientswithMultiple InjuriisandEvaluating Emergency Care,” .lOUANALOFTRAUMA14:187-196, 1974.
Baum, A. S.: “An Alternative Injury Code for Police Reporting: An Evaluation of the New York State Injury Coding Scheme,” PROCEEDINGS, 22nd Conference, American Association for Automotive Medicine, 1978.
Calspan Corporation: “Advanced Training in Injury Coding for the National Accident Sampling System,” Buffalo, NY, July 1982.
Campbell, E. 0. ‘F.: “Collision Tissue Damage Record,” Traffic Injury Research Foundation of Canada, Ottawa, 1967.
Champion, H. R., Copes, W. S., and Sacco, W. J.: “Major Trauma Outcome Study: Establishing National Norms for Trauma Care,” (Accepted for publication in the JOURNAL OF TRAUMA).’
Committee on Medical Aspects of Automotive Safety, American Medical Association: “Rating the Severity of Tissue Damage: I. The Abbreviated Scale,” JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 216227 -280. 1971.
Committee on Medical Aspects of Automotive Safety, American Medical Association: “Rating the Severity of Tissue Damage: II. The Comprehensive Scale,” JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 220:717 -720,1972.
General Motors Corporation, Safety Research and Development Laboratory: “Collision Performance and injury Report,” long form PG 2002, Milford, MI, September 1968.
Gennarelli. T. A.: “Analysis of Head Injury Seventy by AIS-80,” PROCEEDINGS, 24th Conference. American Association for Automotive Medicine, 1980.
Gennarelli, T. A., Champion, H. R., Sacco, W. J., Copes, W. S.. and Alves W. M.: “Mortality of Patients with Head Injury and Extracranial Injury Treated in Trauma Centers,” JOURNAL OF TRAUMA 29:1193- 1202, September 1989.
206
MacKenzie, E. J.,Garthe, E. A., Gibson, G.: “Evaluating the Abbreviated Injury Scala,” PROCEEDINGS, 22nd Conference, American Association for Automotive Medicine, 1978.
MacKenzie, E. J., Shapiro, S. Eastham, J., and Whitney, B.: “Reliability Testing of the AlS ‘80,’ PROCEEDINGS, 25th Conference, American Association for Automotive Medicine, 1961.
Marsh, J. C.: “Existing Traffic Accident Injury Causation Data Recording Methods and the Proposal of an Occupant Injury Classification Scheme,” PROCEEDINGS, 16th Conference, American Association for Automotive Medicine, 1972.
Marsh, J. C., Flora, J. D., Komfield, S. M., and Bailey, J.: “Results of Financial and Functional Consequences of Injury: A Pilot Clinical Study,’ PROCEEDINGS, 22nd Conference, American Association for Automotive Medicine, 1978.
MULTIDISCIPLINARYACCIDENT INVESTIGATION DATA FILE: Editing Manual and Reference Information, Volume l-1976, Contract No. DOT-HS-5-01134, June 1977. Available from the National Technical Information Service, Springfield, VA 22161.
Ryan, G. A., and Garrett, J. W.: “A Quantitative Scale of Impact Injury” Calspan Report No. VJ-1823-R34, Calspan Corporation, Buffalo, NY, October 1988.
Sherman, H. W., Murphy, M. J., and Huelke. D. F.: “A Reappraisal of the Use of Police Injury Codes in Accident Data Analysis,” PROCEEDINGS, 26th Conference, American Association for Automotive Medicine, 1976.
Somers, R. L.: “The Probability of Death Score: An Improvement of the Injury Severity Score,” PROCEEDINGS, 25th Conference, American Association for Automotive Medicine, 1981.
Spence. E. S.: “A Proposed injury Code for Automotive Accident Victims,” PROCEEDINGS, 18th Conference, American Association for Automotive Medicine, 1974.
Stalnaker, R. L., Mohan, D., and Melvin, J. W.: “Head Injury Evaluation: Criteria for Assessment of Field, Clinical and Laboratory Data,” PROCEEDINGS, 19th Conference, American Association for Automotive Medicine, 1975.
States, J. D.: “The Abbreviated and the Comprehensive Research Injury Scales, PROCEEDINGS, STAPP Conference, 13:282-294, (SAE 699810), 1969.
States, J. D., Huelke, Cl. F., and Hames. L. N.: “1974 AMA-SAE-ADAM Revision of the Abbreviated Injury Scale,” PROCEEDINGS, 18th Conference, American Association for Automotive Medicine, 1974.
Williams, R. E. and Schamadan, J. L.: ‘The ‘Simbol’ Rating and Evaluation System,” ARIZONA MEDICINE 26:886667, 1969.
World Health Organization: “Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death,” Geneva, 1977.
207
In addition to the above references to scientiiic and technical information on injury coding, the NASS injury coder is encouraged to consult both basic anatomy texts and medical dictionaries for information and clarification on body regions and medical terminology. The following are suggestions only; other anatomic and medical resources may be consulted.
Clinical NeurosuraerY’ Volume 12, William & Wilkins Co., Baltimore, MD, 1966 (Head Injury Glossary prepared by a’committee of the Congress of Neurosurgeons).
Dictionan,, 3* Edition, Hanley & Beifus, Inc., Philadelphia, PA, 1998.
Dorland’s Medical Dictionaw, 27” Edition, W. B. Saunders Co., 1986.
Grants Atlas of Anatomy, 7” Edition, Williams 6, Wilkins Co., Baltimore, MD, 1978.
Grav’s Anatomy, Running Press, Philadelphia, PA, 1974.
vTerminolopu, 3”’ Edition, John Wiley & Sons, Inc., New York, NY, 1976.
PDR Atlas of Anatomy, I” Edition, Williams B Wilkins, Baltimore, MD, 1996.
Review of Gross Anatomy, 6’ Edition, McGraw-Hill, 1996.
Stedman’s Medical Dictionary, 24” Edition, Williams 8 Wilkins Co., Baltimore, MD, 1982.
Structure and Function in Man, 5e Edition, W. 8. Saunders Co., 1982 (S. W. Jacob, C. A. Francone, W. J. Lossow - authors).
208