Diagnoses Archives

Can we code osteophyte fractures?

Pathologic, chronic, age-indeterminate, stress, and traumatic fractures are all coded differently in ICD-10; only traumatic codes are included within the PTOS inclusion criteria.AIS has clarified that osteophyte/bone spurs are not to be coded. We default to AIS rules, so osteophyte fractures should not be included.

As you know for the hypothermia hospital event, the temperature is defined as < 34 C or 93.2 F. Does this also apply to the diagnosis or may we pick it up per AIS score at 35 C?

If it is present on arrival, for the purposes of diagnoses, you can enter up to 35 c. You are correct that this is different from the hospital event definition.

We found conflicting information in the PTSF FAQs. 8/2/2019 – SAH on first scan, not present on closest to 24 – response recommended to not code the head bleed. 7/3/19 – we are coding CT head scans closest to 24 hours….not always the worst scan…..we are following what we were taught at AIS…. – response was you are correct. 2021 – response: code brain injuries based on what is documented closest to or at 24 hours or initial if >24 hours. We, too, have been recording head readings closest to 24 hours and or first if > 24 per our AIS training, but now we are confused. If there is a bleed on scan one (osf), but on a second scan at 16 hours there is no bleed, we record none- same as in FAQ. If size goes up or down, we record the size closest to 24 – same as in FAQ.

Thanks for the question, and sorry for the confusion. For brain injury, AIS does direct to take findings from what is present at 24 hours, unless initially identified later. In October 2019, the AIS clarification document updated the 24 hour rule. It states, “Within the first 24 hours post injury, patients with transient signs and …

Continue reading “We found conflicting information in the PTSF FAQs. 8/2/2019 – SAH on first scan, not present on closest to 24 – response recommended to not code the head bleed. 7/3/19 – we are coding CT head scans closest to 24 hours….not always the worst scan…..we are following what we were taught at AIS…. – response was you are correct. 2021 – response: code brain injuries based on what is documented closest to or at 24 hours or initial if >24 hours. We, too, have been recording head readings closest to 24 hours and or first if > 24 per our AIS training, but now we are confused. If there is a bleed on scan one (osf), but on a second scan at 16 hours there is no bleed, we record none- same as in FAQ. If size goes up or down, we record the size closest to 24 – same as in FAQ.”

I have a prosthetic hip dislocation (T84.02) with a traumatic mechanism, over reached for something and fell. Like our peri-prosthetic fractures, am I coding this to hip dislocation (S73.0) and including as PTOS?

The S73 code has an Excludes 2 note, excluding dislocation of prosthetic. So if all that is dislocated is the prosthetic, it directs to use the T84 code, which does not qualify for inclusion. Excludes 2 means there could also code S73, if there is injury to anything (hip) other than the prosthetic.

I have a patient that on her initial imagining did not show a brainstem herniation. On a follow up one, it was present. The follow up one that it was on, was greater than 24 hours. In the AIS book, it states that coding of brain injuries should be done at 24 hours or initial confirmed diagnosis is later than 24 hours. Would this herniation be able to be included in the injuries??

The guideline states, “coding of brain injuries should be done at 24 hours or at initial confirmed diagnosis if later than 24 hours.” Since the initial brainstem herniation was not initially diagnosed until after 24 hours, you can code it based on the information you have when the diagnosis was confirmed.

Are we reading the manual correct that if a head bleed is noted on the first CT the registry is to code the size of the head bleed within the first 24 hours. If the head bleed is noted anytime after the first 24 hours that would be considered the initial confirmed diagnosis and the registrar is to capture the injury?

Correct. You are to code brain injuries based on what is documented closest to or at 24 hours, or at initial confirmed diagnosis if later than 24 hours. If a head bleed is noted after the first 24 hours, that would be considered the initial confirmed diagnosis and you would capture the injury.

Effacement of the basilar cisterns. Would this also be considered edema of the basilar cisterns?

This could be used to code cerebrum brain swelling. Partial effacement would go to moderate; compressed – 140664.4, while complete effacement would go to severe; absent/obliterated/closed – 140666.5. I wouldn’t use edema unless the provider notes as edema.

If you have a patient that had a (closed) displaced mandible fx, this will code as an open fx and the question for antibiotic administration becomes valid. Are all displaced mandible fxs considered open – even though this one clearly states closed? I do see in the AIS manual that open/displaced/comminuted all fall into the same category. This causes a message that pops up “based on AIS codes, this record may meet open fx criteria”. I know we can validate this but then it does not populate the NTDS side appropriately when we have “does not meet criteria” marked. On TQIP side, we then get an inclusion criteria – level 2 error message – Element must not be NA as AIS codes provided meet the reporting criteria. We would then have to exclude this chart. What would you suggestion be to make this record work?

If you have an AIS code recorded that falls within the defined coding criteria for these fields, you will need to answer the antibiotic elements as if there is an open fracture present for both PTOS and the NTDB. This criteria is provided by the NTDB/TQIP, and we understand sometimes it is not perfect as …

Continue reading “If you have a patient that had a (closed) displaced mandible fx, this will code as an open fx and the question for antibiotic administration becomes valid. Are all displaced mandible fxs considered open – even though this one clearly states closed? I do see in the AIS manual that open/displaced/comminuted all fall into the same category. This causes a message that pops up “based on AIS codes, this record may meet open fx criteria”. I know we can validate this but then it does not populate the NTDS side appropriately when we have “does not meet criteria” marked. On TQIP side, we then get an inclusion criteria – level 2 error message – Element must not be NA as AIS codes provided meet the reporting criteria. We would then have to exclude this chart. What would you suggestion be to make this record work?”

Looking for help with codes for “small interpeduncular cistern hemorrhage”. Software is populating AIS code 140210.5 brain stem hemorrhage, and ICD 10 S06.389A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of NOS duration, initial encounter.

Interpeduncular cistern does code to brain stem. In the AIS clarification document from October 2019 they have“Interpeduncular fossa (cistern) basal cisterns code as injury involving hemorrhage in the brainstem;” The ICD-10 code has hemorrhage of brain stem also.I would note any specifics related to LOC if you have documentation, as it will assume the LOC …

Continue reading “Looking for help with codes for “small interpeduncular cistern hemorrhage”. Software is populating AIS code 140210.5 brain stem hemorrhage, and ICD 10 S06.389A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of NOS duration, initial encounter.”

Patient came in as a fall from same level w/ an isolated distal femur fx. It was found that they patient also had a hematoma at the femur fx site. The blood seemed to be coming from the fx as there was no injury involving any muscle, etc. The doctors have listed in her chart that there was hemorrhagic shock. What do you suggest for coding this injury? Would you look at the hematoma/bleeding as a sequela to the fx?

If it is a closed fracture, blunt injury, you can code hematoma in addition to the fracture. If it is an open fracture or a penetrating injury, you wouldn’t code those associated. From what you wrote, it sounds like it could be sequela, as they say there is no injury to muscle, but I might …

Continue reading “Patient came in as a fall from same level w/ an isolated distal femur fx. It was found that they patient also had a hematoma at the femur fx site. The blood seemed to be coming from the fx as there was no injury involving any muscle, etc. The doctors have listed in her chart that there was hemorrhagic shock. What do you suggest for coding this injury? Would you look at the hematoma/bleeding as a sequela to the fx?”