trauma room

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 …

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.

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.

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.  

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 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 …

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 …

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 …