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.
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??
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.
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 …
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 …
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 …