trauma room

Hypothermia that is present on arrival and not related to treatment or sequela is coded. You would capture this as 34 degrees since you are not rounding up or down. Hospital event for hypothermia in the PTOS manual reads less than or equal to 34, so 34.2 would not qualify for a hospital event.

You won’t code separately any laceration that is part of the open fracture, with the wound and fracture communicating. You should go ahead and code the procedures, yes, it is okay that there is no separate laceration diagnosis. It is understood that an open fracture has an open wound (or multiple) associated.

The 24 hour rule applies to capture size of the injury, as close to or after 24 hours, to capture the “full” size of the injury. If you have an injury that isn’t identified in the first 24 hours, you would code it when it is identified. However, this does not include anything due to …

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.

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.

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.