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CAISS-AIS FAQS
Prepare for the CAISS-AIS FAQs Coding Exam with this concise study resource covering injury coding, AIS guidelines, and common exam questions. It reinforces essential coding concepts and improves test readiness. Suitable for professionals preparing for the CAISS certification exam. Q: How and when can I code "concussion"? ✓ ✓ ...... ANSWER ....... A: You may only code "concussion" (specifically codes 161000.1 and 161001.1) when the word "concussion" is given by the MD as the only brain injury diagnosis. Q: How do you code cerebral shear injuries that have loss of consciousness less than 6 hours? ✓ ✓ ...... ANSWER ....... A: The correct code is 140643.2 found under "Cerebrum: hematoma, intracerebral, tiny - petechial hemorrhage(s)
[includes radiographic "shearing" lesions] not associated with coma > 6 hours." Q: What do I code if the patient has LOC and an associated anatomical head lesion? ✓ ✓ ...... ANSWER ....... A: If the patient has an anatomic injury to the brain (e.g. SDH, IVH, SAH, etc.) in addition to LOC, the LOC will only be acknowledged by AIS if there is a coma modifier listed with the injury. Remember that in AIS 2008 LOC/coma can only be assigned to one injury [rule page 40] so if you have two injuries with coma modifiers, use the one that provides the highest AIS value for coma and code the other as NFS. Q: A patient arrives to the ED with a severe head injury; he is transported to the ICU in anticipation of organ donation and while the brain death evaluation is completed. His final diagnoses include the expected head injury and brain death. What do you do when coding this chart regarding the brain death itself? ✓ ✓ ...... ANSWER ....... A: Brain death is a situation not an injury. The coder would appropriately code the lesions identified on CT as well as any edema. However, brain death is a sequelae of those injuries. If the patient had no codeable injuries in the brain, the only option in that
Q: What is the correct code for the diagnosis "Subdural hematoma 7mm thickness"? ✓ ✓ ...... ANSWER ....... A: The correct code is 140652.4. If the specific region of the brain (brain stem, cerebellum or cerebrum) is not indicated, the injury should be assigned to the cerebrum. Q: A patient sustains a basilar skull fracture, fractured L zygoma and a nasal fracture. She has bilateral periorbital ecchymosis. There is no mention in the chart of cerebral spinal fluid (CSF) leak. How would you code the basilar skull fracture? ✓ ✓ ...... ANSWER ....... A: The correct code is 150202.3. If the patient has a CSF leak, the treating physician(s) will always mention it in the chart. When there is no mention of CSF leak, the coder may use the "without CSF leak" code. The periorbital ecchymosis could be due to the nasal fracture and is not necessarily a sign of bleeding from the base fracture. Q: How would you code the following injury; small intraventricular hemorrhage in the third and fourth ventricles with associated obstructive hydrocephalus? ✓ ✓ ...... ANSWER ....... A: The only codes for IVH are located within the cerebrum chapter of the dictionary and are listed on page 48 of your dictionary, but the answer will depend
upon whether the patient is unconscious. There are 3 separate codes and if you patient was unconscious for > than 6 hours you would use the code 140677.4. You can only apply this coma modifier one time when you are coding your injuries. There us no code for the obstructive hydrocephalus which is a consequence of the hemorrhage, and a sequela that cannot be coded. Q: Your newest trauma patient has suffered a basilar skull fracture. While reading the CT scan of the head, you notice that there is also a dislocation of the ossicles on the left. After coding the basilar skull fracture correctly, you are left with a decision about the ossicular dislocation. How do you code this specific injury? ✓ ✓ ...... ANSWER ....... A: 240212.1; the ossicles are seen on CT scan but they are the skeletal component of the ear. Thus, the AIS code for the ossicles is found in the face, under the organ "ear". This injury is frequently associated with a basilar skull fracture, which would be coded separately. The patient is likely also demonstrating issues with hearing on the left where the ossicles are dislocated. Q: If Hyperdensities are seen along interhemispheric falx and the tentorium, keeping with acute extra-axial
are coded as one entity unless the coder is sure that the other injuries are not related to the penetrating injury. The best analogy is that of crush injury, where bone, soft tissue and vascular injuries are coded as one entity. Q: The driver of a motorcycle without a helmet is struck by a large truck on the highway. He arrives with a GCS 4 and has the usual workup with a CT-head that does not demonstrate any injury. He remains in a coma for several days and undergoes an MRI which clearly identifies DAI located at the corpus callosum; How would you code this injury and what is your rationale for the choice? ✓ ✓ ...... ANSWER ....... A: Because of the length of coma, the DAI is coded from the concussive section of the head chapter even though we know it is located at the corpus callosum. The coma is consistent for > 24 hours with the MRI appropriately done to confirm the diagnosis and reason for prolonged coma. Code: 161011. Q: A 36 y.o. female is running across the highway and struck by a vehicle at high speed; she is unresponsive at the scene and has an immediate CT-head which identifies a large bleed likely at the sagittal sinus. Operative craniotomy reveals a laceration to the sagittal sinus with a 2000 ml
blood loss; the injury is irreparable; How do you code this injury? ✓ ✓ ...... ANSWER ....... A: The blood loss, although massive, cannot be attached to this injury specifically and laceration is the only available code. Code:
Q: A 45 y.o. male is apneic with GCS of 3 at scene. Bullet entry is in the occipital region of the skull with trajectory down and forward with exit at the throat. CT shows massive damage of the cerebrum, cerebellum, and brain stem along the bullet pathway Please code the brain injury. ✓ ✓ ...... ANSWER ....... A: No matter how many regions of the brain are involved in a penetrating injury if the brain stem is involved you code the injury as 140216.6 and must have CT, MRI or other evidence Q: The patient sustained a gunshot wound to the eye which penetrated the skull base and lodged in the parietal area of the brain. It was noted that there was brain tissue extruding from the wound. What is the best way to code the head injuries? ✓ ✓ ...... ANSWER ....... A: There are two correct codes — 150206.4 for the complex basilar skull fracture and 140690.5 for the penetrating injury to the cerebrum. In AIS 2005 the codes would be the same for the
Q: How do you code massive destruction of the face ✓ ✓ ...... ANSWER ....... A: In AIS 2005 there is a code for massive destruction of the whole face (216008.4) which is assigned to the Face region for ISS purposes although all the other penetrating codes for Face are assigned to the External body region for ISS purposes. Q: A patient arrives after an MVC in which the car rolled several times. CT head - negative for injury, skull normal; CT cervical spine - occipital condyle fracture, normal alignment; neurologic examination is normal- able to move all extremities, GCS= 15; there is no drainage from the ears or nose, no ecchymosis. ✓ ✓ ...... ANSWER ....... A: 150202.3; The occipital condyles are part of the base of the skull despite the diagnosis frequently appearing on the cervical CT scan. As with any basilar skull fracture, an assessment for CSF leak as well as head injury is important. In addition, since the occipital condyles articulate with the first cervical vertebrae, assessment for spinal cord injury is also important. Q: On page 67 of the AIS 2005 Manual, the last code 321021.5 has "bilateral" as descriptor. Does "bilateral" mean "bilateral thrombosis" or "bilateral neurological deficit"? We
have a patient who sustained bilateral vertebral artery dissection and thrombosis with left PCA territory infarction. CT scan states " Apparent migration of intraluminal thrombus arising from the left vertebral artery, resulting in occlusion of the calcarine branch of the left posterior cerebral artery" How should we code this case? ✓ ✓ ...... ANSWER ....... A: Artery dissections are coded under intimal tear and we do not have a code for bilateral under intimal tear. You would code 321004.3 for the left vertebral artery with its subsequent PCA infarction, and 321002.2 for the right side. Q: A patient with clinical diagnosis of DAI recorded by the neurosurgeon and a radiologic finding described as "petechial hemorrhages in the basal ganglia and corpus callosum consistent with DAI" who remains comatose until he dies 15 hours after injury should be assigned which AIS code? ✓ ✓ ...... ANSWER ....... A: The correct code is 140627.5. This question highlights the rule box on page 45 of the AIS dictionary, which directs the coder to "code only the more severe" when both corpus callosum and basal ganglia are noted. An important additional point to note is the directive. If coma exceeds 24 hours, use 161011.5 (THIS IS UNDER CONCUSSIVE INJURY) no matter what anatomic
Q: How should you code asphyxia related to hanging? ✓ ✓ ...... ANSWER ....... A: Asphyxia codes are located in the Other Trauma section. Since we have no information as to neurological deficit, the correct code to use is 020000.3. There are also codes in the Head chapter for "hypoxic or ischemic brain damage secondary to systemic hypoxemia, hypotension or shock" but these codes have a severity code of 9. Q: What is the correct code for a single tiny cerebral contusion? ✓ ✓ ...... ANSWER ....... A: It is 140605. tiny: < 1 cm in diameter Q: What is the correct code for a single small (1-4 cm) cerebral contusion? ✓ ✓ ...... ANSWER ....... A: The correct code is 140606.3 which identifies a single "small" contusion. Q: What is a torn septum pellucida and which code would you use if there was as associated IVH? ✓ ✓ ...... ANSWER ....... A: The septum pellucida is the structure that separates the anterior horns of the lateral ventricles, so
when it is torn we would expect to see intraventricular hemorrhage. The cerebral laceration should be coded (140688.3) in addition to the IVH. Although the IVH is a sequela of the tear, it is a codeable sequela Q: Is a pterygoid fracture considered to be a skull base fracture? ✓ ✓ ...... ANSWER ....... A: The pterygoid plates are a part of the sphenoid bone and are therefore part of the skull base. The exception to this is if they are included in a confirmed LeFort I fracture. In that case the injury is coded to the face and the sphenoid (base fracture) and the pterygoid is not coded additionally. Q: What is Uncal herniation ✓ ✓ ...... ANSWER ....... A: Brain stem compression; includes transtentorial (uncal) Q: What constitutes a subacute SDH? ✓ ✓ ...... ANSWER ....... A: Subacute subdural hematomas are defined arbitrarily as those that present between 4 and 21 days after injury. Q: What constitutes a chronic SDH? ✓ ✓ ...... ANSWER ....... A: Chronic subdural hematomas are arbitrarily
Q: A patient is admitted after an assault with a baseball bat to the head; among his injuries, a tympanic membrane rupture; How do you code this injury? ✓ ✓ ...... ANSWER ....... A: a tympanic membrane rupture is coded as 240216.1; note that frequently this injury is also associated with a basilar skull fracture so look for that on the CT scan or a clinical diagnosis of such. Q: A woman is in MVC with facial trauma multiple fractures of R orbit complains of loss of visual acuity in R eye. Her globe is intact but a hole in her R macula is discovered. Please code this injury to the eye. ✓ ✓ ...... ANSWER ....... A: Code 240904.2; Macula: hole Q: How would you code this finding? Acute left parasymphyseal fracture of the left hemi mandible. Fracture of the angle of the right hemi mandible. When reviewing the physician notes they state, "right angle and left parasymphyseal displaced mandible fractures." ✓ ✓ ...... ANSWER ....... A: The mandible is one of the ring-like bony structures that only receives 1 code. You should code it to the largest mass area. As you go down the codes under mandible, they increase in body mass, so you would use the code for symphysis/parasymphysis 250614.
Q: If your CT reported the following injuries right mandibular condyle, ramus and coronoid process fracture. Complex right maxillary fracture involving the anterior, medial and lateral and superior walls (orbital floor), fracture of right pterygoid plates and orbital fractures involving the apex, lateral, superior and inferior walls with complex fractures of the frontal bone" How would you code this case? ✓ ✓ ...... ANSWER ....... A: This sounds like a panfacial fracture since it involves all 3 regions of the face, and it is not a LeFort. If it involves both sides of the face it would meet the definition of multiple and complex fractures for panfacial. If unilateral, you should code each. Q: A patient involved in an ATV wreck has multiple facial fractures that do not meet the criteria for a LeFort fracture diagnosis. How should they be coded? The highest AIS severity code for individual facial fractures is .2 and that doesn't seem to reflect the severity of these multiple fractures. ✓ ✓ ...... ANSWER ....... A: Panfacial fracture is defined as "multiple and complex fractures that may involve middle and lower face, upper and middle face, or all three, but not LeFort fractures." It assigns severity codes of .3 or .4 depending on the amount of associated blood loss.
the type and amount of displacement of zygomatic fractures. The Knight North scale describes increasing severity from I to VI. Q: How do you code a temporal artery laceration? ✓ ✓ ...... ANSWER ....... A: Code the temporal artery to the FACE. 220200.1 reads "External carotid artery branch(es) laceration NFS [includes facial, temporal, and internal maxillary]. The two codes indented under that code apply as well. Q: What is the correct code for a zygomatico-maxillary complex (ZMC) fracture? ✓ ✓ ...... ANSWER ....... A: The zygomatico-maxillary complex (ZMC) describes the area which includes the zygomatic arch where it joins the maxilla and the frontal skull. It describes a region of the face and is not a description of the severity of the fracture. The correct code is 251800.1. Q: Where is the cribriform plate? ✓ ✓ ...... ANSWER ....... A: Cribriform plate is part of the ethmoid bone
Q: Where would you code CT scan of the face indicating a fracture of the lamina papyracea. ✓ ✓ ...... ANSWER ....... A: 251231.2; The lamina papyracea is the medial wall of the orbit. Q: If you have a LeFort I fracture and bilateral mandibular fractures how would you code the injury? ✓ ✓ ...... ANSWER ....... A: The LeFort I fracture does include the maxillary alveolar process, but NOT the mandible so you would code that separately, depending upon the type of mandibular fracture. Remember that the mandible only gets one code even if the fractures are bilateral. Q: What is a vomer bone and where is it coded? ✓ ✓ ...... ANSWER ....... A: Gray's Anatomy lists the vomer as one of the facial bones. Specifically it is the posterior part of the nasal septum. So the code would be 2510006.2. Q: A patient has a left vertebral artery dissection. Two days later the patient has an MRI that showed a brain stem infarction. Does the brain stem infarction get coded, since it didn't show up until 2 days later and could possibly be caused by the dissection." What is the correct code for this
