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Detailed coding guidelines and conventions for the abbreviated injury scale (ais) used in the caiss certification program. It covers a wide range of traumatic injuries, including those to the head, neck, thorax, abdomen, and extremities. The proper coding for various anatomical structures, injury types, and associated medical terminology. It serves as a comprehensive reference for healthcare professionals responsible for accurately documenting and coding traumatic injuries in patient records. The information presented can be valuable for medical students, trauma specialists, and anyone involved in the assessment and management of trauma patients.
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Branches of vessels - Answer these are not coded unless they are named or listed with a specific descriptor Boxed and Bold Text - Answer Represent AIS coding rules and conventions Brackets - Answer Denote inclusive or exclusive information Semicolons - Answer Separate injury descriptors that are comparable in severity Bold Type - Answer Identifies anatomical structure Supratentorial - Answer Described as blood along the tentorium and is coded to the Cerebrum Temporal Bone - Answer Consists of three portions: the squamous/shell-like portion (in vault), and the mastoid and petrous portions (in base) of the skull Interpeduncular Fossa (Cistern) - Answer Coded as hemorrhage in the brainstem Pterygoid Plates - Answer Is part of the sphenoid bone and is coded to the skull base if in isolation (not coded additionally if part of a LeFort fracture) Skull Base - Answer Occipital Condyles are coded to what part of the skull?
Vasospasm - Answer Is a transient occurrence that may or may not show up on imaging and is the result of injury to the artery and cannot be coded Laceration - Answer Unless contusion or laceration is specified, code total loss of nerve function (paralysis) as a Contusion - Answer Unless contusion or laceration is specified, code partial loss of nerve function (paresis) as Optic Nerve (II) - Answer Includes chiasm and tracts Brain Stem - Answer Includes the hypothalamus, medulla, midbrain, and pons Cerbellum - Answer Infratentorial and posterior fossa are coded to what part of the brain Hematoma NFS - Answer Extra-Axial is coded to Skull Vault - Answer This part of the skull includes the frontal, occipital, parietal, and temporal bones Laceration - Answer Soft Palate perforation is coded as a Fracture - Answer Hard palate perforation is coded as a Mouth Injury - Answer Caustic injury to the mouth is coded as Eye-NFS - Answer Retrobulbar hemorrhage should be coded to Skin Avulsion - Answer Nose amputation is coded as
Persistent Air Leak - Answer Descriptor for as an air leak in the thorax that lasts more than 48 hours and is more than just a simple pneumothorax Intracardiac Septum - Answer Also known as Intraventricular septum Degloving - Answer coded as avulsion Thoracic injury - Answer refers to thoracic cavity injury Traumatic pneumatocele - Answer is a sequela and is not coded hemomediastinum - Answer referred to as mediastinal hematoma Scattered - Answer these types of lung contusions should be coded to the unilateral or bilateral NFS code myocardial injury- major - Answer thorax injury that must be substantiated by surgery, autopsy, or EF <25%, and no CAD Flail Chest - Answer 3 or more ribs fractured in more than one location (posterolateral and anterolateral) and resulting in paradoxical chest movement serosal tear - Answer coded as a partial thickness injury Colon - Answer coded to the cecum