Editors, 2000 edition: Veridian Engineering P.O.

Box 400 Buffalo, New York 14225

Authors, 1990 edition (1996 Update): Association for the Advancement of Automotive Medicine 2340 Des Plaines River Road, Suite 106 Des Plaines. Illinois 60016

Prepared for: U.S: DEPARTMENT OF TRANSPORTATION NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION WASHINGTON, D.C. 20590

ACKNOWLEDGMENTS
The editor of the 2000 NASS Injury Coding Manual gratefully acknowledges the cooperation of many individuals and organizations which provided support and technical guidance. A note of appreciation to Ms. Ruth Ann Isenberg, Mr. Lee N. Franklin, and Mr. Gary R. Toth of the National Highway Traffic Safety Administration and Ms. Elaine Petrucelli of the AAAM injury Scaling Committee for their support and assistance. Gratitude is expressed to Ms. Connie Volkots of Veridian Engineering (Zone Center 1) and Ms. Paula Pitzer and Mr. Peter Pfeiffer of KLD Associates (Zone Center 2) for their technical review and helpful suggestions. A particular note of thanks to Ms. Elizabeth S. Bellis who contributed significantly to the publishing of this manual. Evelyn J. Benton

TABLE OF CONTENTS
PART I INJURY SCALING - HISTORY, DEVELOPMENT AND PURPOSE Abbreviated Injury Scale (AIS) ...................................... MaximumAIS ................................................... Injury Severity Score (ISS) ......................................... Purpose of Injury Scaling .......................................... INJURY CODING-AIS DICTIONARY.. Contents and Fonat of the Dictionary Numerical Injury Identifier .. Examples of Injury Coding . Special Instructions for Coding Pediatric and Brain Injuries Special Guidelines for Coding Injury versus Outcome of Injury Final Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .._..... General Nass Injury Coding Rules ...... ...... ...... ...... ...... ...... ...... ...... ........ ........ ........ ........ ........ ....... ....... ....... ....... ....... ....... ....... ....... 1 1 2 2 2 5 5 6 9 11 12 13 15 27 29 43 51 63 71 105 07 111 115 121 133 149 153 157 169 179 160 168 193 194 195 195 196 197 198 202 205 206

PART II

AIS DICTIONARY LISTING AND CODES ................................. PART III HEAD (Cranium and Brain) ................................................ GUIDELINES ON WHEN TO USE LOSS OF CONSCIOUSNESS INFORMATION FACE (Includes Ear and Eye) ............................................... NECK ................................................................. ............................................................. THORAX.. ABDOMEN AND PELVIC CONTENTS ........................................ CERVICAL SPINE ........................................................ THORACIC SPINE ....................................................... LUMBARSPINE ......................................................... UPPER EXTREMITY ..................................................... LOWER EXTREMITY ..................................................... EXTERNAL - Skin and Subcutaneous Tissue .................................. BURNS ................................................................ OTHER TRAUMA ........................................................ PART IV PART V A. 6.1. 0.2. 8.3. C. Cl. c.2. c.3. D. E. DICTIONARY INDEX . . .._........._..........._..._. ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ...... ...... ...... ...... ...... ...... ...... ......

MEDICAL TERMINOLOGY REFERENCES Glossary of Anatomical & Injury Terms Abbrewatlons Hospital Symbols ....................... Weights and Measures .................. Deciphering Medical Teninology .......... Prefixes .............................. Roots ................................ Suffixes ............................... Lay Terminology - Nass Injury Synonym List Fractures ............................. SOURCE OF ILLUSTRATIONS SUGGESTED REFERENCES ........... .............

APPENDIX A APPENDIX B

ii

LIST OF ANATOMICAL
Abdominal Organs ...................... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ............ ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ............ ......

ILLUSTRATIONS
...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ...... ....... ...... ....... ....... ....... ....... ...... ...... ....... ....... ...... ...... ....... ....... ...... ...... ...... ...... ...... ....... ....... ....... 98 148 47 140 56 46 45 57 124 137 50 80 142 153 99 57 151 152 149 150 113 81 66 44

Anatomical Position and Regional Names ... Sony Skull ............................ BonyPelvis Bony Face ........................... ...........................

Brain ................................ Distribution of Cranial Nerves ............. Ear ................................. Extremities (Upper) Extremities (Lower) .................... ....................

Eye ................................. Heart - Intracardiac Structures Layers of the Skin ...................... Major Muscles Male/Female ........................ - Pelvic Organs .............

Mouth ............................... Nerves, Anterior View ................... Nerves, Posterior View .................. Principal Arteries Principal Veins Spinal Column ...................... ........................ ........................

Thoracic Cavity ........................ Throat ............................... Venous Drainage of the Head

PART I
INJURY SCALING-HISTORY, DEVELOPMENT AND PURPOSE

The overall goals of highway crash research are to reduce fatality, mitigate injury, and decrease economic loss to society. Highway crash reporting and investigation is not a new phenomenon, but only until relatively recently was attention devoted to developing a system of rating the severity of motor vehicle crash related injuries that could be utilized by medical and non-medical researchers alike. Not only would such a system provide uniformity among coders, but also would aid immeasurably in establishing uniform data bases for crash injury statistics, no matter where or by whom they were collected.

Abbreviated

lniurv Scale (AIS

Until 1971, no single comprehensive system for rating tissue damage existed that was acceptable to both physicians and others involved in crash research. A number of scales had been developed by universities, independent researchers, safety organizations and the motor vehicle industry, but almost all of the scales had serious shottcomings from the medical standpoint. In 1971, the first Abbreviated Injury Scale (AIS) was published underthe auspices of the joint Committee on Injury Scaling, comprised of representatives of the American Medical Association (AMA), American Association for Automotive Medicine (AAAM), and the Society of Automotive Engineers (SAE). The 1971 AIS was the product of work begun in 1967 when the AMA sponsored an intensive three-day workshop for physicians, engineers and researchers concerned with crash injury tolerance to see if a single injury scale could be developed to serve the needs of all disciplines involved. In addition to developing a single uniform scale, the AIS attempted to standardize the language used to describe injuries to enable valid statistical evaluations among crash researchers anywhere in the world. Five years later in 1976, the Abbreviated Injury Scale was published in manual format, which included more than two hundred injury descriptions and severity codes as part of the AIS Dictionary. Since 1976, the AIS has been accepted and used by crash researchers in many parts of the world. Based upon the results of this widespread usage, the Abbreviated Injury Scale underwent significant revision during 1978-1979, especially in the area of brain injuries. AISretained the original injuty code descriptions which were adopted with slight modification for coding convenience, for NASS. Many of the injury descriptions were redefined in AISto meld with current medical terminology and to provide a hierarchy of severity levels for some injuries in the thoracic, abdominal, and vascular areas. This NASS Injury Coding Manual is based upon AIS(Update 98), the most recent and up-to-date Abbreviated Injury Scale Dictionary published by the Committee on Injury Scaling. AISincludes specific rules within the dictionary itself to solve some coding dilemmas such as when there is a choice of descriptions or body regions to which an injury can be assigned, or when clinical diagnosis can be used. Synonyms and parenthetical descriptions are used extensivelyto allow the coder to appropriately match the injuty description in the hospital chart with one in the AIS dictionary. These coding rules, together with coder training, should improve intra- and inter-rater reliability. The AIS(Update 98) offers more assistance to coders by providing extensive coding rules and instructions throughout the dictionary. The update also includes the Organ Injury Scale (01s) scores developed by the American Association for the Surgery of Trauma where these scores have appropriate matches to existing injury descriptions in AIS-90. Such matches occur primarily in the THORAX and ABDOMEN AND PELVIC CONTENTS sections. It is not the purpose of this manual to provide an in-depth histoty of the AIS. Additional information is available upon request from the American Association for Automotive Medicine, Suite 106, 2340 Des Plaines River Road, Des Plaines, IL 60018.

Maximum

AIS

AISrecommended the use of an Overall AIS (OAIS), which was an assessment of the total effect of multiple injuries on a victims body and systems. It was intended not as the sum, median, or average of the individual injury codes, but rather a clinical iudaement or estimate made bv a coder exoerienced in the treatment of trauma, preferably a physician. AISrecommended that the highest AIS be used as the surrogate for assessing overall injury severity for victims with multiple injuries. Field research overthe last several years has shown that the OAIS is too subjective to provide reliable assessments of overall injury severity, especially where medical knowledge or expertise is not available. Experience in using the Maximum AIS (MAIS) [highest single AIS code for a patient with multiple injuries] in place of the OAIS has shown it to be a more objective method that does not require the judgement of the researcher. In 1981, The Probability of Death Score was introduced. It is mentioned here only to alert the NASS coder that such a system does exist and to provide at least a thumbnail sketch of its purpose should the NASS coder come upon it in other information on injury scaling.

lniurv Severitv

Score (ISS)

The Abbreviated Injury Scale is a system for rating the severity of individual injuries. It is recognized, however, that motor vehicle crash victims sustain multiple injuries in more than one body region. As with the aforementioned Maximum AIS, computation of the ISS is not required in NASS. The Injury Severity Score (ISS) is a mathematically derived code number based on the AIS. It is a sum of the squares of the highest AIS codes in each of the three most severely injured body regions. A detailed discussion of the ISS is contained in the following article: The Injury Severity Score: A Method for Describing Patients with Multiple Injuries and Evaluating Emergency Care, Baker, S.P., et al., JOURNAL OF TRAUMA, March 1974. t....... This brief introduction is intended to acquaint the NASS injury coder with the major systems currently being used in motor vehicle crash-related injury scaling. It is not intended as a comprehensive background, and the researcher is invited to consult the Suggested References in the Appendix for additional information.

Purpose

of lniurv Scalinq

Injurycoding isashort-hand wayof objectively describing the nature and severity of injuries sustained in traffic accidents. Though occasionally confusing to some, the coding of injuries and their sources is one of the more important tasks the injury coder faces in NASS. The types of injuries that can occur and their causes can be analyzedforthe purpose of designing more effective countermeasures to reduce the frequency and severity of injuries in accidents. NASS is a statistical study of nationwide highway accidents. Statistics rely on accurate and consistent encoding of raw data to produce reliable, useable results. As a step toward this goal, the development of this Injury Coding Manual promotes consistency among coders through the standardization of codes and coding procedures. No manual, however, can feasibly incorporate all injuries and combinations thereof. Hence, the coder must develop a keen sense of judgement and attempt to internalize the logic behind injury coding.

Since statistics necessarily reflect the data inputted, the statistics that are generated from this data for analysis can only be as good as the data provided by& researcher. It is hoped that all individuals will take personal responsibility to ensure that they collect and code high quality injury data. Only through the collection and coding efforts of ggr& researcher and injury coder can the statistics accurately reflect reality. And only then can the ultimate goal of a safer driving environment for all be attainable.

PART II
INJURY CODING-AIS DICTIONARY

The AIS Dictionary contained in this NASS Injury Coding Manual is based upon the AIS(Update 98). The most current and up-to-date Abbreviated Injury Manual was developed by the joint Committee on Injury Scaling. Aithough this manual was developed primarily for NASS and contains information supplementary to what is contained in AIS(Update 98). it does not deviate in AIS codes and other information essential to the injury system unless noted in the text. Contents and Format of the Dictionary The AIS Dictionary is divided into the following sections: Head (Cranium and Brain) Face Neck Thorax Abdomen and Pelvic Contents Seine Upper Extremity Lower Extremity External/Skin Burns Other Trauma

Within each section, except the SPINE, EXTERNAL, BURNS, and OTHER TRAUMA, injury descriptions are alphabetized by specific anatomical parts and are categorized in the following order: Whole Area, Vessels, Nerves, Internal Organs, and Skeletal. In addition, the UPPER EXTREMITY and LOWER EXTREMITY sections have a subsection on Muscles, Tendons, and Ligaments. In most cases, the severity level in each anatomical category goes from least severe to most severe. Valid Aspect Codes for each section are listed at the beginning of the particular sections of the Dictionary. Relevant anatomical illustrations are located at the end of speciiic sections. AddRional illustrations can be found at the end of the Part Ill, AIS Dictionary Listing AndyCodes, ,pages 158-167. The Anatomical Index which follows the Dictionary lists all of the injury descriptions in AIS(Update 98) in alphabetical order, by the body region in which the injury is located, and the page on which it can be found. Each injury description has been assigned a unique 7-digit numerical code (see pages 6-8). The single digit to the right of the decimal point is the AIS number, according to the following severity code: AIS Code 1 2 3 4 5 6 7 Descriotion Minor Moderate Serious Severe Critical Maximum Injured Unknown Severity

Signs and symbolsare

used throughout the dictionary to help the coder. Examples of each follow:

Brackets

[ ] give specific instruction or direction. Example: Alvaolar ridge (bone) fracture with or without injury to teeth [Do not code teeth separately where these occur simultaneously.]

Parenthesis

( ) give synonyms or further descriptive information. Example: Pancreas laceration stellate; tissue loss) complex (avulsion; massive; rupture:

Boxed Information

gives coding guidelines. VESSELS

Example:

I
Diaaonal Numerical

Descriptions for vessel lacerations distinguish between complete and incompleW transection See footnotes g and h. The terms laceration, puncture and perforation are oftentimes used interchangeably to
describe vessel injuries and are of the same severity. When perforation or puncture is used. code as laceration.

means and/or, i.e., one or more of the descriptors must be present. Example: Tibia fracture NFS openldisplacedlcomminuted

lniuw Identifier

AISintroduced a unique B-digit code for each injury diagnosis to assist in computerization of data. The addition of injury descriptions in AIS-90, especially for the brain and extremities, has required a more flexible numerical system than that used in 1985. In AIS-90, each injury description is assigned a unique 6-digit numerical code in addition to the AIS severity score. As summarized in the diagram below, the first digit identifies the body region; the second digit identifies the type of anatomic structure; the third and fourth digits identify the specific anatomic structure or, in the case of injuries to the external region, the specific nature of the injury: the fifth and sixth digits identify the level of injury within a specific body region and anatomic structure. The digit to the right of the decimal ooint is the AIS score.

Body Region Type of Anatomic Structure Specific Anatomic Structure Level AIS Aspect

--.-

An additional digit has been added to identity the Aspect. This code measures the location of the injury being reported. It is a refinement of the first number, i.e., a suffix to the body region. It has meanrng only in relationship to the body region to which it is applied. The Aspect Code cannot be used independent of the body region for coding or analysis, Note that while the combination of Body Region codes do not always precisely pinpoint the location of an injury, they do provide additional resolutron. The following conventions are used in assigning the numerics to specific injury descriptions: 1. Body Region 1 2 3 4 5 6 7 6 9

Head Face Neck Thorax Abdomen Spine Upper Extremity Lower Extremity Unspecified

2.

Type of Anatomic Structure 1 Whole Area 2 Vessels 3 Nerves Organs (incl. muscles/kg.) 4 Skeletal (incl. joints) 5 6 Head-LOG 9 Skin Specific Anatomic Structure or Nature (refer to appropriate section below) Whole Areg (Injury to External Body) Skin - Abrasion 02 - Contusion 04 - Laceration 06 - Avulsion 06 Amputation 10 Burn 20 Crush 30 Degloving 40 Injury - NFS 50 Trauma, other than mechanical 90

3.

Head - LOC 02 04,06.08 10 m 02 04 06

Length of LOC Level of Consciousness Concussion

Cervical Thoracic Lumbar

Vessels. Nerves. Oraans. Sbletal-Bones. Joints are assigned consecutive two-digit numbers beginning with 02. 4. Level Specific injuries are assigned consecutive two-digit numbers beginning with 02. To the extent possible, within the organizational framework of the AIS, 00 is assigned to an injury NFS as to severity or where only one injury is given in the dictionary for that anatomic structure. An injury NFS as to lesion or severity is assigned level 99. 5. AIS AIS Code 1 2 3 4 5 6 7 6. Aspect 1 2 3 4 5 6 7 a 9 0 R L : A P S iJ W Right Left Bilateral Central Anterior/front/ventral Posterior/back/dorsal Superior/upper InferiorAower Unknown/multiple regions Whole region

Minor ~~~ Moderate Serious Severe Critical Maximum Injured Unknown Severity

Examules

of lniurv Codinq

Below are two examples of injury descriptions taken from a medical report. Instructions for coding the injuries follow the descriptions. Examole 1: The lateral right 4, 5, and 6 ribs are fractured. pneumothorax. There was no evidenceof

A simple method of locating the correct section of the manual is to go to the Dictionary Index and look up the key word rib. The coder will find that the rib cage is located under the THORAX section on page 83 (see below).

CODE

ASPECT

INJURY DESCRIPTION

450299.1 450202.1 450210.2 450211.3 450212.1 450214.3 450220.2 450222.3 450230.3 450232.4 450240.4 450242.5 450250.3 450252.4 450260.4 450262.3 450264.4 450266.5

Rib cage NFS [Use one line of code - rib fxs] contusion

multiple rib fractures NFS [Use if no other information is available. See footnote before coding in this section.] with hemo-/pneumothorax 1 rib with hemo-/pneumothorax (O/S Grade I)

2-3 ribs any location, or multiple fractures of single rib, with stable chest or NFS (O/S Grade I, /I or 111) with hemo-/pneumothorax > 3 ribs on one side and 5 3 ribs on the other side. stable chest or NFS with hemo-/pneumothorax > 3 ribs on each of two sides, with stable chest or NFS with hemo-/pneumothorax open/displaced/comminuted (any or combination: t 1 rib)

with hemo-/pneumothorax flail (unstable chest wall, paradoxical chest movement) unilateral or NFS (O/S Grade 111 IV) or without lung contusion with lung contusion 3 (O/S Grade 111 IV) or

(OIS Grade 111 IV) or

bilateral flail with or without lung contusion (O/S Grade V)

Under the-Rib cage section, the coder must choose the appropriate code based upon other information in the medical report. In this instance, we know that there are three rib fractures wirhout pneumothorax. This would point to the code 450220.2 (the next code would be chosen if pneumothorax was present). The last decision to be made concerns Aspect - the location of the injury. In this case, we know that the fracture occurred on the right side because the medical report states this. Therefore, the final correct code for this injury is 450220.2,1. Examole 2: There is a subluxation of the sternoclavicular displacement of the clavicle. joint on the right with anterior

The coder should note the key words sternoclavicular joint and go to the Dictionary Index to look up this term. The coder will find that stemoclavicular joint is listed as being under the UPPER EXTREMITY section on page 128 of the manual. If the coder is unfamiliar with the word subluxation, he/she should look up the word in Part Ill, The Glossary of Anatomical and Injury Terms. Subluxation is defined as an incomplete or partial dislocation. This definition enables the coder to correctly assign the code 751230.2 (see below).

CODE

ASPECT

INJURY DESCRIPTION

751299.1 751210.1 751220.1 751230.2 751240.2

Sternoclavicular contusion sprain dislocation

joint NFS

laceration into joint

The medical report states that the injury occurred on the right side of the body, so Aspect is coded as 1. Therefore, the complete code is 751230.2,1.

10

Scecial

Instructions Pediatric

for Codina Pediatric

and Brain lniuries

lniurieg

Age can be an important variable in relation to injury severity. It is well documented that an older patient will have a higher probability of unfavorable outcome as compared to a healthy younger person given the same injury seventy. Very young children may be similarly worse off. AISinjury descriptions and their AIS severity were reviewed by a group of pediatric trauma surgeons to determine which did not apply to the pediatric population. It was determined that all but a few adequately reflected relative severity of injuries in young children. The exceptions related to the size of brain hematomas, blood loss in severe lacerations, or internal bleeding (by volume), due to abdominal or thoracic injuries. The exceptions were incorporated into AISand are in this 2000 NASS Injury Coding Manual.

Analysis of various data bases have indicated that serious brain injuries (AIS L 3) were undercoded when compared to injuries in other body regions. To correct this inconsistency, the Brain section was expanded in AISto include brain contusions with a range from AIS 3 to AIS 5 that accounts for size, location and multiplicity of these injuries. The volume, size and location descriptors for cerebral and cerebellar hematomas have also been revised to more adequately reflect the relative severity of these injuries. The terminology to describe these injuries is clinically more acceptable.

11

It should be emphasized that the AIS codes specific individual injuries only (i.e., a single AIS score for each injury for any one person). Also, the AIS clearly distinguishes between an injury, which is coded, and the result(s) of an injury which is not coded. For example, the novice coder may want to code pain in terms of injury coding. It is important to note that pain is a conseouence of trauma. It is the jgjyry (a result of the trauma) that is causing the pain that the coder needs to code. This principle was employed so that the AIS can be used as a measure of the severity of the injury itself and not as a measure of consequences, impairments, or disabilities that result from the injury. Consequences of several injuries have been included in the AIS as part of certain injury descriptions in order to specify injury severity more precisely. For example, in the THORAX section, hemothorex or pneumothorax is not an injury per se, but resufts from fractured ribs or other chest trauma such as lung laceration. It is the fracture or laceration that is coded, but it is acknowledged by increasing the AIS that the existence of hemo-l pneumothorax makes the injury more serious. Another example of deviation from this general philosophy occurs in the HEAD section, which must account for non-anatomic brain injuries (commonly called concussions) because clinical signs and symptoms are the & means by which the severity of certain injuries is measurable. Outcomes that may be related to injuries but v ache asphyxia (suffocation) deafness death drowning include: obstruction parn spontaneous abortion swelling tenderness

It is acknowledged that research studies conducted for specific purposes may have need for information on various outcomes, including those listed here. Individual data users are urged to develop their own designs for inclusion of such information. The Injury Coding Manual suggests that this type of information may be recorded as data items for ready use in special studies or for future retrieval as needs arise. j&?&r no circumstances, however, should outcome be the basis for assionina the AIS code unless soecificallv listed in the Dictionanl, Source of further information: LAY TERMINOLOGY - NASS LESION SYNONYM LIST (Part V, Section D. p. 198)

Hemorrhage manual.

and swelling are exceptions for the brain and may be coded where indicated in the

12

Final Notes The Injury Coding-AISDictionaryhas beendesigned toeliminateas much guessworkas possibleand to enable even the inexperienced coder to acquire an adequate understanding of injury coding within a short time. The sections entitled DICTIONARY INDEX (Part IV, p.169) and MEDICAL TERMINOLOGY REFERENCES (Part V, p. 179) should be useful tools to improve the coders injury coding skills. When a case occurs in which the coder feels the manual is inadequate, other Zone Center and NHTSA personnel will be consulted to devise a uniform code. If the problem requires medical determination, then the Committee on Injury Scaling will be contacted. A number of new injury codes and descriptions appear in this 2000 Injury Coding Manual. These codes and descriptions represent additions/revisions adopted by the Committee on Injury Scaling and/or approved by NHTSA for use in NASS. Coding rules and instructions have been combined into the section entitled General NASS Injury Coding Rules. Coding rules and instructions relevant to specific sections of the Manual are included at the beginning of that section.

13

Table of NASS Injury Coding Rules and Pages

lniutv Codina Rules 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 20. 29. 30. 31. 32. 33. 34. 35. 36. 37. Injuries ....................................................... .......................................................... DoNotDoubleCount Coding PAR Injury Data ........................................................ Unsubstantiated Presumption of No injuv or Unknown if injured from PAR. .......................... ............................................... Injury vs Consequences/Outcomes .................................................... Not Further Specified (NFS) AIS Uncertainty Rule .......................................................... CodingAIS-6 ................................................................ Bilateral Injuries .............................................................. Coding Same Type lntegumentary Injuries ......................................... Undetermined Type of Anatomic Structure-Code Skin ............................... ........................................................... SoftTissueTrauma ........................................................ LacerationTypelnjuries ........................................................... DicingTypelnjuries Valid Codes and Aspects for Seat Belt Contusions ................................... Burns ...................................................................... Whiplash ................................................................... .............................................................. StrainvsSprain Crush ...................................................................... ............................................................... OpenFracture ............................................................... Multiple Fractures in a Bone .................................................... .................................................. Costal Cartilage Fracturenear ....................................................... Joint - Ligament Injuries. Coding Brain Injuries ............................................ .............................................................. InternalOrgans Injuries Involving Skin and Internal Structures ....................................... Blood Loss .................................................................. Transection ................................................................. ...................................................... Tears:AnlnjurySynonym Multiple Vessel or Nerve Injuries ................................................. ................................................................ VesselInjury Side Interior Surface Contacts ................................................... Injuries Produced by Objects, on the Occupant ...................................... Direct vs Indirect Injury ........................................................ Non-Contact Injury Sources -- Codes fire in vehicle, flying glass, other noncontact injury source, and air bag exhaust gases .......................... .............................................................. AirBagRelated I ............. SkullFractures

ml!? 15 15 15 15 15 16 16 16 16 16 17 17 17 17 17 17 18 18 18 19 19 20 20 20 20 21 21 21 22 22 22 23 23 23 23 24 25

14

GENERAL NASS INJURY CODING RULES

Instructions are included throughout the AIS dictionary to help coders make appropriate decisions concerning injury diagnoses. These are not repeated here. A number of coding principles, however, apply across body regions. The following rules should be learned and applied diligently.

1.

Unsubstantiated

Injuries injuries. If the words, questionable, possible, or probable are used,

NASS does not code unsubstantiated do not code the injury.

2.

Do Not Double Count

The injury coder should take care not to code the same injury twice. When information for the same injury is available from two different sources (e.g., interview and medical report) only the injuries not already coded from medical records should be coded.

3.

Coding

PAR Injury Data

Data from the PAR are to be coded if specific injury descriptions are detailed and not reported from another source. If the PAR provides enough specific information to identify an injury description, code that Number of Injuries for This Occupant using the NASS maininjury program. Example: Minor bleeding, head: 190099.1,9

If the PAR indicates complaint of pain, Not injured, or Unknown if injured, or if a K, A, B, or c severity rating is the only information available and no injury description is identified, DO NOT open NASS maininjury for this occupant. Code Injured, details unknown in NASSmain (Occupant form/Injury tab/Zone subtab) if the PAR only indicates K, A, or B and no injury description is identified.

4.

Presumption

of No injury or Unknown

if injured

from PAR.

If the PAR is blank where the injury severity is assessed and the person was at the scene during the police investigation, code: Not injured. However, ifthe person was not present during the police investigation, code: Unknown if injured.

5.

Injury vs Consequences/Outcomes of injury

Excluding Other Trauma indicated on page 157. the AIS does not assign codes to consequences (e.g., blindness), but rather to the injury per se (e.g., optic nerve avulsion).

Foreign bodies (e.g., glass, gravel, dirt, etc.) are not injuries and therefore are not coded. However, they may be associated with an injury. Surgical procedures and other treatment interventions should not be used to determine the severity of an injury. No injury should be upgraded based only on intervention.

15

6.

Not Further Specified

(NFS) is lacking.

The use of not further specified (NFS) allows for coding injuries when detailed intonation

Injury unspecified means that an injury has occurred to a specific organ or body part, but the precise injury type is not known. For example, a kidney injury could be a contusion or a laceration, but this information may not be available. In this example, the kidney injury is coded as NFS. Assign the Injury Level 99 when NFS is used. [See Numerical Injury Identifier, page 6.1 Sever@ unspecified means that a specific injury (e.g., laceration) has occurred, but the level of severity is not specifically given or is unclear. In this example, the injury should be coded as laceration NFS. To the extent possible within the organizational framework of the AIS, 00 is assigned to an injury NFS as to severity. [See Numerical Injury Identifier, page 6.1 Use of NFS should not be confused with AIS code 7 which is assigned in those cases where trauma has occurred and no information is available regarding specific organ within a region, For example, blunt/traumatic abdominal injury is assigned code 515099.7,O.

7.

AIS Uncertainty

Rule

If there is any question about the seventy of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injurys category).

8.

Coding AISis not an

AIS- is used only for injuries specifically assigned severity level 6 in the AIS. The use of AISarbitrary choice simply because the patient died. An AIS- injury is never upgraded to an AIS-6.

9.

Bilateral

Injuries

Bilateral injuries are coded separately for organs such as the kidneys, eyes, and ears unless the dictionary specifically allows for coding as a single injury (e.g., lung injuries). Maxillae, mandibles, and the rib cage are coded as single structures. Example: Fracture right 6-7 and left 4-6 ribs. Code 450220.2,3 (2-3 ribs any location).

10.

Coding Same Type lntegumentary

Injuries avulsions. contusions, and

Use the following rules when coding same type injuries (i.e., abrasions, lacerations) to a body region. (a) 63 (4

When the same type soft tissue injuries occurs to 1. 2 aspects of a body region due to different contact points, code as separate injuries. Any number of same type soft tissue injuries resulting from the same contact point, occurring to a body region, exceot the face, will have one line of code. If same type soft tissue injuries resulting from the same contact point occur to the face and involve > 1 and 5 3 different aspects, code each aspect separately. If 2 4 different aspects, enter one line 01 code using aspect whole region. If any of the words multiple. numerous, several, or the plural of a lesion is used to describe same type soft tissue injuries @there are no details of location, enter one line of code from the EXTERNAL - Skin and Subcutaneous Tissue section (e.g., multiple contusions, Code 990400.1,O). If multiple same type soft tissue injuries occur to a specific body region g~9 the aspect is unknown, enter one line of code using the WHOLE AREA section for that body region (e.g., multiple facial abrasions, Code 290202.1 .O).

Cd)

16

11.

lJndeterr@ned

Type of Anatomic

Structure

- Code Skin

If the medical or interview information indicates a contused knee, elbow, wrist, ankle, etc., and does not specifically state whether the contusion is to the bone or joint, code the injury as integumentary/skin. If the contusion is known to be the bone or joint, code using the Skeletal or Skeletal-Joints Example: Contused right knee, 890402.1,1 Contused left knee joint, 850802.1.2 Section.

12.

Soft Tissue Trauma

If the medical indicates soft tissue trauma and a specific injury cannot be determined from the medical or some other source (e.g., interview), code the injury as a contusion.

13.

Laceration

Type Injuries flap

When an injury is described as a type of laceration (e.g., avulsion type laceration, laceration), use the avulsion code. For all ambiguous situations, use laceration over avulsion.

14.

Dicing Type Injuries (e.g., dicing type lacerations, dicing type abrasions)

When an injury is described as a dicing type code abrasion.

15.

Valid Codes and Aspects

for Seat Belt Contusions

For seat belt bruises due to a three-point system, code: Shoulder Chest Abdomen 790402.1 ,I ,2 (R.L) 490402.1,1,2,4,0 (R,L.C,W) 590402.1.1.2,4,7,8,0 (R.L,C.S,I,W)

Code 790402.1 ,1,2, 490402.1,4, and 590402.1,4 if unspecified. [Note: Code only those injuries that are consistent with the type of restraint worn (e.g., do not code 790402.1 or 490402.1 if only a lap belt was used).] 16. Burns

Thermal burn injuries should be coded using the Rule of Nines to assign the AIS severity level for (a) and (b) below. See the Rule of Nines diagram: (4 If only one body region is burned, use that body region code (e.g., burned upper extremity lo = 792002.1) and the appropriate aspect;

If more than one body region is burned, enter one line of code using the BURNS section (e.g., 2 burns to chest and upper extremities = 992018.3). Code the aspect as 0 (Whole Region).

17

17.

Whiplash

Cervical spine strain may, in some cases, still be referred to as whiplash. Whiplash is not a medical term and is not used in AI.590 (Update 98). If an injury is described as whiplash, it should be coded as; cervical spine strain (no fracture or dislocation) 640276.1,6 provided the guidelines below are followed: (a) Interviewee reports: ER reports: Code: Interviewee reports: ER reports: Code: Interviewee reports: ER reports: Code: interviewee reports: ER reports: Code: Whiplash. Pain, stiffness, or limited ROM in neck but does not diagnose strain. Do not code whiplash since ER, in essence, ruled it out. Whiplash. Neck supple and does not diagnose strain. Do not code whiplash since ER. in essence, ruled it out. Whiplash. (No medical attention sought.) Do not code whiplash. Whiplash. (No indication that neck was soecifically examined.) Code whiplash, data source interviewee (since ER did not rule out its possibility). For NASS purposes,

(b)

(c)

(d)

Neck injuries may sometimes be described as strains and sometimes as sprains. neck injuries should be coded as strains.

Interviewee allegations of upper back strain or lower back strain are subject to the same test i.e., (a) through (d) above as an interviewee reported whiplash.

18.

Strain vs Sprain

The following definitions have been used traditionally to differentiate sprain and strain injuries: &g&la ioint injury which causes pain and disability depending on the degree of injury to ligaments and muscle tendons near the joint. an injury to a muscle or musculotendinous unit that results from overstretching may be associated with a sprain or fracture. and

In common medical practice, however, physicians often do not adhere strictly to these definitions, and may use the terms interchangeably. Care should be exercised in selection of the proper code: use Sprain for joint injuries and strain for muscle injuries. Neck injuries may sometimes be described as strains and sometimes as sprains. neck injuries should be coded strains (see above definitions). For NASS purposes,

19.

Crush

Crush is a description of etiology, not of injury. However, it is included because it is used in medical charts. Crush for coding purposes means destruction of skeletal, vascular and soft tissue systems. The Crush injury description is used only when the injury meets the criteria in the dictionary. If the Crush code is used. individual injuries are not coded separately. In order to code Crush, the following specific information should be known: Head (Skull) -. numerous and extensive displaced or comminuted skull fractures accompanied extrusion or significant displacement of brain matter. by

18

Thorax (Chest) Extremity-

massive w

deformation of chest wall gig internal organs. (i.e., muscle and/or vascular

massive destruction of bone and internal structures system).

20.

Open Fracture The

An open (compound) fracture, by definition, means that the skin overlaying the fracture is lacerated. external laceration is implicit in the code for open fracture and is not coded separately. Exception: open fracture of the skull with lacerated brain matter (code as two injuries).

21.

Skull Fractures

The skull bones are divided into two areas of interest (i.e.. vault and base). The entries in the column entitled Skull Bones are intended to provide useful anatomical reference points that are often cited in medical records. Skull Bones Frontal bone including frontal sinus and not otherwise specified Temporal bone, including not otherwise specified Parietal bone (entire bone) Occipital bone, including not otherwise specified

Area Vault

Subarea Frontal TemporaU Parietal Occipital

Asoect(s) 5 (4 12 (Iv-) 6 (P)

Base

Anterior

8 (1)

Middle

8 (1)

Posterior

8 (1)

Frontal bone, orbital plate--anterior cranial fossa: right and left Ethmoid bone, cribriiorm plate Sphenoid bone, body and lesserwings --forms a portion of anterior cranial fossa Sphenoid bone, sella turcica Sphenoid bone, greater wings _- forms a portion of middle cranial tossa: right and left Temporal bone -- mastoid and squamous portions Temporal bone, petrous portion Occipital bone -- posterior cranial fossa: right and left Occipital bone, including ring area (i.e., foramen magnum)

Code only one fracture per aspect, assigning the code with the higher AIS; Maximum number of codeable skull fractures is five. Each aspect that was fractured is coded independently of whether the fracture in the aspect originated in the aspect or is a continuation of a fracture line(s) that originated in another aspect. If vault and base are involved record two lines of code. A skull fracture not otherwise specified as to location is coded: 150400.2,9 Multiple skull fractures (or one of its synonyms: several, numerous, etc.) where little specific information is available, are coded: 150400.2,9 Statements such as: massive skull fracture(s) information is available, is coded: 150404.3.? or extensive skull fracture(s), where little specific

19

22.

Multiple

F_ractures in a Bone

For multiple fractures to the same bone: (4 (4 If multiple fractures to the same bone are determined, then code each separately. If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one comminuted fracture. Assign one line of code with the appropriate AIS. Exceptions: mandible multiple fractures to the mandible are assigned one line of code. Choose the code and AIS for the more specific fracture type. Comminuted must be explicitly stated and is g&t derived from the presence of multiple fractures. Fractures to the right& left sides are assigned Aspect code 3 (Bilateral).

Fractures to the right side a inferior portion of the mandible (Le., mental protuberance area) are assigned Aspect code 1 (Right). Fractures to the left side m inferior portion of the mandible (i.e., mental protuberance area) are assigned Aspect code 2 (Left). Fractures to the right @@ left sides & a fracture to the inferior portion (i.e., mental protuberance area) are assigned Aspect code 3 (Bilateral). ribs . pubis skull multiple fractures to the same rib are assigned one line of code. Choose the code and AIS for the more specific fracture type. multiple fractures to the pubis (right, left, inferior, and/or superior) are assigned one line of code determined by the particular fracture type. see rule 21.

23.

Costal Cartilage

Fracture/Tear

A diagnosed costal cartilage fracture/tear should be coded as a rib fracture.

24.

Joint - Ligament

Injuries

Joint injuries involving fracture, dislocation, or fracture and dislocation of the extremities and associated ligament/tendon injuries do not require a separate code for the ligament/tendon injuries. If an injury is described as an avulsion/chip fracture, then treat this injury as a ligament injury and code the injury as a rupture (laceration).

25.

Coding Brain Injuries right hemisphere and left hemisphere (cerebrum),

The brain is divided into the following four suborgans: cerebellum, and brain stem.

Code one line of code per injury type per aspect for each brain suborgan. following the guidelines below: (a) (W (4 (d) (4 (f) If both edema and swelling are present, code once for presence. If surrounding edema is included for another injury, do not code edema/swelling. Do not code a brain stem hemorrhage if a contusion or laceration is present. Do not code a cerebellar or cerebral intracranial hemorrhage if brain stem injury is present (e.g., lacerated). If contusion & compression or contusion & hematoma are diagnosed code both.

If a crushed brain stem is coded, do not code brain stem contusions or lacerations. 20

(9)
04 (0 26.

When a brain lesion is described as an avulsion or transection. use the laceration injury description code. If it is unknown if a diagnosed cortical contusion is to the cerebellum or cerebrum, code to the cerebrum. Pituitary injury is code 140799.3,8

Internal Organs

Where the coding manual assigns a single line of code for multiple same type injuries, use that specific injury code when applicable. Example: 2 cm laceration right anterior ventricle, 3 cm laceration right atrium. Code multiple myocardium lacerations (441016.64).

For each major specific anatomic structure (organ) in the thorax or abdomen where one line of code does not represent multiple same type injuries, code one row per injury type, choosing the highest AIS for each particular injury type. Example: The spleen is markedly lacerated, and approximately 50% of it is avulsed and lying free in fragments in the abdomen. Code laceration, complex (544226.5,2).

For multiple internal injuries to an organ of the thorax (except heart) or abdomen, code one row oer iniurvtvue, choosing the highest AIS for each particular type. Example: Minor contusion spleen, one major laceration spleen, one superficial spleen. Code contusion (544212.2,2) and laceration (544226.4,2). laceration

The following terms may be used as a guide in differentiating between superficial, major, or complex lacerations or perforations to internal organs of the neck, thorax. and abdomen. However, the final choice of whether or not to use the superficial or major AIS levels depends on the term within the COntext of the & injury description.

Superficial Major _ Complex -

minor, partial thickness, small deep, full thickness, large, severe massive, tissue loss, segmental loss, stellate (abdomen)

NOTE: When organs are lacera&!pedorated and the medical report indicates massive, extensive, or significant blood loss, code the higher AIS.

27.

Injuries

Involving

Skin and Internal Structures

If a deep laceration or puncture penetrates the soft tissue and it can be determined that it is associated with a similar lesion to a related internal structure, onlythe injury with the higher AIS (the internal injury) should be coded. If in doubt that the external and~intemal lesions are related, then code both.

28.

Blood Loss

A number of injuries to the skin, vessel lacerations, brain lesions. and internal organs are described in terms of blood loss by volume. The following table should help in assessing blood loss when information in the hospital chart is not specific, and in coding these injuries in children.

21

As a rule of thumb, 1,000 cc of blood = 20% blood loss in an average adult. Blood loss -- Consider all blood loss regardless of Cavity when estimating total blood loss When blood loss is ~20% and more than one injury qualifies for the blood loss, choose the most severe associated injury.

Pounds x .4536 = Kilograms weight in Kilograms x 15 = 20% blood loss threshold 29. Transection

When a vessel injury is described as transection without additional data, code as complete transection (total severance). If incomplete transection is indicated, one AIS code less severe than transection should be used. Examples: Aortic transection (abdominal) - code: 520208.5. Aortic laceration with incomolete transection - code: 520206.4

30.

Tears: An Injury Synonym

If the injury description states only tear, then code as follows: (a) (b) If involving internal organs, use the laceration code. If involving the external integumentary system, use the laceration or avulsion code as appropriate. If unknown which to select, then choose the laceration code.

31.

Multiple

Vessel or Nerve Injuries

For multiple injuries to a vessel or nerve located in the same body region or the same region of the spinal cord (e.g.. cervical), code onlv one line of code, choosing the injury with the highest AIS among all the injuries present. Example: Laceration aorta (thoracic). severance severance (laceration-major). aorta. Code only one injury, 420210.5

22

32.

Vessel Injury

Code a vessel injury separately if: (4 (b) (c) there is-no accompanying, accompanying documented organ injury or

organ injury does not include vessel injury in its description or

Named vessel injury occurs with organ injury S@ is higher in severity than descriptor for organ injury.

INJURY 33.

SOURCE

GUIDELINES

Side Interior Surface Contacts

If a side interior surface contact (left or right) occurs and it is uncertain whether the side hardware or armrest was involved, then code Left side interior surface, excluding hardware or armrests or Right side interior surface, excluding hardware or armrests, respectively.

34.

Injuries Produced

by Objects on the Occupant

If an object on the occupant (e.g., eyeglasses, pen, pencil, etc.) produces an injury due to contact, consider the object as a medium through which force is transmitted rather than the injury source itself. Determine and code the mechanism that contacted the object on the occupant. Example: Drivers face strikes steering wheel rim causing eyebrow. Code Injury Source as Steering wheel rim. eyeglasses to lacerate right

35.

Direct vs Indirect Injury indirect, induced, noncontact, and airbag related

Definitions and procedures for coding InjurySourcefordirect, injuries are listed below:

Injury Source is defined as the vehicte component or object that directly caused the injury (direct injury) or initiated the injury mechanism (indirect injury). Direct iniury - an injury to a particular Body Region caused by the traumatic contact of that Body Region with a vehicle component or other object. The vehicle component or other object is coded as the injury source for that injury. Brain injuries, anatomic or non-anatomic, and skull injuries may be caused by the face or head striking a component or object. For these cases, consider the brain or skull injury as a direct injury. Indirect or induced iniury - an injury to a particular Body Region caused by a blow or a traumatic contact in some other Body Region (e.g., head/neck). In the case of the lower or upper extremities, an injury to a particular body member caused by a blow or traumatic contact to a different body member within the same body region (e.g. knee/acetabulum). The injury source for an indirect injury would be the vehicle component contacted bytheother Body Region or member (i.e., the occupant contact that initiates the injury mechanism).

23

36.

Non-Con+t Injury Sources - Codes fire in vehicle, source, and air bag exhaust gases

flying glass, other noncontact

injury

These noncontact injury sources are to be usad only for the following specific types of injuries: (4 head or neck injuries in which the torso is supported (e.g., by seat back or belt) and head or neck experiences traumatic forces due to inertial motion -- code other noncontact injury source: flying glass injuries -- code flying glass; burns due to chemicals or gaseous inhalation -- code other noncontact injury source; burns due to flame -- code fire in vehicle; and burns due to air bag exhaust gases -- code air bag exhaust gases.

(b) (4 Cd) (6

The following examples illustrates the above definitions.

Injury Mechanism From Crash Evidence

Determined lniurv Source

Example 1 Neck strain 640276.1

a. b.
C.

d. e. f. 9. Example 2 Hip Dislocation 850610.2 Examole 3 Shoulder-elbowwrist fracture/ dislocation 75-30.1

head strikes windshield forehead hits roof of convertible top head strikes steering wheel rim back hits seatback, no head restraint, head rolls back over seat neck forced into lateral flexion by impact forces torso restrained by belt, head and neck inertia causes neck injury back hits seat back, head hits head restraint, neck is injured Knee strikes knee bolster forces transmitted along femur forcing femoral head out of the acetabulum Occupant braced hands on instrument panel, transmitting forces to wrist, elbow, and shoulder

a. windshield b. roof or convertible top c. steering wheel rim d. other noncontact injury source e. f. g, other noncontact injury source other noncontact injury source head restraint

knee bolster

instrument panel

EXamDIe 4 Acute lumbar strain 640676.1

Jackknife over seat belt, rotation about seat belt stretches back muscles

belt restraint

24

37.

Air Bag Related

Air bag related is coded when a body part set in motion by a deploying air bag contacts a component which produces an injury. Example: Deploying aitiag flings an into A-pillar which produces a fracture. Code Injury Source as A-pillar and Direct/Indirect Injury as air bag related.

DO NOT use air bag related if the air bag produced the injury

25

PART III AIS DICTIONARY LISTING AND CODES

HEAD (Cranium
Codina Rules Rule

and Brain)

AIS Uncertainty

If there is any question about the severity of an injury based upon all available documented code conservatively (i.e.. the lowest AIS code in that injurys category).

information,

Skull Fractures The skull bones are divided into two areas of interest (i.e., vault and base). The entries in the column entitled Skull Bones are intended to provide useful anatomical reference points that are often cited in medical records. Area Vault Subarea Frontal Temporat/ Parietal Occipita Asoechs) 5 (4 12 (RN 6 (P) Skull Bones Frontal bone including frontal sinus and not otherwise specified Temporal bone, including not otherwise specified Parietal bone (entire bone) Occipital bone, including not otherwise specified

Base

Anterior

8 (0

Middle

8 (1)

Posterior

a (1)

Frontal bone, orbital plate--anterior cranial fossa: right and left Ethmoid bone, cribriform plate Sphenoid bone, body and lesserwings --forms a portion of anterior cranial fossa Sphenoid bone, sella turcica Sphenoid bone, greater wings --forms a portion of middle cranial fossa: right and left Temporal bone -- mastoid and squamous portions Temporal bone, petrous portion Occipital bone -- posterior cranial fossa: right and left Occipital bone, including ring area (i.e., foramen magnum)

Code only one fracture per aspect, assigning the code with the higher AIS; Maximum number of codeable skull fractures is five. Each aspect that was fractured is coded independently of whether the fracture in the aspect originated in the aspect or is a continuation of a fracture line(s) that originated in another aspect. If vault and base are involved record two lines of code. A skull fracture not otherwise specified as to location is coded: 150400.2,9 Multiple skull fractures (or one of its synonyms: several, numerous, etc.) where little specific information is available, are coded: 150400.2,9 Statements such as: massive skull fracture(s) information is available, is coded: 150404.3,? or extensive skull fracture(s), where linle specific

29

~,-,1

Multiple

Fracturee

in a Bone

For multiple fractures to-the same bone: (a) (4 If multiple fractures to the same bone are determined, then code each separately. If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as gne cornminute fracture. Assign one line of code with the appropriate AIS. Exceptions: skull skull fractures

Coding

Brain Injuries (cerebrum),

The brain is divided into the following four suborgans: right hemisphere and left hemisphere cerebellum, and brain stem.

Code one line of code per injury type per aspect for each brain suborgan, following the guidelines below: (a) W (0) W W 0) (9) (W If both edema and swelling are present, code once for presence. If surrounding edema is included for another injury, do not code edema/swelling. Do not code a brain stem hemorrhage if a contusion or laceration is present. Do not code a cerebellar or cerebral intracranial hemorrhage if brain stem injury is present (e.g., lacerated). If contusion a compression or contusion and hematoma are diagnosed code both.

If a crushed brain stem is coded, do not code brain stem contusions or lacerations. When a brain lesion is described as an avulsion or transection, description code. Pituitary injury is code 140799.3.8 use the laceration injury

See page 40 for guidelines on when to use Loss of Consciousness

information.

Valid Asoect Codes: @ - 1,2,5,6,,9,0

1,2,3,5.6.8,9,0 (R,L,A.P.U,W)

(Fl,L,B.A,P,I.U,W)

+ - 1,2,9 (R.L,U) ? - 1,2.5,6,9 (R.L,A,P,U)

! - 1.2,3,9 (R,L,B,U) Remarks (4 (RLJJ) (R,L,I,U)

w Frontal Parietal Temporal 5 1,2.9 1,2.8,9 6 1,2,8.9 1,2.3,9 6 8

&g&j

Aspect 8 covers; Mastoid Process, Svoid Process, Petrous portion. Aspect 8 is for Sella turcica.

Occipital Sphenoid Cerebrum Cerebellum Brainstem

P) (R.L,I,U)

30

I
CODE 115099.7 115999.7 113000.6 190099.1 190202.1 190402.1 190600.1 190602.1 190604.2 190606.3 190800.1 190802.1 190804.2 190806.3 190808.3 I

Closed head init@ or Yrsumatic brain injury are not specitic diagnosis and, depending on local usage, may mean almosf any type 01head injury. Therefore, if this vague information is the only description available. the brain injury should be coded under Whole Area and assigned Ihe code 7. These descriptors should never be used when more specific information is available. I

ASPECT

INJURY DESCRIPTION

Closed head injury/blunt

head trauma/traumatic

brain injury

NFS

died without further evaluation; no autopsy 0 @ (Crush) Massive destruction of both cranium (skull) and brain Scalp NFS abrasion contusiotisubgaleal laceration NFS minor (superficial) maior (> 1Ocm long and into subcutaneous blood loss > 20% by volume avulsion NFS superficial (minor: 5 lOOcm*) tissue) hematoma

major (> 100cm but blood loss < 20% by volume) blood loss > 20% by volume total scalp loss

See page 151 for diagram of actual injury size. 31

I
CODE 120299.3 120202.5 120204.3 120206.3 120499.5 120402.5 120404.5 120406.5 120602.4 120899.3 120802.4 120804.5 120806.3 121099.3 121002.5 121004.4 121006.3 121299.3 121202.4 121204.3

Vessel injuries should be coded separate from the injuries to the brain. If specific vessel is not known, cods as intracranial vessel NFS. code 121299.3.9.

Thrombosis includes any injury to the vessel resulting in its occlusion (e.g., intimal tear. dissection). Open lacsrstion mesns the vessel is bleeding out of the body (externally).

ASPECT

INJURY DESCRIPTION

Anterior

cerebral artery NFS laceration thrombosis (occlusion) traumatic aneurysm

Basilar artery NFS laceration thrombosis (occlusion) traumatic aneurysm

5 8

Carotid-cavernous Cavernous

fistula

sinus NFS

laceration open laceration or segmental loss (open means vessel is bleeding outside the body externally) thrombosis (occlusion) + Internal carotid artery NFS laceration thrombosis (occlusion) traumatic aneurysm 9 Intracranial vessel NFS [Use this description if specific vessel is not

laceration thrombosis (occlusion)

32

CODE

- ASPECT

INJURY DESCRIPTION

gmental loss (open means vessel 122606.4 thrombosis (occlusion)

33

CODE

- ASPECT

INJURY DESCRIPTION

122899.3 122802.5 122804.3 122806.3

Vertebral

artery NFS laceration thrombosis (occlusion) traumatic aneurysm

34

Because of limitations in diagnostic capabilities. it is often impossible lo assign specific injury descriptors to cranial nerve injuries. Therefore, many cranial nerve injuries may be described only by the type of dysfunction that exists in normal nerve function. Unless contusion or laceration is specified, code as laceration if total loss of nerve function (paralysis) is described. Code as contusion if subtotal loss of function (paresis) is documented. Do not increase the severity for bilateral or multiple injuries of the same nerve. Nerve injuries should be coded separate from the injuries to the brain. If specific nerve is not known. code as cranial nerve NFS. code 130299.2,9.

CODE

ASPECT

INJURY DESCRIPTION

35

CODE

-ASPECT

INJURY DESCRIPTION

131899.2

132204.2 132499.2 132402.2 132404.2 132699.2 132602.2 132604.2 8 +

laceration XI (Spinal accessory contusion laceration XII (Hypoglossal contusion laceration nerve) NFS nerve) NFS

36

1
CODE 140299.5 140202.5 140204.5 140206.5

The injuries in this section should be coded only if verified by CT scan, MRI. surgery. x-ray. angiography qr autopsy. Clinical diagnosis alone is not an adequate determination for establishing the e&fence of an anatomic lesion for coding purposes.

ASPECT

INJURY DESCRIPTION

Brain stem (hypothalmus. compression hernial contusion

medulla, midbrain, pons) NFS (uncal) or cerebellar tonsillar

(includes transtentorial

diffuse axonal injury (white matter shearing) [Use this code only if medical indicates white matter shearing or diagnosis is diffuse axonal injuv (DAI).] infarction injury involving hemorrhage laceration massive destruction (crush) penetrating injury transection 6 Cerebellum NFS [Use this section only if cerebellum, infratentorial posterior fossa are named. Otherwise, code as Cerebrum.] or

140208.5 140210.5 140212.6 140214.6 140216.6 140218.6 140499.3 140402.3 140403.3 140404.4 140405.5 140406.5 I 6 I

contusion, single or multiple, NFS [include surrounding edema for size] small (superficial); (ZZ15cc; 3 3cm diameter) large (15-30~~; > 3cm diameter) extensive (massive; total volume > 3Occ) diffuse axonal injury (white matter shearing) [Use this code only if medical indicates white matter shearing or diagnosis is diffuse axonal injun/ (DAI).] hematomaihemorrhage NFS [Use this code for extra axial unless further described as epidural or subdural, includes surrounding edema] epidural or extradural NFS [include surrounding edema

140410.4

140414.4

37

CODE

ASPECT

INJURY DESCRIPTION

Cerebellum 140418.4 140422.5 140426.4 140430.4 140434.5 140438.4 140442.4 140446.5

(continued) 6 small (s 3Occ in adults; 5 2cm thick; smear; tiny; moderate) large (> 3Occ in adultq extensive) 6 > 2cm thick; massive;

intracerebellar including petechial and subcortical NFS [include surrounding edema for size] small (5 15~; < 3cm diameter) large (> 15cc: > 3cm diameter)

subdural NFS small (I 3Occ in adults; i 2cm thick; smear: tiny; moderate) large (> 3Occ in adults;extensive) > Zcm thick; massive:

Injury involving any of the following but not further specified anatomically other than cerebellum, infratentorial or posterior fossa: [Use this category even in the presence of anatomically described substantiated injuries.] 140450.3 6 brain swelling/edema not including surrounding edema NFS [Code one or other, i.e., swelling or edema, but not both. DO NOT code if result of anoxia or other nontraumatic cause.] I infarction (acute due to traumatic vascular occlusion) ischemia subarachnoid hemorrhage

140458.3 140482.3 140466.3 140470.3 140474.4

subpial hemorrhage 6 laceration

s 15cc or s lcm diameter/thick

if s 10 years old if i 10 years old

aa t 15cc or L lcm diameter/thick Note: Adult means > 10 years old . See Rule 25

38

CODE

-ASPECT

INJURY DESCRIPTION

140699.3 140602.3 140604.3 140606.3 140608.4 140610.5 140611.3 140812.3 140614.3 140616.4 140618.5 140820.3 140822.3 140624.4 I 140626.5 140628.5 I I I

Cerebrum

NFS [Use if described as brain injury]

contusion NFS [include surrounding edema for size] single NFS small (superficial; < 30~~; < 4cm diameter; midline shift < 5mm) large (deep; 30-50~~; > 4cm diameter;midline shift > 5mm) extensive (massive; > 5OcP) 9 I I multiple NFS multiple, on same side but NFS small (superficial; total volume ~3Occ; midline shift s 5mm) large (total volume 30-50cc;a midline shift > 5mm) extensive (massive; total volume > 5Occ) multiple, at least one on each side but NFS , I small (superficial: total volume 5 30~~)~ large (total volume 30-5Occ) extensive (massive; total volume > 5Occ) diffuse axonal injury (white matter shearing) [Use this code only if medical indicates white matter shearing or diagnosis is diffuse axonal injuw (DAI).] + hematomtiemorrhage NFS [Use this code for extra axial unless further described as epidural or subdural] epidural or extradural NFS [include surrounding hematoma for size) small (5 5Occ adult: 5 2%~ if I 10 years old; zzlcm thick; smear; tiny; moderate) 3 bilateral

140629.4 140630.4 140632.4 140634.5

a < 15cc or 5 2cm diameter

if i 10 years old

15-30~~ or 2-4cm diameter if zc10 years old > 3Occ or > 4cm diameter if s 10 years old

Note: Adult means > 10 years old 39

CODE

ASPECT

INJURY DESCRIPTION

large (> 5Occ adult; > 2%~ if s 10 years old; > lcm thick; massive: extensive) 140638.4 140640.4 140642.4 140644.4 140646.5 140648.5 140650.4 140652.4 140654.5 140656.5 3 + 3 + + + intracerebral NFS [include surrounding edema for size) small (s 3Occ; < 4cm diameter) petechial hemorrhage(s) subcortical hemorrhage bilateral large (> 3Occ; >4cm diameter) subdural NFS small (5 5Occ adult; s 25cc if i 10 years old; s lcm thick; smear: tiny; moderate) bilateral large (> 5Occ adult; > 2%~ if i 10 years old; > lcm thick: massive; extensive) Injury involving any of the following but not further specified anatomically other than cerebrum, supratentorial. anterior cranial fossa or middle cranial fossa: [Use this category even in the presence of anatomically described substantiated injuries.) 140660.3 I brain swelling/edema NFS (not including surrounding edema) [Code one or other, i.e., swelling or edema, but not both. DO NOT code if result of anoxia or other nontraumatic cause.] mild (compressed ventricle(s) w/o compressed brain stem cisterns) moderate (compressed ventricle(s) and brain stem cisterns) 140666.5 I severe (absent/obliterated ventrfcle(s) or brain

i: 15cc or i 2cm diameter if d 10 years old > 15cc or > 2cm diameter if i 10 years old

Note: Adult means > 10 years old * See Rule 25 40

CODE

-ASPECT

INJURY DESCRIPTION

lar hemortiagelintracerebral

hematoma in

41

-I
CODE 150200.3

Code all skull fractures under vault unless specified as base. Code associated brain or cranial nerve injuries separately under Nerves. Vessels. or Organs. Code nasc-ethmoidal fracture as basilar. In these cases, do not code facial fractures separately.

ASPECT

INJURY DESCRIPTION

Base (basilar) fracture NFS (may involve ethmoid, orbital roof, sphenoid, temporal-including petrous, squamous or mastoid portions - or occiptal bones) without CSF leak with CSF leak complex (oper? with torn, exposed or loss of brain tissue; comminuted.w1 ring.1 hingebM) Any of the following clinical signs may be indicators of basilar skull fracture: hemotympanum; perforated tympanic membrane with blood in canal: mastoid hematoma (battle signs); CSF otorrhea; rhinorrhea; periorbiial ecchymosis (racoons eyes).

150202.3 150204.3 150206.4

150400.2

Vault fracture NFS (may involve frontal, occipital, parietal, or temporal bones not otherwise specified) [Use this code if unknown if base or vault is fractured.] closed (simple; undisplaced; diastatic; linear) comminuted (compoundb, open but dura intact; depressed < 2cm; displaced)

150402.2 150404.3 150406.4 150408.4

complex (oper? with tom, exposed or loss of brain tissue) massively depressed (large areas of skull depressed > 2cm)

The term compund is uniquely applied to skull fracture; it means open fracture. means a compound fracture plus torn dura, exposed or loss of brain tissue.

Open skull fracture

If extensive fractures occur to a single basilar fossa or if two or more of the three basilar fossa (anterior, middle, and posterior) are fractured, then code as a basilar fracture. A hinge fracture extends from the left to the right temporal bones. The fracture may extend across (1) the middle cranial fossa. often involving the sella turcica; (2) the posterior cranial fossa. from one petrous portion to the opposite petrous portion; or (3) both the middle and posterior cranial fossae. 42

GUIDELINES

ON WHEN TO USE LOSS OF CONSCIOUSNESS

INFORMATION

Injuries coded under this section are based on leveliloss of consciousness data. A nonanatomical injury is coded in addition to substantiated anatomic iniuries and when there are no substantiated anatomic iniurfes. Onlyg9g non-anatomic injury is coded per individual. Loss of consciousness codes cannot be used if: (1) death occurs within 24 hours and patient has not regained consciousness or (2) the patient survives and the diagnosis is closed head injur)r with no information about LOC or length of unconsciousness except for descriptors 160820.4. 160822.5 or 160824.5. The Glascow Coma Score is included under the Level of Consciousness section as one indicator of neurologic status that needs corroboration for the presence of brain injury. The presence of alcohol or other drugs will oftentimes confound the assessment of brain injury based upon neurologic status. Similarly, intubation of patients following injury limits the application of GCS to assess the presence or absence of brain injury. For these reasons GCS should never be used as the sole indicator of brain injury based on level of consciousness. Use code 115099.7 if the patient has been intubated and/or only GCS data is available, unless a brain injury is substantiated in the medical record. Anatomical iniuries For coding head injuries other than those to the skull, the coder may know the anatomical injury, the level of consciousness, or the duration of unconsciousness. If an anatomical injury is substantiated by autopsy, CT scan, MRI (magnetic resonance imaging), surgery, x-ray, or angiography, it should be coded using the section titled Internal Organs. (Recall that clinical diagnosis alone is not an adequate determination for establishing the existence of an anatomical injury for coding purposes.) Where LOC accompanies a documented anatomical lesion, the LOG should be considered only if it reflects a more serious injury than is described by the anatomical lesion alone. In these cases, code the higher AIS non-anatomical lesion gncJ the documented anatomical lesion. Non-Anatomical iniuly

In the absence of a documented anatomic injury, only information on status of consciousness may be available to the coder. In these cases, the following sections on length of unconsciousness or level of consciousness should be used. Self-reported LOC or reports of bystanders with no corroboration by EMS or medical personnel and no evidence of head trauma should be disregarded. Abrasions, contusions, pr lacerations to the scalp are coded under Whole Area and are not automaticallv oresumed to have an associated brain injury. Neurological deficit One or more of the following sequela that was not present pre-injury constitute a neurological deficit if it lasts for more than a transient period (i.e., minutes): hemiparesis: hemiplegia; weakness; sensory loss; hypesthesia; visual field defect: asphasia; dysphasia; seizure; central (not peripheral) facial weakness or palsy; deviation of both eyes to the same side; unequal pupils (anisocoria): pupils fixed or not reactive. The latter three must be due to head, not eye or orbital, injury. Add an AIS of 1 (where indicated in the manual) if the injury involves a neurological deficit for more than a transient period. The deficit assessment must be made by a medically qualified observer and must be contained on an official record of a medical facility or an E.M.T. service.

43

Length of Unconsciousness This section may be used only within the immediately preceding guidelines. This section should always be used in preference to the one that follows, called the Level of Consciousness. The necessity to use this section in preference to the one titled Internal Organs (pages 37-41) oftentimes reflects inadequate data sources. The length of unconsciousness must be recorded by emergency (i.e., EMS) or medical personnel (i.e., ER), and must be related to head injury. If length of unconsciousness is unknown, proceed to the level of consciousness section.

CODE

ASPECT

INJURY DESCRIPTION

Unconsciousness 180202.2 160204.3 160206.3 160208.4 160210.4 160212.5 1-6 hn. 0 c 1 hr.

known to be

with neurological deficit

with neurological deficit 6-24 hrs. (includes 1 calendar day when hours cannot be estimated) with neurological deficit

44

Level of Consckusness This section is used only ii an injury cannot be coded by the internal Organs (pages 37-41) or Length of Unconsciousness (page 44) sections. The level of consciousness and its duration must be obsewed by emergency (i.e., EMS) or medical personnel (i.e., ER), and must be related to head injury. The necessity to use this section in preference to the one titled Internal Organs oftentimes reflects inadequate data sources.

CODE

ASPECT

INJURY DESCRIPTION

160499.1

160614.3

1-6 hrs. unconsciousness I

45

CODE

-ASPECT

INJURY DESCRIPTION

Level of Consciousness

160824.5

46

VENOUS DRAINAGE OF HEAD

SUIFRIOR

SAGII
SINUS

PITROSAI. SINUS
STRAIGIII SIN115

; ; , \\ -

CAVERNOIlS SINUS

Adapted Additional

from: Source illustrations:

(5).

p. 383 Jacob. et

al..

p.

402

47

Facial m"SCleS Submandibular Sublingual TOllg"e Soft palate

Stcrnocleidomasloid Trapezius

Adapted

irom:

*ourcc

(7).

,'.

261

40

BWJNSTM: nla1amus

Arachnoid Svbarachnoid Pia mater

neninges (cross Adapted Additional from: source source illStratios: (8). (3,.

of the brain section)

P. 314 - top P. 195 - bottom ,acob. et al., P. 237, 247

49

Parfetal Fronral

bone bone

Ethmoid bone Sphenoid

Ethnoid bone: crista galli Cribiform place

Parietal

bone

Foramen magnum Occinical bone

Adapted Addxrional

fmm:

Source Source Illustrations:

(5). (a),

p.98-top p. 141-botrom Jacob. et al..

pP.99.

108-S

50

FACE (Includes
Codina Rules AIS Uncertainty Rule

Ear and Eye)

If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injurys category).

Bilateral

Injuries

Bilateral injuries are coded separately for organs such as the eyes, and ears unless the dictionary specifically allows for coding as a single injury. Maxillae and mandibles are coded as single structures.

Coding Same Type htegumentary

Injuries avulsions. contusions, and

Use the following rules when coding same type injuries (i.e., abrasions, lacerations) to a body region. (9 (b) Cc)

When the same type soft tissue injuries occurs to 2 2 aspects of a body region due to different contact points, code as separate injuries. Any number of same type soft tissue injuries resulting from the same contact point, occurring to a body region, exceot the face, will have one line of code. If same type soft tissue injuries resulting from the same contact point occur to the face and involve z 1 and 5 3 diierent aspects, code each aspect separately. If 2 4 diierent aspects, enter one line of code using aspect whole region. If any of the words multiple, numerous * , several, or the plural of a lesion is used to describe &same type soft tissue injuries ggg there are no details of location, enter one line of code from the EXTERNAL - Skin and Subcutaneous Tissue section (e.g., multiple contusions, Code 990400.1.0). If multiple same type soft tissue injuries occur to a specific body region &@ the aspect is unknown, enter one line of code using the WHOLE AREA section for that body region (e.g., multiple facial abrasions, Code 290202.1 ,O).

(d)

Laceration

Type injuries flap

type of laceration (e.g., avulsion type laceration, When an injury is described as a laceration), use the avulsion code. For all ambiguous situations, use laceration over avulsion.

Dicing Type Injuries When an injuryisdescribed code abrasion. as a dicingtype (e.g., dicing type lacerations, dicing type abrasions)

51

Multiple

Fractures

in a Bone

For multiple fractures to.the same bone: (a) W If multiple fractures to the same bone are determined, then code each separately. If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one comminutecf fracture. Assign one line of code with the appropriate AIS. Exceptions: mandible multiple fractures to the mandible are assigned one line of code. Choose the code and AIS for the more specific fracture type. Comminuted must be explicitly stated and is goJ derived from the presence of multiple fractures. Fractures to the right g9g left sides are assigned Aspect code 3 (Bilateral). Fractures to the right side anrJ inferior portion of the mandible (Le., mental protuberance area) are assigned Aspect code 1 (Right). Fractures to the left side and inferior portion of the mandible (i.e., mental protuberance area) are assigned Aspect code 2 (Left). Fractures to the right& left sides and a fracture to the inferior portion (i.e., mental protuberance area) are assigned Aspect code 3 (Bilateral).

Valid ASDeCt Codes: 1,2,3,4,7,8,9,0 * - 1,2,4.7,8,9,0 + - 1,2,9 (R,L.U) % - 1,2.3,8,9 (R,L.B,I.U) ! - 1.2,3,9 (R,L,B.U)

(R.L.B.C,S.I,U,W)

(R,L,C,S,I,U,W)

@gi$J

Cheek Chin Ear Eye Eyebrow Forehead Lips Nasal Spine Nose

52

CODE

ASPECT

INJURY DESCRIPTION

215099.7 215999.7 290099.1

Bluntfhumatic

facial injury NFS

died without further evaluation: no autopsy Skin/Subcutaneous tissuehluscle [Including lip, external ear (pinna/auricle), forehead, eyebrow -- for eyelid or orbit (soft tissue) - see Eye-Skin] NFS abrasion contusion laceration NFS minor (superficial) major (> 1Ocm long and into subcutaneous blood loss > 20% by volume avulsion NFS superficial (minor; 5 25cm*) tissue)

290202.1 290402.1 290600.1 290602.1 290604.2 290606.3 290800.1 290602.1 290804.2 290806.3

major (> 25cm but blood loss < 20% by volume) blood loss > 20% by volume

See page 151 for diagram of actual injury size. 53

[also see NECK] CODE ASPECT INJURY DESCRIPTION

220200.1 220202.1 220204.3

External cartoid artety branch(es) including facial and internal maxillary laceration NFS minor major (blood loss > 20% by volume)

m CODE

[also see CRANIAL NERVES under HEAD] ASPECT INJURY DESCRlPTfON

230299.1 230202.2 , 230204.2 230206.2

Optic nerve injury NFS [Intraorbital portion only; for intracranial portion or location unknown, code under cranial nerves in HEAD section.] contusion laceration avulsion

54

CODE

ASPkT

INJURY DESCRIPTION

241002.2 241200.1 241202.2 297099.1 297202.1 297402.1 297602.1 297602.1 241499.1 241699.1 + + + +

with retinal detachment Sclera laceration involving globe (includes rupture) Skin-Eyelid or orbit (soft tissue) NFS

abrasion contusion laceration avulsion Uvea injury Vitreous iniurv

55

CODE

-ASPECT

INJURY DESCRIPTION

243099.1 243299.1 243202.1 243204.1 243206.1 243400.1 243402.1

8 a

Mouth injury NFS Gingiva (gum) NFS contusion laceration avulsion

Tongue

laceration NFS superficial

56

CODE

ASPECT

INJURY DESCRIPTION

to teeth [Do not code

as singe

250610.2

mminuted (any or combination)

but

LeFort I - horizontal segmented fracture of the alveolar process of the maxilla in which the teeth are usually contained in the detached portion of the bone. LeFort II - unilateral or bilateral fracture of the maxilla in which the body of the maxilla is separated from the facial skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline of the hard palate, through the floor of the orbit and into the nasal cavity. LeFort III - a fracture in which the entire maxilla and one or more facial bones are completely separated from the base of the skull. 57

CODE

ASPECT

INJURY DESCRIPTION

251200.2

58

-.

Condyle

Ramvs Alveolar Angle Body ridge

Adapted

source source Addi~ioal,illus~ra~io: from:

(3). (5).

p. 72 - tap p. 106 - t.otrom Jacob. et al.. p.

97

59

MOUTH

Lip (pulled outward) mngiva (gum)

MIDDLE EAR (ossicular

chain):

mihs.

Ic~,

stapes

EXTERNAL LAP.:

INNER EAR:

Pinna

(auricle)

Tympanic membrane (eardrum) External auditory meatus (ear canal)

Adapted Additlonal

from: Source illustrations:

(8).

p. 542 and (3). Jacob, et al..

p. pp.

255 320-l

60

con,unct*va

61

NECK
Coding Rules Rule information,

AI.5 Uncertainty

If there is any question about the severity of an injury based upon all available documented code conservatively (i.e., the lowest AIS code in that injurys category).

Internal

Organs

The following terms may be used as a guide in differentiating between superficial, major, or complex lacerations or perforations to internal organs of the neck. However, the final choice of whether or not to use the superficial or major AIS levels depends on the term within the m of the m injury description.

Superficial Major Complex -

minor, partial thickness, small deep, full thickness, large, severe massive, tissue loss, segmental loss, stellate (abdomen)

NOTE: When organs are lacerated/perforated and the medical report indicates massive, extensive. or significant blood loss, code the higher AIS.

Valid Aspect Codes: *- 1,2,5,6,9,0

1,2,5,6,9,0

(R,L.A.P,U,W)

(R,L,A,P,U,W)

+ - 1,2,9 (R.L,U)

63

CODE

ASPECT

INJURY DESCRIPTION

315099.7 315999.7 311000.6 390099.1 390202.1 390402.1 390600.1 390602.1 390604.2 390606.3 390600.1 390802.1 390804.2 390806.3

BkuWTrsumetic

neck/throat

injury NFS

died without further evaluation; no autopsy 0 * Decapitation Skin/Subcutaneous abrasion contusion (hematoma) laceration NFS minor (superficial) major (> 20cm long and into subcutaneous blood loss > 20% by volume avulsion NFS superficial (minor: < 100cm) tissue) tissue/Muscle NFS

major (z- 1OOcm but blood loss < 20% by volume) blood loss > 20% by volume

See page 151 for diagram of actual injury size.

Descriptions for vessel lacerations distinguish between complete and incomplete transection. See foctnotes g and h. The terms laceration, puncture. and perforation are oftentimes used interchangeably to describe vessel injuries and are of the same severity. When perforation or puncture is used, code as laceration. Thrombosis includes any injury to the vessel resulting in its occlusion (e.g., intimal tear, dissection)

CODE

ASPECT

INJURY DESCRIPTION

320210.4

320214.5

with neurological deficit (stroke) not head injury

320410.2 320412.2

with thrombosis

(occlusion)

secondary

to trauma

thrombosis (occlusion) secondary to trauma

(superficial: incomplete transection; incomplete circumferential volume)

involvement; blood loss s 20% by

(rupture; complete transection: segmental loss: complete circumferential blood loss > 20% by volume)
65

involvement;

CODE

ASPECT

INJURY DESCRIPTION

320606.3

wtth neurological deficit (stroke) not head injury

321016.3 321018.3 321020.4

with thrombosis (occlusion) secondary to trauma thrombosis (occlusion) secondan, to trauma with neurological deficit (stroke) not head injury related

(superficial; volume)

incomplete transection; incomplete circumferential

involvement; blood loss s 20% by

(rupture; complete transection; segmental loss: complete circumferential blood loss > 20% by volume) 66

involvement;

CODE

ASPECT

INJURY DESCRIPTION

Brachial plexus

[see SPINE]

Cervical spinal cord or nerve root [see SPINE] 330299.2 330499.1 + + Phrenic injury Vagus nerve injury [see also THORAX and ABDOMEN]

67

CODE

ASPECT

INJURY DESCRIPTION

341002.3 341499.1 341402.1 341404.2 Trachea 341899.2 341802.2 5 5 Thyroid

with ductal involvement or transection gland NFS contusion (hematoma) laceration [see THORAX]

Vocal cord NFS (not due to intubation) unilateral

68

CODE

ASP&X

INJURY DESCRIPTION

Cervical spine 350200.2 5 Hyoid fracture

[see SPINE]

69

Pharynx

Larynx Esophagus Trachea

Carotid artery

70

THORAX
Codina Rules Specific Rules for Thoracic lnjuty To be used when coding injuries that involve results(i.e., hemo/pneumothorax, a

hemo/pneumomediastinum)

When L two thoracic injuries occur in the same patient, only one thoracic injury description code and AIS can account forthe presence of (any mixture of) results (i.e., hemo-l pneumothorax and/or hemolpneumomediastinum -- unilateral or bilateral. If tension pneumothorax is diagnosed with rib fractures but without a documented lung injury, use the thoracic injury description to code the tension pneumothorax (442210.5) and code the rib fracture(s) without pneumothorax. If an occupant has a pleural laceration & rib fractures & hemothorax and/or pneumothorax -unilateral or bilateral but no luna lacerations or vessel iniuries. then incorporate the results into the rib fracture code. If an occupant has a flail chest with unilateral or bilateral lung contusion(s). then the lung contusion(s) is/are a coded separately. Code: 4 5 02 60.4,+ -- is used for unilateral flail chest when it is unknown if any lung contusion occurred 4 5 02 62.3,+ -- is used for unilateral flail chest when it is known that no lung contusion occurred 4 5 02 64.4,+ _- is used for unilateral flail chest when it is known that unilateral or bilateral lung contusion occurred 4 5 02 66.5,3 -- indicates bilateral flail chest with or without lung contusion (unilateral or bilateral)

cl

Code:

Code: Code:

If a hemo-/pneumothorax (unilateral or bilateral) is present with flail chest and lung contusion, then do m code the results separately. However, if a lung laceration is present, then incorporate the results into the appropriate lung laceration injury description. Where a specific anatomical injury description is lacking and only hemothorsx, pneumothorax, hemomediastinum, or pneumomediastinum are given, use the injury description Thoracic Cavity Injury NFS.

cl

AIS Uncertainty

Rule information, code

If there is any question about the severity of an injury based upon all available documented conservatively (i.e., the lowest AIS code in that injurys category).

Bilateral Injuries Bilateral injuries are coded separately for organs such as the kidneys, eyes, and ears unless the dictionary specifically allows for coding as a single injury (e.g., lung injuries). The rib cage is coded as a single structure. Example: Fracture right 6-7 and left 4-6 ribs. Code 450220.2,3 (2-3 ribs any location).

71

Multiple

Fracture0

in a Bone

For multiple fractures tothe same bone: (a) (b) If multiple fractures to the same bone are determined, then code each separately. If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one comminuted fracture. Assign one line of code with the appropriate AIS. Exception: ribs multiple fractures to the same rib are assigned one line of code. Choose the code and AIS for the more specific fracture type.

Internal

Organs

Where the coding manual assigns a single line of code for multiple same type injuries, use that specific injury code when applicable. Example: 2 cm laceration right anterior ventricle, 3 cm laceration right atrium. Code multiple myocardium lacerations (441016.6,4).

For each major specific anatomic structure (organ) in the thorax where one line of code does not represent multiple same type injuries, code one row per injury type, choosing the highest AIS for each particular injury type. The spleen is markedly lacerated, and approximately 50% of it is avulsed and lying Example: free in fragments in the abdomen. Code laceration, complex (544228.5,2).

For multiple internal injuries to an organ of the thorax (except heart), code one row oer iniurv tvoe, choosing the highest AIS for each particular type. Example: Minor contusion spleen, one major laceration spleen, one superficial spleen. Code contusion (544212.2.2) and laceration (544226.42). laceration

The following terms may be used as a guide in differentiating between superficial, major, or complex lacerations or perforations to internal organs of the thorax. However, the final choice of whether or not to use the superficial or major AIS levels depends on the term within the gg&+@ of the entile injury description.

Superficial Major Complex -

minor, partial thickness, small deep, full thickness, large, severe massive, tissue loss. segmental loss, stellate (abdomen)

NOTE: When organs are lacerated/perforated and the medical report indicates massive, extensive. or significant blood loss, code the higher AIS.

Transection When a vessel injury is described as transection without additional data, code as complete transection (total severance). If incomplete transection is indicated, one AIS code less severe than transection should be used. Examples: Aortic transection (abdominal) _ code: 520208.5. Aortic laceration with incomplete transection - code: 520206.4

72

Costal Cartilage

Fracture/Tear

A diagnosed costal cartilage fracturehear should be coded as a rib fracture.

Valid Codes and Aspects

for Seat Belt Contusions

For seat belt bruises due to a three-point system, code: Shoulder Chest Abdomen 790402.1 ,1,2 (R,L) 490402.1,1.2,4,0 (R,L,C,W) 590402.1,1,2,4,7,8,0 (R,L.C,S.I,W)

Code 790402.1 ,1,2, 490402.1,4, and 590402.1,4 if unspecified. [Note: Code only those injuries that are consistent with the type of restraint worn (e.g., do not code 790402.1 or 490402.1 if only a lap belt was used).]

Valid AsDect Codes: # - 1.2,3.4.9,0

1,2,3,4,9,0

(R.L.B,C,U.W)

(R.L,B.C,tJ,W)

+ - 1,2.9 (R,L,U) ! - 1,2.3,9 (R,L,B,U) \ - 1,2,3.4,9 (R,L.B,C,U) & - 1,2,4,9,0 (R.L.C,U,W)

73

I
CODE 415099.7 415999.7 411000.2 413000.6 I

Blunt chest injury is not a specific diagnosis and. depending on local usage, may mean almost any type of chest injury. Therefore. if it is the only information available. B should be coded under Whole Area and assigned the code 7. This descriptor should never be used when more specific information is available.

ASPECT

INJURY DESCRIPTION

Bluntrrraumatic

chest (thoracic)

injury NFS

died without further evaluation; no autopsy + 0 Breast avulsion, female (Crush) bilateral destruction/obliteration by external forces of a substantial portion of the chest cavity including skeletal, vascular, internal organs, and tissue systems. Skin/Subcutaneous abrasion contusion (hematoma) laceration NFS minor (superficial) (O/S Grade I, 11) (O/S Grade I) tissue/Muscle/Chest wall NFS

490099.1 490202.1 490402.1 490600.1 490602.1 490604.2 490606.3 490800.1 490802.1 490804.2 490806.3

major (> 20cm long and into subcutaneous tissue) blood loss > 20% by volume avulsion NFS superficial (minor 5 lOOcm*)

major (z=100cm but blood loss s 20% by volume) blood loss > 20% by volume

See page 151 for diagram of actual injury size. 74

Descriptions for vessel lacerations distinguish behveen complete and incomplete transection. See fcotnotes g and h. The terms %ceration. puncture and perforation are oftentimes used interchangeably to describe vessel injuries and are of the same severity. When perforation or puncture is used, code as laceration.

CODE

ASPECT

INJURY DESCRIPTION

420216.6

420606.4

majo?

(superficial: incomplete transection; incomplete circumferential volume)

involvement; blood loss 5 20% by involvement;

(rupture; complete transection: segmental loss; complete circumferential blood loss > 20% by volume) 75

CODE

ASPECT

INJURY DESCRIPTION

421408.4 421699.3 421602.3 421604.3 421606.4 421899.3 421602.3 421804.3 421806.4 4 + Subclavian

majo? vein NFS (a// O/S Grade 11)

laceration (perforation, puncture) NFS minoP mafoP Vena Cava, superior and thoracic (a// OIS Grades IV and Vj portion of inferior NFS

laceration (perforation, puncture) NFS minor with or without thrombosis@ maioS

(superficial; incomplete transection; incomplete circumferential volume)

involvement: blood loss < 20% by

(rupture: complete transection; segmental loss; complete circumferential blood loss > 20% by volume) 76

involvement;

CODE

-ASPECT

INJURY DESCRIPTION

Other named arteries NFS (e.g., bronchial, esophageal, intercostal, internal mammary) (a// O/S Grade 1) intimal tear, no disruption laceration (perforation. puncture) NFS mine? majo? 422299.2 Other named veins NFS (e.g., azygos, bronchial, cardiac, intercostal, hemiazygos, internal mammary, internal jugular) (a// O/S Grades I except azygos, Grade II) laceration (perforation, puncture) NFS mine? 422206.3 major

(superficial; incomplete transection: incomplete circumferential volume)

involvement; blood loss < 20% by involvement;

(rupture; complete transection; segmental loss; complete circumferential blood loss > 20% by volume) 77

CODE

ASPECT

INJURY DESCRIPTION

Spinal cord [see SPINE] Phrenic nerve 430499.1 4 [see NECKJ

Vagus nerve injury [see also NECK and ABDOMEN]

70

CODE

ASPECT

INJURY DESCRIPTION

440808.4

79

-.

CODE

ASPECT

INJURY DESCRIPTION

441099.1 441002.1 441004.1 441006.4 441008.3 441010.3 441012.5 441014.6 441016.6 441016.6 441200.5 441300.5 441499.3 441402.3

Heart (Myocardium)

NFS

contusion (hematoma) NFS minor [patients presenting with dysrrhthmia, wall motion abnormality, other ECG changes not related to CAD] major [this diagnosis must be substantiated surgery, autopsy, EF < 25% absent CAD] laceration NFS no perforation, no chamber involvement perforation (ventricular or atrial with or without tamponade) complex or ventricular rupture multiple lacerations: > 50% tissue loss of a chamber avulsion Intracardiac lntraventricular Lung NFS contusion NFS with or without hemo-/pneumothorax [This diagnosis should be coded m there is a history of chest trauma g@ a physicians diagnosis is documented by x-ray, CT, MRI, surgery or autopsy. Clinical pulmonary dysfunction is insufficient evidence of a codeable injury.] unilateral with or without hemo-/pneumothorax [If associated with flail chest, see Rib cage _ Flail. page 83.1 bilateral with or without hemo-/pneumothorax laceration [See footnote before coding in this section.] NFS with or without hemo-/pneumothorax unless described as follows: with pneumomediastinum with hemomediastinum with blood loss > 20% by volume with tension pneumothorax with parenchymal laceration with massive air leak with systemic air embolus valve laceration (rupture) or inter-atria1 septum laceration (rupture) e.g., by

441406.3 441410.4 441414.3 441416.3 441418.4 441420.4 441422.5 441424.5 441426.5

80

CODE

- ASPECT

INJURY DESCRIPTION

unilateral with or without hemo-/pneumothorax

unless

441456.5

81

CODE

ASPECT

INJURY DESCRIPTION

Thoracic

cavity injury NFS [Use this section Q& when there is no

82

.--

CODE

ASPtiCT

INJURY DESCRIPTION

450230.3

> 3 ribs on one side and

3 ribs on the other side

450264.4 450266.5 450899.1 450802.1 450804.2 4 Sternum NFS contusion fracture

with lung contusion

(O/S Grade 111 IV) or

bilateral flail with or without lung contusion (O/S Grade V)

(O/S Grade /I or I//)

If rib fracture(s) coexists with lung laceration(s) dare associated with hemo-/pneumothorax, consider the hemo-l pneumothorax under the lung laceration only. Code the rib %acture(s) as if no hemo-/pneumothorax was present. Do not code the hemo-/pneumothorax separately. 83

Aorta

(arch) artery &

Pulmonary "d"S

Atrium (right b left) Ventricles (right left) SepWl

Pericardium

Hyocardim

(muscle)

Epicardium

Endocarditm

Adapfed Additional

from:

Source source illustrations:

(6). (3).

p. 22 - cop p. 3117 - h"ti"Cl .,ncc,l,, 11,~n, , pp.

345.

348

84

85

ABDOMEN
Codina Rules AIS Uncertainty Rule

AND PELVIC CONTENTS

If there is any question about the severity of an injury based upon all available documented code conservatively (i.e., the lowest AIS code in that injurys category).

information,

Duct Involvement

Injuries

to the Gallbladder,

Liver and Pancreas

If there is one ductal injury involving more than one organ sharing the same duct, assign the injuryto the organ with the higher AIS. If the AIS is the same, then choose and code onlyof the involved organs. If a separate ductal injury occurs to more than one organ (e.g., right hepatic duct and pancreatic duct), code each involved organ.

Internal

Organs

Where the coding manual assigns a single line of code for multiple same type injuries, use that specific injury code when applicable. Example: 2 cm laceration right anterior ventricle, myocardium lacerations (441016.6,4). 3 cm laceration right atrium. Code multiple

For each major specific anatomic structure (organ) in the abdomen where one line of code does not represent multiple same type injuries, code one row per injury type, choosing the highest AIS for each particular injury type. Example: The spleen is markedly lacerated, and approximately 50% of it is avulsed and lying free in fragments in the abdomen. Code laceration, complex (544228.52).

For multiple internal injuries to an organ of the abdomen, code one row oer iniurv tvoe, choosing the highest AIS for each particular type. Example: Minor contusion spleen, one major laceration spleen, one superficial laceration spleen. Code contusion (544212.22) and laceration (544226.4,2).

The following terms may be used as a guide in dffferentiating between superficial, major, or complex lacerations or perforations to internal organs of the abdomen. However, the final choice of whether or not to use the superficial or major AIS levels depends on the term within the context of the g&e injury description. Superficial Major Complex minor, partial thickness, small deep, full thickness, large, severe massive, tissue loss, segmental loss, stellate (abdomen)

NOTE:

When organs are lacerated/perforated and the medical report indicates massive, extensive, or significant blood loss, code the higher AIS.

07

Transection

When a vessel injury is described as transection without additional data, code as complete transection (total severance). If incomplete transection is indicated, one AIS code less severe than transection should be used. Examples: Aortic transection (abdominal) - code: 520208.5. Aortic laceration with incomolete transection - code: 520206.4

Valid Codes and Aspects

for Seat Se/t Contusions

For seat belt bruises due to a three-point system, code: Shoulder 790402.1 ,1,2 (R,L) Chest 490402.1.1,2.4,0 (R,L,C.W) Abdomen 590402.1.1,2,4,7,8,0(R,L,C,S.I,W)

Injuries

Involving

Skin and Internal Structures

If a deep laceration or puncture penetrates the soft tissue and it can be determined that it is associated with a similar lesion to a related internal structure, only the injury with the higher AIS (the internal injury) should be coded. If in doubt that the external and internal lesions are related, then code both.

Valid AsDeCt Codes:

l - 1,2,4,7,8,9,0

1.2.4,7,8,9,0

(R,L,C,S,I,U.W)

(R,L,C,S,I,U,W)

+ - 1,2,9 (R,L,U) = - 7,8,9 (S.I,U)

Blunt abdominal injuv is not a specific diagnosis and, depending on local usage. may mean any type of abdominal injury. Therefore, if it is the only information available, it should be coded under Whole Area and assigned the code 7. This descriptor should never be used when fnOre soecific information is available.

CODE

ASPECT

INJURY DESCRIPTION

515099.7

Sluntrrraumatic

abdominal

injury NFS

515999.7 590099.1 590202.1 590402.1 590600.1 590602.1 590604.2 590606.3 ,590600.1 590602.1 590804.2 590806.3 t

died without further evaluation: no autopsy SkinlSubcutaneous abrasion contusion (hematoma) laceration NFS minor (superficial) major* (> 2Ocm long and into subcutaneous blood loss > 20% by volume avulsion NFS superficial* (minor; < IObcm)
major (> IOOcm but blood loss 5 20% by volume)

tissuehhscle

NFS

tissue)

blood loss > 20% by volume

See page 151 for diagram of actual injury Size. 69

Descriptions for several vessel lacerations distinguish between complete and incomplete transection. See footnotes g and h. The terms laceration, puncture. and perfarstion are oftentimes used interchangeably to descdhs vssssl injuries, and are of the same sevedty. When perforation or puncture is used. code as laceration.

CODE

ASPECT

INJURY DESCRIPTION

Aorta, abdominal

NFS

(superficial; volume)

incomplete

transection;

incomplete

circumferential

involvement;

blood loss s 20% by

(rupture; complete transection; blood loss > 20% by volume)

segmental

loss; complete

circumferential

involvement;

90

CODE

-ASPECT

INJURY DESCRIPTION

521604.3

mine? with or without thrombosis

(superficial: incomplete transection: incomplete circumferential volume)

involvement; blood loss i 20% by

(rupture; complete transection; segmental loss; complete circumferential blood loss > 20% by volume) 91

involvement;

CODE

ASPECT

INJURY DESCRIPTION

Lumbar spinal cord Cauda aquina 530499.1 =

[see SPINE]

[see SPINE]

Vagus nerve injury [also see NECK 8 THORAX]

92

CODE

ASPECT

INJURY DESCRIPTION

540620.2 540622.3 540624.4 540626.4 540640.3

laceration NFS no perforation (partial thickness) (O/S Grade /j

perforation (full thickness but not complete transection) (O/S Grades I/, 111, IV) massive (avulsion; complex; tissue loss) (O/S Grades II, /I/, Iv) rupture NFS [Use this code only when a more detailed description is not available1

93

CODE

- ASPECT

INJURY DESCRIPTION

540822.2

540826.4

disruption -Z 50% of circumference; 541023.3 541024.4

no perforation

enteric contamination; devascularization; massive odenopancreatic complex)

I Cystic duct iniuw Lode as for Gallbladder1

Dl = superior or first part; D2 = descending or second part; D3 = horizontal or third part; D4 = ascending or fourth part Duct involvement applies only to gallbladder, liver and pancreas. Injuries to these organs, which really share the same duct system, not infrequently involve injuries to the duct systems of each organ. When there is one ductal injury, it should be assigned to either (not both) of the two involved organs. On the other hand, when separate ductal injuries (e.g., to the right hepatic duct and the pancreatic duct) occur, they should be assigned to both organs, 94

CODE

- ASPECT

INJURY DESCRIPTION

541299.2 541210.2 541220.2 541222.2 541224.3 541226.4 541499.2 541410.2 541420.2 541422.2 541424.3 541426.4 541699.2 541610.2 541612.2

Gallbladder

NFS (O/S Grade 1)

contusion (hematoma)

laceration (perforation) NFS (O/S Grade l/j minor (superficial; no cystic duct involvement) massive (avulsion; complex; rupture: tissue loss; cystic duct; laceration or transection) (O/S Grade 111) with common bile or hepatic duct laceration or transection (O/S Grades Wand V) a Jejunum-ileum (small bowel) NFS (O/S Grade I)

contusion (hematoma) laceration NFS

no perforation (partial thickness: < 50% of circumference) (O/S Grade I or I/) perforation (full thickness; 250 % of circumference without transection) (01.9 Grade 1//j massive (avulsion; complex; rupture: tissue loss: transection: devascularization) (O/S Grades War V) + Kidney NFS contusion (hematoma) NFS minor (superficial: subcapsular, nonexpanding, confined to renal retroperiioneum or without parenchymal laceration) (O/S Grade I or II) major (large; subcapsular, > 50% surface area or expanding) laceration NFS minor (superficial; < lcm parenchymal depth of renal cortex without urinary extravasation) (O/S Grade I!, moderate (> lcm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation) (O/S Grade 111) major (extending through renal cortex, medulla and collecting system: main renal vessel involvement with contained hemorrhage) (O/S Grade IV) hilum avulsion; total destruction of organ and its vascular system (O/S Grade V) rupture NFS [Use this code onJ when a more detailed injury description is not available.]

541614.3 541620.2 541622.2 541624.3

541626.4

541628.5 541640.4

95

CODE

- ASPECT

INJURY DESCRIPTION

541899.2 541810.2 541612.2

Liver NFS contusion (hematoma) NFS minor (superficial: subcapsular, 5 50% surface area, nonexpanding; intraparenchymal 5 1Ocm in diameter) (O/S Grade I or /I) major (ruptured subcapsular or parenchymal, > 50% surface area or expanding; intraparenchymal > 10cm or expanding; subcapsular; blood loss > 20% by volume) (O/S Grade 111) laceration NFS minor (superficial; i 3cm parenchymal depth, ZG IOcm in length, simple capsular tears; blood loss < 20% by volume) (O/S Grade I or 11) moderate (> 3cm parenchymal depth, with major duct involvement; blood loss > 20% by volume) (O/S Grade /I/) major (parenchymal disruption of 5 75% of hepatic lobe or 1-3 Couinards segments within a single lobe; multiple lacerations > 3cm deep; burst injury) (O/S Grade /V) complex (parenchymal disruption of > 75% of hepatic lobe or involving > 3 Couinards segments within a single lobe or involving retrohepatic vena cavakentral hepatic veitiepatic artery/portal vein) pulpefication (O/S Grade V) hepatic avulsion (total separation of all vascular attachments) (O/S Grade V/) rupture NFS [Use this code g& description is not available.] when a more detailed injury

541614.3

541820.2 541822.2

541824.3

541626.4

541820.5

541830.6 541840.4 542099.2 542010.2 542020.2 542022.2 542024.3 542026.4 8

Mesentety

NFS

contusion (hematoma) laceration NFS minor (superficial major (blood loss > 20% by volume) complex (avulsion; massive; rupture; stellate; tissue

96

CODE

- ASPECT

INJURY DESCRIPTION

rnvo vemen (O/S Grade I or II) 542820.2 542822.2 542824.3 542826.4 542820.4 542830.4 542832.5 laceration NFS minor (superficial; no evidence of duct involvement) (O/S Grade I) moderate (with major vessel or major duct involvement) (O/S Grade II/) if involving ampulla major (multiple lacerations) if involving ampulla (O/S Grade IV) (O/S Grade IV)

complex (avulsion; massive; rupture; stellate; tissue loss: massive disruption of pancreatic head)

97

CODE

- ASPECT -

INJURY DESCRIPTION

543099.1 543010.1 543020.1 543022.1 543024.2 543026.3 543299.1 543210.1 543220.1 543222.1 543224.2 543226.3 543400.3 543402.4 543699.2 543610.2 543620.2 543622.2 543624.3 543625.4 543626.5

Penis NFS contusion (hematoma) laceration (perforation) NFS

minor (superficial) major complex (amputation; avulsion: massive: rupture) 0 Perineum NFS

contusion (hematoma) laceration (perforation) NFS

minor (superficial) major complex (avulsion; massive: rupture) 8 Placenta abruption NFS

blood loss > 20% by volume a Rectum NFS contusion (hematoma) laceration NFS no perforation (partial thickness; < 50% of circumference) (O/S Grades I and II) perforation (full thickness: 2 50% of circumference) (O/S Grade //I) perforation (full thickness: extending into perineum) (O/S Grade IV) massive (avulsion; complex; rupture: tissue loss: devascularization; gross fecal contamination of pelvic space) (O/S Grade V) 6 Retroperitoneum hemorrhage or hematoma [If this injury occurs in combination with other abdominal injury, code it separately using this description o& if it can be determined that it is unrelated to the other injury. This description may also be used when no anatomical injury has been documented.] The following organs or structures, when injured, may cause retroperitoneal hemorrhage: pancreas, duodenum, kidney, aorta, vena cava, mesenterlc vessel: also pelvic or vertebral fractures. (O/S Grade I)

543800.3

98

CODE

-ASPECT

INJURY DESCRIPTION

544099.1 544010.1 544020.1 544022.1 544024.2 544299.2 544210.2 544212.2

Scrotum

NFS contusion (hematoma) laceration (perforation) NFS minor (superficial) major (amputation: avulsion; complex)

Spleen NFS contusion (hematoma) NFS minor (superficial; subcapsular 5 50% surface area; intraparenchymal, nonexpanding 5 5cm in diameter) (O/S Grade I or /I) major (subcapsular > 50% surface area or expanding; ruptured subcapsular or parenchymal; intraparenchymal > 5cm in diameter or expanding) (O/S Grade III) laceration NFS (rupture) minor (superficial: simple capsular tear i 3cm parenchymal depth: no major (i.e., trabecular) vessel involvement) (O/S Grade I or I/) moderate (no hilar or segmental parenchymal disruption or destruction: > 3cm parenchymal depth or involving major (i.e., trabecular) vessels) (O/S Grade 111) major (involving segmental or hilar vessels producing major devascularization of > 25% of spleen with no hilar injury) (0I.S Grade IV) complex (with hilar disruption producing total devascularization; tissue loss; avulsion; stellate; pulpefication) (06 Grade V) rupture (fracture) NFS [Use this code gg!y when a more detailed injury description is not available.]

544214.3

544220.2 544222.2

544224.3

544226.4

544226.5

544240.3 544499.2 544410.2 544420.2 544422.2 544424.3 544426.4 7 Stomach

NFS contusion (hematoma) laceration NFS no perforation (partial thickness) perforation (full thickness) (O/S Grade /.J (O/S Grade I)

(O/S Grades /I and Ill)

massive (avulsion; complex; rupture: tissue loss: with major vessel involvement) (O/S Grades IV and V)

99

CODE

ASPECT

INJURY DESCRIPTION

544826.3

545026.3 545028.4

massive (avulsion; complex; rupture: tissue loss) (O/S Grade A) with posterior tissue loss (O/S Grade V)

100

-.-

CODE

-ASPECT

INJURY DESCRIPTION

545240.3

complex (awlsion; massive; rupture; involving uterine artery; placental abruption > 50%)

545424.2 545426.3 545699.1 545610.1 545620.1 545622.1 545624.2 545626.3 0 Vulva NFS

major (deep) (O/S Grade 111) complex (avulsion; massive: rupture) (O/S Grades /V and V)

contusion (hematoma)

(O/S Grade 1)

laceration (perforation) NFS minor (superficial) (O/S Grade II)

major (deep) (O/S Grade /I/) complex (avulsion; massive; rupture) (O/S Grades IV and V)

101

CODE

ASPECT

INJURY DESCRIPTION

Lumbar spinal Pelvis

[see SPINE]

[see LOWER EXTREMITY for bony pelvis]

102

Diaphrqm

I +----

Gallbladder Pancreas Duodenum

Diapnragm Spleen Adrenal Kidney Abdominal Ureter Bladder Jrt?rhra Xectum Adopted Additional from: Source Source illuscrncions: (Z), (61, Fig. 2-26 - tap p. 90 - bottom Jacob. et al.. pp. 453. 460, 463. I ;:;-y-jj,#y+;..~.,,::: 494. 496

gland

aorta

103

la---

Ovarian

(Fallopian)

cube

Bladder

Adapted from: source Additional illusrrarione:

(5).

p. 567. 572 Jacob, et .al..

pp. 508, 567-a.

573-4
Mid-saggital male SeCtiOn pe1v1s of

104

CERVICAL SPINE
Codina Rules AIS Uncertainfy Rule

If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injurys category).

Whiplash Cervical spine strain may, in some cases, still be referred to as whiplash. Whiplash is not a medical term and is not used in A&SO. If an injury is described as whiplash, it should be coded as; cervical spine strain (no fracture or dislocation) 640276.1,6 provided the guidelines below are followed: (a) Interviewee reports: ER reports: Code: Interviewee reports: ER reports: Code: Interviewee reports: El3 reports: Code: Interviewee reports: ER reports: Code: Whiplash. Pain, stiffness, orlimited ROM in neck but does not diagnose strain. Do not code whiplash since ER, in essence, ruled it out. Whiplash. Neck supple and does not diagnose strain. Do not code whiplash since ER, in essence, ruled it out. Whiplash. (No medical attention sought.) Do not code whiplash. Whiplash. (No indication that neck was specifically examined.) Code whiplash, data source interviewee (since ER did not rule out its possibility). For NASS purposes,

(b)

(c)

(d)

Neck injuries may sometimes be described as strains and sometimes as sprains. neck injuries should be coded as strains.

Interviewee allegations of upper back strain or lower back strain are subject to the same test i.e., (a) through (d) above as an interviewee reported whiplash. Strain vs Sprain The following definitions have been used traditionally to differentiate sprain and strain injuries: & &&a j&t injury which causes pain and disability depending ligaments and muscle tendons near the joint. an injury to a muscle or musculotendinous be associated with a sprain or fracture. on the degree of injury to and may

unit that results from overstretching

In common medical practice, however, physicians often do not adhere strictly to these definitions, and may use the terms interchangeably. Care should be exercised in selection of the proper code; use Sprain for joint injuries and strain for muscle injuries. Neck injuries may sometimes be described as strains and sometimes as sprains. neck injuries should be coded strains (see above definitions). For NASS purposes,

105

Non-Contactlnjucy Sources - Codes firein vehicle, and air bag exhaust gases These noncontact injurysources (a)

flying glass , othernoncontactinjury

source,

are to be used only for the following specific types of injuries:

head or neck injuries in which the torso is supported (e.g., by seat back or belt) and head or neck experiences traumatic forces due to inertial motion -- code other noncontact injury source; flying glass injuries -- code flying glass; burns due to chemicals or gaseous inhalation -- code other noncontact injury source; burns due to flame -- code fire in vehicle; and burns due to air bag exhaust gases -- code air bag exhaust gases.

(b) Cc) W W

The following example illustrates the above definitions.

Injury Mechanism InJulJ From Crash Evidence

Determined lniuw Source

Examole 1 Neck strain 640278.1

a. b.

head strikes windshield forehead hits roof of convertible top c. head strikes steering wheel rim d. back hits seatback, no head restraint, head rolls back over seat e. neck forced into lateral flexion by impact forces f. torso restrained by belt, head and neck inertia causes neck injury g. back hits seat back, head hits head restraint, neck is injured

a. windshield b. roof or convertible top c. steering wheel rim d. other noncontact injury source e. 1. g. other noncontact injury source other noncontact injury source head restraint

Valid AsDect Codg: 6 (P) Not coded: Kyphosis. lordosis, scoliosis

kyphosis lordosis scoliosis

= abnormal increase in anterior convexity, thoracic spine (lateral view) = abnormal increase in anterior concavity, cervical and lumbar spine (laieral view) = appreciable lateral deviation in the normal straight vertical line of the spine

CODE

- ASPECT

INJURY DESCRIPTION

615099.7 615999.7

Blunt/traumatic injury)

cervical

spine injury NFS (includes unspecified cord

died without further evaluation. no autoosv

ragnosis of compression

or epidural or

(Brown-Sequard) 640212.4 640214.4 640216.4 640218.4 640220.5

syndromes) but NFS as to fracture/dislocation

with no fracture or dislocation with fracture with dislocation with fracture and dislocation complete cord syndrome NFS (quadriplegia or paraplegia with no

107

CODE

- ASPECT

INJURY DESCRIPTION

640221.5

C-4 or below NFS as to fracture/dislocation,

of NFS as to

640264.5 640266.5 640268.5 640269.6 640270.6 640272.6 640274.6

with fracture with dislocation with fracture and dislocation C-3 or above NFS as to fracture/dislocation with no fracture or dislocation with fracture with dislocation

CODE

-ASPECT

INJURY DESCRIPTION

THORACIC SPINE
Codina Rules AIS Uncertainty Rule

If there is any question about the severii of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injurys category).

Valid Aspect Codes: 7 (3

l - 1.2,4,7.8,9.0

1,2.4.7.8,9.0

(R.L,C,S,I,U,W,)

(R.L.C,S,I,U,W)

111

CODE

ASPECT

INJURY DESCRIPTION

616099.7 616999.7 690099.1 690202.1 690402.1 690600.1 690602.1 690604.2 690606.3 690600.1 690802.1 690804.2 690806.3

Blunt/traumatic injury)

thorecic

spine injury NFS (includes unspecified cord

died without further evaluation, no autopsy * Skin/subcutaneous abrasion contusion (hematoma) laceration NFS minor (superficial) mafor (5 1Ocm long and into subcutaneous blood loss > 20% by volume avulsion NFS superficial* (minor: s 100cm) major (> 1OOcm but blood loss 5 20% by volume) blood loss > 20% by volume tissue) tissue/muscle NFS

See page 151 for diagram of actual injury size. 112

CODE

- ASPECT

INJURY DESCRIPTION

r motor function; includes lateral

640440.5 640442.5 640444.5 640446.5 640448.5 640450.5 640460.5 640462.5 640464.5 640466.5 640468.5 incomplete cord syndrome NFS as to fracture/dislocation (preservation of some sensation or motor function) with no fracture or dislocation with fracture with dislocation with fracture and dislocation complete cord syndrome NFS as to fracture/dislocation (paraplegia with no sensation or motor function) with no fracture or dislocation with fracture with dislocation with fracture and dislocation 113

CODE

- ASPECT

INJURY DESCRIPTION

650499.2 650400.2 650402.2

Disc injury NFS herniation NFS without nerve root damage (radiculopathy)

650416.2

114

LUMBAR SPINE
Codina Rules AIS Uncertainty Rule

If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injurys category).

Valid Asmct

Code:

8 (I) SPINE]

WHOLE AREA [See THORACIC

115

CODE

-ASPECT

INJURY DESCRIPTION

630602.3

116

CODE

- ASPECT

INJURY DESCRIPTION

Cord contusion NFS (includes the diagnosis of compression

or epidural or

640610.4

CODE

ASPECT

INJURY DESCRIPTION

650604.2

Fracture without cord contusion or laceration with or without dislocation

650634.3 650684.1 630699.2 630660.2 630662.2 630664.2 630666.3 630668.2 630670.2 0 8 lnterspinous

major compression ligament

(> 20% loss of height)

laceration (disruption)

Nerve root or eacral plexus, single or multiple, NFS contusion (stretch iniury) laceration NFS single multiple avulsion (rupture) NFS single

640678.1

Strain, acute with no fracture or dislocation

118

Pedicle

\\

TRORACIC (DORSAL)

II

Lu?mAR

SACRAL

COCCYcFAL

Addirional

i11"srracio"s:

Jacob. et al.. PP. 112-3, 248. 252. 256-7

119

UPPER EXTREMITY
Codina Rules Rule information,

AIS Uncertainty

If there is any question about the seventy of an injury based upon all available documented code conservatively (i.e., the lowest AIS code in that injurys category).

Undetermined

Type of Anatomic

Structure

- Coda Skin

If the medical or interview information indicates a contused knee, elbow, wrist, ankle, etc., and does not specifically state whether the contusion is to the bone or joint, code the injury as integumentarylskin. If the contusion is known to be the bone or joint, code using the Skeletal or Skeletal-Joints Example: Contused right elbow, 790402.1 ,l Contused left knee elbow, 750610.1,2 Section.

Joint - Ligament

Injuries and associated

Joint injuries involving fracture, dislocation, or fracture and dislocation of the extremities ligament/tendon injuries do 6gt require a separate code for the ligament/tendon injuries. If an injury is described as an avulsiotichip injury as a rupture (laceration).

fracture, then treat this injury as a ligament injury and code the

Valid Codes and Aspects

for Seat Belt Contusions

For seat belt bruises due to a three-point system, code: Shoulder Chest Abdomen 790402.1,1,2 (R,L) 490402.1,1.2.4,0 (R,L,C,W) 590402.1,1,2,4,7,&O (R,L,C.S,I,W)

Code 790402.1 ,1,2, 490402.1,4, and 590402.1.4 if unspecified. [Note: Code only those injuries that are consistent with the type of restraint worn (e.g., do not code 790402.1 or 490402.1 if only a lap belt was used).] Crush Crush is a description of etiology, not of injury. However, it is included because it is used in medical charts. Crush for coding purposes means destruction of skeletal, vascular and soft tissue systems. The Crush injury description is used only when the injury meets the criteria in the dictionary. If the Crush code is used, individual injuries are not coded separately. In order to code Crush*, the following specific information should be known: Extremity massive destruction of bone and internal structures (i.e., muscle and/or vascular system).

Open Fracture An open (compound) fracture, by definition, means that the skin overlaying the fracture is lacerated. external laceration is implicit in the code for open fracture and is not coded separately. The

121

Multiple

Fractures

in a Bone

For multiple fractures tothe same bone: (4 (b) If multiple fractures to the same bone are determined, then code each separately. If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one cornminuted fracture. Assign one line of code with the appropriate AIS.

Air Bag Related Air bag related is coded when a body part set in motion by a deploying air bag contacts a component which produces an injury. Example: Deploying airbag flings arm into A-pillar which produces a fracture. Code Injury Source as A-pillal and Direct/indirect Injury as air bag related.

DO NOT use air bag related if the air bag produced the injury.

Valid AsDect Codes: + - I,29

1,2,3,9 (R,L,B,U)

(R,L,U)

! - 1,2.3.9 (R.L.B,U)

122

CODE

ASPECT

INJURY DESCRIPTION

715000.2

790604.2 790606.3 790600.1 790802.1 790604.2 I awlsion

major (5 IOcm long on hand or 20cm on entire blood loss > 20% by volume NFS superficial extremity) (5 25cm on hand or 5 lOOcm* on entire

major (> 25cm on hand or > 1OOcm on entire extremity)

* **

See page 151 for diagram of actual injury size. Increased pressure in a confined anatomical space adversely affects the circulation and threatens the function and viability of the tissue. 123

DeSCriptiOnS savaral vassal lacerations distinguish between complete and incomplete for transection. See footnotes g and h. The terms laceration: punctura. and perforation are oftentimes used in!erchangeably to describe vessel injuries. and are of the same severity. When perforation or puncture is used. coda as laceration.

CODE

ASPECT

INJURY DESCRIPTION

(superficial; incomplete transection: volume)

incomplete circumferential

involvement;

blood loss < 20% by

(rupture: complete transection: segmental loss; complete circumferential blood loss > 20% by volume) 124

involveAent;

CODE

-ASPECT

INJURY DESCRIPTION

721099.1 721002.1 721004.1 721006.1 721008.3 721299.1 721202.1 721204.1

Other named arteries NFS (e.g., distal to elbow or small arteries of extremities) intimal tear, no disruption laceration (perforation. puncture) NFS minoP major

Other named veins NFS (e.g.. distal to elbow or small veins of extremities) laceration NFS mine+

(superficial; incomplete transection; incomplete circumferential volume)

involvement; blood loss 5 20% by

(rupture; complete transection; segmental loss; complete circumferential blood loss > 20% by volume) 125

involvement;

CODE

ASPECT

INJURY DESCRIPTION

Brachial 730299.1 730202.1 730204.1 730499.1 730410.1 730420.1 730430.2 730440.2 + +

Plexus

[see SPINE]

Digital nerve NFS contusion [Use for diagnosis of palsy] laceration Median, radial, or ulnar nerve NFS contusion [Use for diagnosis of palsy] laceration NFS single nerve multiple nerves

126

CODE

ASPECT

INJURY DESCRIPTION

740200.1 740210.1 740220.1 740400.2 740402.1 740600.2

Tendon laceration (rupture, tear, avulsion) NFS multiple tendons (in hand) multiple tendons (other than hand) Muscle laceration (rupture, tear, avulsion) Muscle strain or contusion Joint capsule laceration (rupture, tear, avulsion)

127

CODE

ASPECT

INJURY DESCRIPTION

751099.1 751010.1 751020.1 751030.2 751040.2 751050.3 751299.1 751210.1

Shoulder

(glenohumerel contusion sprain dislocation laceration into joint

joint) NFS

massive destruction of bone and cartilage (crush) + Sternoclavicular contusion joint NFS

751230.2 751240.2

dislocation laceration into joint

128

CODE

ASPECT

INJURY DESCRIPTION

751499.1 751410.1 751420.1 751430.2 751440.2 751450.3

Wrist (carpus) joint NFS (capitate, hamate, lunate, pisifon, [navicular), trapezium, trapezoid, triquetrum) contusion sprain

scaphoid

dislocation at radiocarpal. intercarpal or pericarpal articulations laceration into joint massive deStructiOn of bone and cartilage (crush)

129

CODE

ASPECT

INJURY DESCRIPTION

orearm fracture NFS [Use only if more specific anatomic information is

130

Radius : Head Neck

fuberosity Sryloid process

Ulna: 01ecranon process Coronoid process

4i
7

I 1 Ill

Head

Adapted rrorn: source (8). P. 162

Additional illustrations: .Incob, et al.. pp. 118-21

131

Carpal* : capitate, lunate,

hamare, pisiform; (radial! (ulnar)

Lateral 6 medial epicondyles Radial head 01ecranon

Radial

nerve

Ulnar

nerve

Adapted Additional

from:

Source source 8ource illustration:

(8). (a). (7).

p. I68 p. 166 p. 206-7 Jacob. et

top left - right al., p.

132

132

LOWER EXTREMITY
Codina Rules Rule information,

AIS Uncertainty

If there is any question about the severity of an injury based upon all available documented code conservatively (i.e., the lowest AIS code in that injurys category).

Undetermined

Type of Anatomic

Structure

- Code Skin

If the medical or interview information indicates a contused knee, elbow, wrist, ankle, etc., and does not specifically state whether the contusion is to the bone or joint, code the injury as integumentary/skin. If the contusion is known to be the bone or joint, code using the Skeletal or Skeletal-Joints Example: Contused right knee, 890402.1 .l Contused left knee joint, 850802.1,2 Section,

Multiple

Fractures

in a Bone

For multiple fractures to the same bone: (a) W If multiple fractures to the same bone are determined, then code each separately. If the fractures cannot be differentiated, or if the fracture is nonspecific, then it should be considered as one comminuted fracture. Assign one line of code with the appropriate AIS. Exceptions: pubis multiple fractures to the pubis (right, left, inferior, and/or superior) are assigned one line of code determined by the particular fracture type.

Joint - Ligament

Injuries and associated

Joint injuries involving fracture, dislocation, or fracture and dislocation of the extremities ligament/tendon injuries do g&t require a separate code for the ligament/tendon injuries.

If an injury is described as an avulsionJchip fracture, then treat this injury as a ligament injury and code the injury as a rupture (laceration).

Crush is a description of etiology, not of injury. However, it is included because it is used in medical charts. Crush for coding purposes means destruction of skeletal, vascular and soft tissue systems. The Crush injury description is used only when the injury meets the criteria in the dictionary. If the Crush code is used, individual injuries are not coded separately. In order to code Crush, the following specific information should be known: Extremity massive destruction of bone and internal structures (i.e., muscle and/or vascular system).

133

Open Fracture

The

An open (compound) fracture, by definition, means that the skin overlaying the fracture is lacerated. external laceration is implicit in the code for open fracture and is not coded separately.

Valid Aspect Codes:

1,2,3,5,6,9.0

(R,L.B,A,P,U,W)

+ - 1,2,9 (R,L,U) ? - 1,2,5,6,9 (R,L.A.P,U) ! - 1,2,3,9 (R,L,B,U)

Valid Aspect Codes for Pelvis:

Acetabulum Coccyx and/or Sacrum Ilium and/or lschium Pubic ramus

129 6 1.23 5

RLSJ) 03 O=i,L,U) (4

134

CODE

ASP&T

INJURY DESCRIPTION

tern but NFS as to sit

890600.1 890602.1 890604.2 890806.3 890800.1 890802.1 890804.2 890806.3

laceration NFS minor (superficial) maior* (> 20cm long and into subcutaneous blood loss > 20% by volume avulsion NFS superficial* (minor: < 100cmz) major (> lOOcm*) blood loss > 20% by volume tissue)

See page 151 for diagram of actual injury size. Increased pressure in a confined anatomical space adversely affects the circulation and threatens the function and viability of the tissue. 135

Descriptions for several vessel lacerations distinguish between complete and incomplete transection. See footnotes g and h.

The terms laceration; pun&e. and perforation are oftentimes used interchangeablyto describe vessel injuries, and are of the same severity When perforation or puncture is used, code as laceration.

CODE

ASPECT

INJURY DESCRIPTION

820806.3

~;;;cial;

incomplete transection;

incomplete circumferential

involvement; blood loss i 20% by

(rupture; complete transection; segmental loss; complete circumferential blood loss > 20% by volume) 136

involvement;

CODE

-ASPECT

INJURY DESCRIPTION

821099.1 621002.1 621004.1 821006.1 621008.3 821299.1 621202.1 821204.1

Other named arteries NFS (e.g., distal to knee or small lower extremity arteries) intimal tear, no disruption laceration (perforation, puncture) NFS minoP majo?

Other named veins NFS (e.g., distal to knee or small lower earemity veins) laceration (perforation, puncture) NFS minoP

g h

(superficial; incomplete transection; incomplete circumferential volume)

involvement;

blood loss 5 20% by

(rupture; complete transection; segmental loss; complete circumferential blood loss > 20% by volume)

involverhent;

maCODE ASPECT INJURY DESCRIPTION 830299.1 830202.1 830204.1 830499.2 830402.2 830404.3 830406.3 830408.3 830699.2 830602.2 830604.2 830606.2 830608.2 + + + Digital nerve NFS contusion laceration Sciatic nerve NFS contusion (neuropraxia) laceration NFS incomplete complete Femoral, tiblsl, peroneal contusion laceration, avulsion NFS single nerve multiple nerves nerve NFS

138

CODE

ASPiCT

INJURY DESCRIPTION

139

CODE

ASPECT

INJURY DESCRIPTION

Ankle (Tarsus) Joint NFS (calcaneus. cuboid. cuneifons (medial, intermediate, and lateral), navicular {scaphoid), talus (talar)) [Use this category only if specific anatomy is unknown. If fibula, tibia or talus is

850699.1

CODE

-ASPECT

INJURY DESCRIPTION

851610.2

open/displacectkomminuted

(any or

651614.3

oDenldisDlaced/comminuted

(anv or

141

CODE

ASPECT

INJURY DESCRIPTION

851800.3 851801.3 651804.3 851808.3 851810.3

Femur fracture but NFS as to site [See Pelvis for Hip fracture.] open/displaced/comminuted site condyfar head intertrochanterfc (any or combination) but NFS as to

651814.3 851818.3 851822.3 852000.2 +

shaft subtrochanteric supracondyfar

I
852002.2 +

Foot fracture NFS [Use only if more specific anatomic infonation 1 unknown.] I Leg or Ankle fracture NFS [Use only if more specific anatomic information is unknown.] Malleous fracture [see Fibula]

is

852200.2 852400.2 852600.2

+ + ?

Metatarsal

or Tarsal fracture

Patella fracture Pelvis fracture NFS, with or without dislocation, of any or one combination: acetabulum, ilium, ischium, coccyx, sacrum, pubis and/or pubic ramus [Enter one line of code per aspect. Simple closed fractures of superior and inferior right or leff rami are not coded as comminuted fractures, but as closed fracture. Use this code for diagnosed hip fracture not further described anatomical1y.l closed openldisplacedlcomminuted (any or combination)

852602.2 852604.3 852606.4 0

substantial deformation and displacement with associated vascular disruotion or with maior retrooeritoneal hematoma: ooen book fracture: NFS as to blood loss (crush) blood loss 5 20% by volume blood loss > 20% by volume

852608.4 852610.5 852800.3 853000.3 6 5 Sscroilium Symphysis

fracture with or without dislocation pubis separation (fracture)

Femur bone order: head, neck, greater trochanter, intertrochanteric, lesser trochanter, shaft, medial condyle, lateral condyle. The proximal portion of the shaft is subtrochanteric; the distal part of the shaft is supracondylar.

CODE

- ASPECT

INJURY DESCRIPTION

853602.1 853604.2 I I amputation

Tibia bone order: condyles, intercondyioid

spine, shaft, malleoli. 143

Head h [Femur:

Posterior

Adapted from: Source Additional illustration:

(8).

p. 173 Jocob, et al..

p. 122

144

Fibular collateral ligamenr Lateral h medial meniscus (semil"nar) Tibia1 collateral 1igWJXllt

Pacellar Patella

ligament

Anterior (~parella

CX.4

pulled

. 1
Knee joint

Sciatic nerve

Posterior

Tibia1 COllater?Al ligament

Adapted Addirional

from:

source source illuscrnCione:

(5). (3).

p. 138-9 - lefr p. 203 - right 3acob. et al..

PP.

l'+O.

262

145

Digits/Phalanges-

UMlE

Tarsals:

calcaneus (heel), cuhoid. cuneiforms, navicu1ar, ra1vs Fibular Tibia1 coverage caverage

Fibula Tibia Lateral Medial malleolus malleolus

Digits/ Phalanges

MetaCarSalS

Tarsals

Adapted from: Source Additional illustrations:

(8).

p. 177 Jacob, et al.,

pp.

125-6

146

Ilium Sacroiliac joint

S*CrTO coccyx Femur :

Symphysis Pubic Pubic lschium

pubis (su,erior) (inferior)

Head Neck Greater trochanrer Intercrochanferic line

ramus ramus

Acerabulum

Female

Adapted from: source Additional illustrations:

(6).

p. 57 Jacob,

et al..

pp.

123-4

147

EXTERNAL - Skin and Subcutaneous

Codina Rules AIS Uncertainty Rule

Tissue

If there is any question about the severity of an injuly based upon all available documented code conservatively (i.e., the lowest AIS code in that injurys category).

infonation.

Valid AsDect Codes: > - 9,0 (U,W)

9,0 (U,W)

I
CODE 990200.1 990400.1 990600.1 990600.2

This section should be used only if no information is available on a specific body part or area. Multiple minor external injudes to one or more body regions should be coded as one injury (AIS 1) using this section, e.g., coverall abrasions = 990200.1 or multiple lacerations = 990600.1.

ASPECT

INJURY DESCRIPTION

> 5 > >

Abrasion Contusion (hematoma) Laceration Avulsion

149

EPIDERMIS

Sweat

gland DERMIS

Oil Hair

gland shaft

SUSCUTANEOUS TISSUE

Adapted Additional

from: Source illustrations:

(a),

p.105 Jacob.

et

al..

p.77

150

DIAGRAM OF ACTUAL INJURY SIZE

lOcm/3.9 in.

20cm/7,8 in.

100cm2/15.5 in.?

25cm2/3.9 in.2

151

BURNS
Codina Rules

AIS Uncsrtainiy

Rule

If there is any question about the severity of an injury based upon all available documented information, code conservatively (i.e., the lowest AIS code in that injurys category).

Varying Bum Degrees When burns occur in varying degrees, code the most serious burn.

Bodv Reaion: (-) Any Region (l-9) Valid Aspect Code: $ (Any valid aspect for Body Region coded)

153

The following bum injury descriptions are not a substitute for a comprehensive bum scale. but only intended as gross estimates of the severity. If a bum amputation occurs, code as amputation in bcdy region. If ampuiation is required sometime after the event, code the bum, not the amputation.

CODE

ASPECT

DEGREE

TOTAL BODY SURFACE*

-92008.2

992028.5

face/hand/genitalia 2 or 3 (or full thickness)

involvement 40-89% t 90%

992030.5 992032.8

0 0

2 or 3 (or charring to head or trunk or

Total body surface (TSS) is assessed by using the diagram of nines that follows. entire upper extremity (all sides) is 9% of the TBS. 154

For example, one

RULE OF NINES

\ :I \

Reprinted American American

with permi ,ssion 0: al Fqn Associ ation College of SUrgeOn,

OTHER TRAUMA

CODE

ASPECT

INJURY DESCRIPTION

919200.2

Inhalation injury NFS including nonintentional carbon monoxide exposure Absence of carbonaceous deposits, erythema, edema, bronchorrhea or ObStNCtiOn

=F
919202.3 919204.4 919206.5 919208.6 I

919201.2

minor or patchy areas of erythema, carbonaceous deposits in proximal or distal bronchi (below 20mg% carboxyhemoglobin) [any or combination] moderate degree of erythema, carbonaceous deposits, bronchorrhea with or without compromise of the bronchi (20-40mg% carboxyhemoglobin) [any or combination] severe inflammation with friability copious carbonaceous deposits, bronchorrhea, bronchial obstruction (5 40mg% carboxyhemoglobin) [any or combination] Evidence of mucosal sloughing, necrosis, endoluminal obliteration [any or combination1

157

_-

Anatomical

Position

and Regional

Names

Adapted

from:

SCUI-C~ (8).

P.20

158

Principal

Arteries

Superficial Posterior Exrernal Vertebral auricular carotid Common carotid Left Arch

temporal

Rrachiocephalic (innominate)

subclavian of aorta

Thoracic

aorta

Ahdominal aorta Inferior mesent Common iliac Internal ili External iliac

TcsticularlOvarian

Deep palmar Superficial

arch palmar

arch

Anterior losterior

tibia1 tibia1

Dorsalis Dorsal Anterior Adapted from: source (8). p. 471 View

pedis arch

159

Principal

Veins

External Internal

jugular jugular Subclavian Cephalic I Axillaty Great cardiac Rrachial Basilic Splenic

Brachiocephalic Superior Anterior vena cava cardiac

Superior Inferior Iiiac :

mesenteric Venb cava

Renal Inferior

mesenteric

Falmar

digitals

it---

Posterior

tibia1

Adapted

from:

SourCe

I?,),

p. 478

160

NERVES

Brachial

plexus

Lumbar

plexus

sacra1

plexus

Common peroneal (Lateral Poplit

Common peroneal Superficial pel

(Medial

Popliteal) Deep peroTlea

Anterior

View

Adapted

from:

Source

(I),

p.

140

161

llllNC1lAl.

PLEXUSES

amI NERVES

Lumbar Cauda Sacra1 Coccygeal Pudendal ;,Sciatic

plexus equina plexus plexus

Adapted

from:

Source

(7).

p.

20s

162

- Triceps l.arissims dOTSi

auteus maximus >c

Quadriceps:

NiiJ

::_ HLlCX~igS!

t-

Biceps femoris Semirendinosus Semimembranors

Adapted Additional

from: Source illustrations:

(61,

p.113 Jacob,

et

al.,

pp.lST-201

163

Internal jugular Y. tomnon cararid a.

Lobes

of right

lung

,.

+-

Pulmonary Heart

Y.

Inferior Adrenal

vena cava gland

crura of diaphragm Kidney

yjy ,&+ I! ,,.. I

i ; Esophagus Celiac trunk Spleen

Penis

(cut)

Epididymis Tesris scrorum

Adapted

from:

Source

(5).

P. 17

164

Lung Descending Prriocardial

Esophagus
aorra cavj

Ascending tlesenrery

colon (cut) L&

A-Descending

Transverse colon Jejunum (cut) colon Aorta tomon artery

Sigmaid

iliac and vein colon

Appendix Urerine tube Broad ligament Round ligament LerS

-Rectum -

ouary uterus

of

Adapted

from:

source

(5).

P. 16

165

Right brachiocepha: Wi Subclavian vein Cephalic vein Axi11iary vein Delmid muscle upper, middle & lover lobes Of right lung
Brachial vein

Ascending cecum lipperdix

colon

spermatic cord

Adapted

from:

source

(5).

p.

15

166

Pectoralis minor muscle (cut head) Cephalic vein Lhillary vein - killary artery l.efr. lung -PPericardial sac

Gallbladder crearer omenturn Ascending colon cecum

Sromach Transverse colon

Descending

calm,

Adapted

from:

source

(5))

P. 14

167

PART IV DICTIONARY INDEX

Page 89

Anatomical

Description

Section Abdomen & Pelvic Contents

36 142 139 36 128 130 93 57 140 93 90 75 75 75 130 109 109 36 124 124 32 93 124 107 124 75 75 37 74 79 79

Abdomen, whole area [use for Abdominal injury NFS, Penetrating or Skin] Abducens nerve Acetabulum [see Pelvis] Achilles tendon Acoustic nerve Acromioclavicular joint Acromion Adrenal Gland Alveolar ridge [see also Teeth in Face, Page SE] Ankle Anus Aorta abdominal thoracic Aortic root Aortic valve Arm NFS Atlanta-axial Atlanta-occipital Auditory nerve [see Acoustic nerve] Axillary artery Axillary vein Basilar artery Bladder (urinary) Brachial artery Brachial plexus Brachial vein Brachiocephaiic artery Brachiocephalic vein Brain stem Breast Bronchus distal to main stem main stem 169

Head Lower Extremity Lower Extremity Head Upper Extremity Upper Extremity Abdomen 8 Pelvic Contents Face Lower Extremity Abdomen & Pelvic Contents Abdomen & Pelvic Contents Thorax Thorax Thorax Upper Extremity Spine (cervical) Spine (cervical) Head Upper Extremity Upper Extremity Head Abdomen & Pelvic Contents Upper Extremity Spine (cervical) Upper Extremity Thorax Thorax Head Thorax Thorax Thorax

Page 141 55 65 54 65 32 65 32 129 128 129 116 32 90 37 32 33 33 39 71 79 55 130 142 139 94 55 55 76 35 68 139 94 64 135 123 149

Anatomical

Description

Sectlon Lower Extremity Face Neck Face Neck Head Neck Head Upper Extremity Upper Extremity Upper Extremity Spine (lumbar) Head Abdomen 8 Pelvic Contents Head Head Head Head Head Thorax Thorax Face Upper Extremity Lower Extremity Lower Extremity Abdomen & Pelvic Contents Face Face Thorax Head Neck Lower Extremity Abdomen & Pelvic Contents Neck Lower Extremity Upper Extremity External 170

Calcaneus Canaliculus (tear duct) Carotid artery common external external internal internal Carotid - cavernous sinus Carpal joint [see Wrist] Carpal - metacarpal joint Carpus Cauda equina Cavernous sinus Celiac artery Cerebellum Cerebral artery anterior middle posterior Cerebrum Chest [see Thorax] Chordae tendinae Choroid Clavicle coccyx [see Pelvis] Collateral ligament Colon (large bowel) Conjunctiva Cornea Coronary artery Cranial nerve NFS Cricoid cartilage [see Larynx] Cruciate ligament [see Collateral ligament] Cystic duct Decapitation Degloving injury Degloving injury Degloving injury

Page 79 138 126 109 118 112 94 55 55 128 79 42 55 53 57 36 97 136 138 136 142 141 130 140 142 130 42 95 56 128 36 130 31

Anatomical

Description

Section Thorax Lower Extremity Upper Extremity Spine Spine Spine Abdomen & Pelvic Contents Face Face Upper Extremity Thorax Head Face Face Face Head Abdomen & Pelvic Contents Lower Lower Lower Lower Lower Upper Extremity Extremity Extremity Extremity Extremity Extremity

80

Diaphragm Digital Nerve Digital Nerve Disc cervical lumbar thoracic Duodenum Ear canal Ear NFS Elbow joint Esophagus Ethmoid bone [see Skull, base] Eye, whole organ or NFS Face, whole area [use for Penetrating or Skin] Facial bone(s) NFS Facial nerve Fallopian tube [see Ovarian tube] Femoral artery Femoral nerve Femoral vein Femur Fibula Finger Foot joint NFS bone NFS Forearm NFS Frontal bone [see Skull, vault] Gallbladder Gingiva (gum) Glenohumeral joint [see Shoulder] Glossopharyngeal nerve Hand NFS Head, whole area [use for Penetrating, Scalp, Head/ Brain injury NFS, Crush] Heart

Lower Extremity Lower Extremity Upper Extremity Head Abdomen 8 Pelvic COntentS Face Upper Extremity Head Upper Extremity Head

Thorax

_.

Page 140 130 69 36 37 95 90 90 142 55 75 75 128 141

Anatomical

Description

Section Lower Extremity Upper Extremity Neck Head Head Abdomen & Pelvic Contents Abdomen & Pelvic Contents Abdomen & Pelvic Contents Lower Extremity Face Thorax Thorax Upper Extremity Lower Extremity

Hip Humerus Hyoid bone Hypoglossal nerve Hypothalamus [see Brain stem] Ileum (small bowel) [see Jejunum] Iliac artery (common, internal, external) Iliac vein (common, internal, external) Ilium [see Pelvis] Inner ear Innominate artery [see Brachiocephalic Innominate vein artery]

109 114 118 80 80 32 80 55 142 95 127 66 66 95 140 94 68

[see Brachiocephalic vein] lnterphalangeal joint lnterphalangeal joint [see Metatarsal, Phalangeal or lnterphalangeal joint] lnterspinous ligament cervical lumbar thoracic Intra-atrial septum [see lntraventricular septum] Intracardiac valve Intracranial vessel NFS lntraventricular septum Iris lschium [see Pelvis] Jejunum (small bowel) Joint capsule NFS Jugular vein external internal Kidney Knee Large bowel [see Colon] Larynx

Spine Spine Spine Thorax Thorax Head Thorax Face Lower Extremity Abdomen & Pelvic Contents Upper Extremity Neck Neck Abdomen B Pelvic Contents Lower Extremity Abdomen & Pelvic Contents Neck r

172

Page 141 96 142 135

Anatomical

Description

Section Lower Extremity Abdomen & Pelvic Contents Lower Extremity Lower Extremity

80 a2 58 142 57 57 57 143 126 37 96 128 130

141 142 37 55 56 127 139 80 64

Lateral malleolus [see Fibula] Liver Leg NFS Lower extremity, whole area [use for Penetrating, Skin, Degloving, Amputation, Crush, Compartment syndrome] Lung Main stem bronchus [see Trachea] Malar [see Zygoma] Malleous Mandible Maxilla Maxillary sinus [see Maxilla] Medial malleous [see Tibia] Median nerve Medulla [see Brain stem] Mesentery Metacarpal - phalangeal joint [see Carpal-Metacarpal] Metacarpus [see Carpus] Metatarsus joint bone Midbrain [see Brain stem] Middle ear [see Inner ear] Mouth NFS Muscle NFS Muscle NFS Myocardium [see Heart] Neck, whole area [use for Penetrating or Skin]

Thorax Thorax Face Lower Extremity Face Face Face Lower Extremity Upper Extremity Head Abdomen & Pelvic Contents Upper Extremity Upper Extremity

Lower Extremity Lower Extremity Head Face Face Upper Extremity Lower Extremity Thorax Neck

173

Page

Anatomical

Description

Section

NeNe root
105 ii8 114 58 42 35 109 35 97 35 35 54 57 cervical lumbar thoracic Nose Occipital bone [see Skull, base or vault] Oculomotor nerve Odontoid Olfactory nerve Omentum Optic nerve intracranial segment intracananicular segment intraorbital segment Orbit [see also Optic nerve. intraorbital segment in Face, Page 541 Orbital roof [see SkulLbase] Ossicular chain (ear bone) Ovarian tube Ovary Pancreas Parietal bone [see Skull, vault] Patella Patellar tendon Pedicle cervical lumbar thoracic Pelvis Penis Pericardium Perineum Peroneal nerve [see Femoral, tibia& peroneal nerve] Phalangeal joint [see Metatarsal, Phalangeal or lnterphalangeal joint] Pharynx Phrenic nerve Pituitary gland 174 Spine Spine Spine Face Head Head Spine (cervical) Head Abdomen & Pelvic Contents Head Head Face Face

42 55 97 97 97 42 142 139 109 ii8 114 142 98 ai 98 138 141

Head Face Abdomen 8 Pelvic Contents Abdomen 8 Pelvic Contents Abdomen & Pelvic Contents Head Lower Extremity Lower Extremity Spine Spine Spine Lower Extremity Abdomen & Pelvic Contents Thorax Abdomen & Pelvic Contents Lower Extremity Lower Extremity

68 67 41

Neck Neck Head

Page
98 al 37 136 136 142 76 al 76 126 130 98 55 98 68 a3 ii8 142 142 33 68

-Anatomical

Description

Section Abdomen & Pelvic Contents Thorax Head Lower Extremity Lower Extremity Lower Extremity Thorax Thorax Thorax Upper Extremity Upper extremity Abdomen B Pelvic Contents Face Abdomen B Pelvic Contents Neck Thorax Spine (lumbar) Lower Extremity Lower Extremity Head Neck Head Upper Extremity Lower Extremity Face Abdomen B Pelvic Contents Upper Extremity Head Head External Head Head Head Head

Placenta Pleura Pons [see Brain stem] Popliteal artery Popliteal vein Pubic ramus [see Pelvis] Pulmonary artery Pulmonary region [see lung] Pulmonary vein Radial nerve [see Median, radial or ulnar nerve] Radius Rectum Retina Retroperiioneum Retropharyngeal area [see Pharynx] Rib cage Sacral plexus

[See NeNe root]

Sacroilium Sacrum [see Pelvis] Saggital sinus [see Superior longitudinal sinus] Salivary gland Scalp Scapula Sciatic nerve Sclera Scrotum Shoulder Sigmoid sinus Sinus NFS Skin NFS as to body region Skull base vault Sphenoid bone [see Skull, base or vault] Spinal accessory nerve
175

31 130
138 55 99 128 33 33 149 42 42 42 36

Page

Anatomical

Description

Section

107 116 112 109 ii8 114 99 128 a3 99 76 76 141 33 142 142 142 58 42 58 129 139 100 a2 a2 74

68 68 143 138 143 56 a2

Spinal cord cervical lumbar thoracic Spinous process cervical lumbar thoracic Spleen Sternoclavicular joint Sternum Stomach Subclavian Artery Subclavian vein Subtalar joint Superior longitudinal sinus Symphysis pubis Talus Tarsus [see Metatarsal or Tarsal] Teeth [see also Alveolar ridge in face, Page 571 Temporal bone [see Skull, base or vault] Temporomandibular joint Tendon NFS Tendon NFS Testes Thoracic cavity [see also Thorax, whole area] Thoracic duct Thorax, whole area [use for chest injury NFS. Penetrating or Skin] [see also Thoracic cavity] Thyroid cartilage [see Larynx] Thyroid gland Tibia Tibia1 nerve [see Femoral, tibial, peroneal nerve] Toe Tongue Trachea 176

Spine Spine Spine Spine Spine Spine Abdomen 8 Pelvic Contents Upper Extremity Thorax Abdomen & Pelvic Contents Thorax Thorax Lower Extremity Head Lower Extremity Lower Extremity Lower Extremity

Head Face Upper Extremity Lower Extremity Abdomen & Pelvic~ Contents Thorax Thorax Thorax

Neck Neck Lower Extremity Lower Extremity Lower extremity Face Thorax

Page 141

Anatomical

Description

Section Lower Extremity

141

109 ii8 114 33 36 35 55 130 126 123

100 100 93 101 55 101 67 78 92 91 76

109 ii8 114 34 66 109 ii8 114

Transmetatarsal joint [see Subtalar, transtarsal or transmetatarsal joint] Transtarsal joint [see Subtalar, transtarsal or transmetatarsal joint] Transverse process cervical lumbar thoracic Transverse sinus Trigeminal nerve Trochlear nerve Tympanic membrane (ear drum) Ulna Ulnar nerve [see Median, radial or ulnar nerve] Upper extremity, whole area [use for Penetrating, Skin, Degloving, Amputation, Crush] Ureter Urethra Urinary bladder [see Bladder] Uterus Uvea Vagina Vagus nerve Vagus nerve Vagus nerve Vena Cava inferior superior Vertebra [see dislocation or fracture] cervical lumbar thoracic Vertebral artery Vertebral artery Vertebral body cervical lumbar thoracic 1-n

Lower Extremity

Spine Spine Spine Head Head Head Face Upper Extremity Upper Extremity Upper Extremity

Abdomen 8 Pelvic Contents Abdomen & Pelvic Contents Abdomen 8 Pelvic Contents Abdomen 8 Pelvic Contents Face Abdomen 8 Pelvic Contents Neck Thorax Abdomen 8. Pelvic Contents Abdomen & Pelvic Contents Thorax

Spine Spine Spine Head Neck Spine Spine Spine

Page

Anatomical

Description

Section

Vessels Each body region, except the SPINE and EXTERNAL has a section titled Vessels. In addition to listing specific arteries and veins, a nonspecific description is included to code vessel injuries when precise information is lacking. The coder is urged to become acquainted with these default codes by body region. 55 / 36 55 68 101 129 58 Vestibular apparatus [see also Acoustic nerve in Head] Vestibular nerve [see Acoustic nerve] Vitreous Vocal cord Vulva wrist Zygoma Face Head Face Neck Abdomen & Pelvic Contents Upper Extremity Face

The following traumatic events to the whole body or an entire body region are listed as follows: 154 a2 157 43 a2 Bums Hemothorax NFS [see Thoracic cavity NFS] Inhalation Loss of Consciousness (including concussion) Pneumothorax NFS [see Thoracic cavity NFS] Bums Thorax Other Trauma Head Thorax

178

PART V MEDICAL TERMINOLOGY

This section consists of four parts: A. Glossarv of Anatomical and lniurv Terms

REFERENCES

Thisalphabetical listdefinestermsas used inthis manual withthepurposeof expediting injurycoding. Refer to your medical dictionary and/or anatomy textbook for additional information.

9.

Abbreviations,

Svmbols,

Weiahts and Measures

This section includes commonly used abbreviations, symbols, and weights/measures found in hospital records. It will aid the injury coder in interpreting and coding injury information. If you encounter an abbreviation, etc., not included here, consult a medical abbreviations dictionary.

C.

This part is comprised of three lists of common medical prefixes, roots, and suffixes. By recognizing the parts of a word, its definition may be extracted quickly without the assistance of a medical dictionary, thus building your vocabulary.

D.

Lav Terminoloav

- NASS Lesion Svnonvm

List (particularly in interviews) into injuries

This list attempts to translate laytermsfrequentlyencountered codeable in NASS.

E.

Fractures

This section includes fractures frequently encountered in NASS CDS. Refer to the Glossary or a medical dictionary for additional information.

179

A. GLOSSARY OF ANATOMICAL

& INJURY TERMS

abrasion wearing or rubbing away by friction of cells or tissues from an area of skin or membrane. amputation, traumatic cutting off of a body part, such as a limb, as a result of an injury angiography, cerebra/ radiographic visualization of the blood vessels supplying the brain, including the extracranial portions, after the introduction of contrast material aphasia loss or impairment of speech (due to trauma) autopsy an examination of the internal organs of a body after death for the purpose of determining the cause of death or studying the pathological changes present awlsion tearing away of a part of a body structure in which a portion is separated from underlying tissues and adjacent parts, and left hanging as a flap awlsion, major a tearing away of 95 cm2 of skin but blood loss 40% body; see page 151 for diagram of actual injury&e

by volume on the face or hand, or z-100 cm on the

avulsion, superficial a tearing away of 525 cm of skin on the face or hand, or z-100 cm on the body; see page 151 for diagram .of actual injury size Babinskis syndrome condition in which when the sole of the foot is stroked, the great toe turns upward instead of downward, indicating an organic lesion in the brain or spinal cord bilateral involving both organs or body parts where they exist in pairs (e.g.. eyes, ears, lungs, upper or lower exiremities) cauda equina collection of spinal nerve roots descending resembles a horses tail

from the lower part of the spinal cord; their appearance

a bony surface in the posterior skull formed by a portion of the basilar part of the occipital bone and the upper part by a part of the sphenoid bone coma a state of unconsciousness with inability to respond, either verbally or through other recognized body motions, even to painful stimuli computerized tomography (CT scan) the gathering of anatomical information from a cross-sectional plane of the body by using pencil-like x-ray beams to scan the section of the body being studied; it combines the speed of a computer with the sensitivity of x-ray detectors

180

concussion (of the brain) clinical syndrome characterized by immediateand transient impairment of neural function such as alteration of consciousness, disturbance of vision, etc., due to mechanical forces conjugate deviation deflection of two similar body parts (e.g., the eyes) in the same direction at the same time contrecoup occurring to a body part opposite the area of impact (e.g., a contrecoup injury to the shoulder is a direct result of trauma to the elbow) contusion (of the brain) structural alteration of the brain, usually involving the surface, characterized by brain tissue death, and due to mechanical forces contusion (integumentary) bruise characterized by hematoma without a break in the skin; commonly referred to as black and blue CT scan - see computerized tomography

decerebrate a type of movement, spontaneous or induced, characterized extremities and indicative of brain stem dysfunction

by extensor rigidity of one or both upper

decorticate atype of movement, spontaneous or induced, characterized by abnormal, inappropriate flexion of the upper extremity and extension of the lower extremity detachment separation of an anatomic structure from its support; most common example is detached retina of the eye, in which retina separates from choroid diastasis form of dislocation in which there is a separation of two bones normally attached to each other without existence of a true joint (e.g., symphysis pubis) dislocation displacement of a bone at a joint from its nonal anatomical position

distal a comparative ten indicating a point, structure or location further from the root or attachment point (e.g., the knee joint is distal to the hip) dura (also dura mater) outermost, toughest and most fibrous of the three membranes covering the brain and spinal cord edema presence of abnormally large amounts of fluid in the body tissue electroencephalogram (EEG) a diagnostic procedure used to detect brain disorders; it records underlying cerebral activity through a montage of externally applied scalp electrodes epidural situated upon or outside the outermost and most fibrous of the three membrane (dura) covering the brain and spinal cord

181

flail chest term used to d&cribe an abnormal ability for the chest to contract and protract (i.e., respiratory embarrassment) as a result of significant injuries to any one or more of the structures in the thoracic cavity (e.g., multiple rib fractures) flank the part of the body below the ribs and above the ilium footdrop dropping of foot due to paralysis of anterior leg muscles fracture break in a bone - see specific fracture for more precise definition fracture, avulsion or chip an indirect fracture caused by avulsion or pull of a ligament occurring at a joint fracture, basilar skull break in the base of the cranium fracture, blowout a break in the orbital floor forcing the orbital contents into the maxillary sinus: the eye muscles may be injured fracture, closed break in a bone that does not produce an open wound in the skin; commonly called a simple fracture fracture, cornminuted break in a bone in which the bone is splintered or fragmented fracture, compoundsee fracture, open

fracture, depressed skull break in the skull in which a fragment(s) is pushed inward, causing a change in the normal skull contour fracrure, displaced break in a bone that causes one segment to be moved out of its normal anatomical remainder of the bone fracture, linear a break in a bone extending lengthwise fracture, open break in a bone in which there is an external wound leading to the break: commonly called compound except in the head where open implies exposure of dura or brain surface (do not code any accompanying laceration unless the laceration was not caused by the fracture) fracture, ring a break in the base of the skull area surrounding foramen magnum (where spinal cord passes into skull): also referred to as annular basal fracture fracture, simp/e - see fracture, closed fracture, transverse break in a bone at right angles to the long axis of the bone fracture, undisplaced break in a bone that does not cause the bone to be moved out of its normal anatomical position relation with the

fracfure, (of the liver) sometimes used to describe laceration of the liver friction bums brush bums: bums caused by rubbing hematoma collection of blood within a confined area hemiparesis a slight paralysis on one side of the body hemiplegia paralysis on one side of the body hemomediasfinum a collection of blood around the structures (heart, esophagus, etc.) between the two pleural sacs that tine the thoracic cavity and encase the lungs hemorrhage blood flowing profuselyina relatively non-confined space, such as bleeding resulting from adeep laceration

hemothorax a collection of blood in the pleural portions of the thoracic (chest) cavity hernia an abnormal protrusion of an organ or other body part structure through a membrane or wall in which it is normally encased hygroma accumulation of cerebrospinal fluid in a specified part of the brain

hypesthesia condition of decreased pain sensation

lower portion of the small intestine, extending from the jejunum to the large intestine

incus
one of three small bones in the tympanic (ear) cavity infarction, cerebra/ an ischemic condition of the brain, producing a persistent focal neurological deficit in the area of one of the cerebral arteries inhalation bum a burn in the respiratory system caused by breathing of smoke or hot air ischemia localized decrease in the flow of blood usually due to an arterial obstruction jejunum the upper portion of the large intestine extending between the duodenum and the ileum laceration, complex a term sometimes used to describe a rupture to an internal organ

133

laceration, major (use this definition Q& for external integumentary (skin) injury] a cut or incision into subcutaneous tissue & >20 cm on the body, or >lO cm (4 in.) on the head, face or hand; see page 151 for diagram of actual Injury Size laceration, superficial a cut or incision not into subcutaneous tissue, regardless of length&r into subcutaneous tissue but 5 10 cm on the face, head or hand, or 520 cm on the body; see page 151 for diagram of actual Injury Size Le Fori I fracture a horizontal segmented fracture of the alveolar process of the maxilla (the supporting bone of the upper teeth), in which the teeth are usually contained in the detached portion of the bone Le Fort /I fracfure unilateral or bilateral fracture of the maxilla, in which the body of the maxilla is separated from the facial skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline of the hard palate, through the floor of the orbit, and into the nasal cavity Le Fort /I/ fracture a fracture in which the entire maxilla and one or more facial bones are completely separated from the brain case magnetic resonance imaging (MR/) a diagnostic device which produces pictures of the bodys internal tissues that are similar to the computerized, cross-sectional x-rays made by CT scanners; the MRI method uses electromagnets instead of x-ray tubes malleus one of the three small bones in the tympanic (ear) cavity mediastinum a body cavity occupying the space bordered by the lungs on either side, diaphragm below, thoracic inlet above, sternum in front, and vertebrae behind: contains the heart, esophagus, trachea, etc. MRI - see magnetic resonance imaging muscle be//y the fleshy, contractile part of a muscle necrosis death of a cell or group of cells that is in contact with living tissue neurological deficit visible or measurable effects of trauma, such as confusion, restlessness, (blurred/doubWtunneI vision), amnesia, paralysis, loss of speech, seizure obstruction a blockage or clogging, such as in the esophagus or airway ossicular chain ear bone comprised of three small bones (malleus, incus, and stapes) between the outer ear (pinna) and Inner ear papilledema excessive accumulation

visual

field

defects

of fluid in the optic nerve

paraplegia paralysis of the lower part of the body

104

paresthesia sensation of prickling. tingling or creeping on the skin having no identiiiable cause, sometimes associated with injury or irritation of a sensory nerve or nerve root paresis partial paralysis ._, perforation a hole through an organ or other body structure resulting from contact with an external force or object petechial a rounded spot of hemorrhage on the surface of the skin or a membrane pia innermost covering of the brain and spinal cord plexus a network of nerves pneumocephalus presence of air or gas in the intracranial cavity pneumomediastinum an accumulation of air in the space between the two pleural sacs (the lining of the thoracic cavity) pneumothorax an accumulation

of air or gas in the thoracic (chest) cavity

pneumothorax, tension closed pneumothorax in which the tissues surrounding the opening into the pleural cavity act as valves, allowing air to enter but not escape. The resultant positive pressure in the cavity displaces the mediastinum to the opposite side, with consequent embarrassment of respiration. Called also pressure pneumothorax. proximal a comparative term indicating a point, structure or location closer to the root of the limb (e.g., the hip joint is proximal to the knee)
puncture

a wound made by a pointed object - see also perforation puncture. deep [use this definition &for external integumentary (skin) injury] a perforation into subcutaneous tissue & >20 cm on the body, or ~-10 cm on the head, face or hand; see page 151 for diagram of actual Injury Size puncture, superficial a perforation not into subcutaneous tissue, regardless,of length a into subcutaneous tissue but 510 cm on the face, head or hand, or 520 cm on the body: see page 151 for diagram of actual Injury Size quadriplegia paralysis of all four,extremities

simultaneously;

also called tetraplegia

remarkable a term used to describe an organ or other body pan or feature that is substantially different from the nom? opposite of unremarkable respiratory embarrassment medical term used to describe a condition resulting from a thoracic or throat injury that restricts ones ability to breathe normally 185

rib, cracked a partial fracture, one that does not break the bone through and through rupture forcible tearing or breaking of a body structure (i.e., membrane, organ, tendon, etc.) segmental loss a term used to indicate that a section of a vessel is gone (indicative of two lacerations): segmental loss and transection are equivalent in severity Severance - see transection spondylolisthesis forward displacement

of one vertebra over another

sprain bending of a joint beyond its normal range of motion with partial rupture or other injury to its soft tissue attachments, but without luxation (dislocation) of bones: characterized by rapid swelling, heat, pain and disablement of the joint stapes one of the three small bones in the tympanic (ear) cavity strain an overstretching

of a muscle

subarachnoid situated beneath the middle membrane covering the brain and spinal cord s&cortical situated beneath the gray matter of the brain subdural situated beneath the outermost and most fibrous of the three membranes (dura) covering the brain and spinal cord subgaleal beneath the scalp subluxation an incomplete or partial dislocation subpial situated or occurring beneath the innermost membrane covering the brain and spinal cord tamponade, cardiac acute compression of the heart due to effusion of fluid into the outer layer (pericardium) collection of blood in pericardium due to heart rupture or penetration tear a shearing injury - see also laceration, rupture tetraplegia see quadriplegia

of the heart or

thorax the bony cage consisting of the ribs which give it shape, muscles which cover the ribs and vital organs located within the cage, such as the heart and lungs; commonly called chest cavity

transection, severance a cut made across the long axis unilateral involving only one pair of organs or body parts (e.g., eyes, ears, lungs, upper or lower extremities) unremarkable a term used to describe an organ or other body part or feature that is considered within the norm; opposfte of remarkable whiplash a popular term for hyperextensiotiyperfiexion injuries of the neck (cervical spine): the term should not be used to imply any specific resultant pathologic condition or syndrome wound, closed an injury to the body caused by an outside force in which the skin is not broken wound, open an injury to the body caused by an outside force in which the skin is broken

187

6.1. ABBREVIATIONS

Abbrev. aa A4 Abd AC ad A.D. ad lib Adm AE AU AM AMA Amb. ante ant AXOX AOB A&P

Meaning of each auto accident

Abbrev. AV

Meaning atrioventricular or auriculoventticular blood alcohol concentration below elbow

BAC abdomen, abdominal BE acute bil to BK right ear B.M.R at liberty BP. admit F3S above elbow above knee before noon against medical advice ambulatory

below knee basal metabolic rate blood pressure breath sounds, bowel sounds, blood sugar

c
CAD CAT coronary artery disease computerized tomography _ axial

G
before

cervical vertebra

cc
anterior CBC alert & oriented x three ecu alcohol on breath chr antero-posterior, auscultation and palpation, auscultation and percussion arterial pressure anterior, posterior and lateral (projection of x-ray) left ear both ears CN II-XII

chief complaint complete blood count coronary care unit

second (2) to twelfth (12) cranial nerves central nervous system complaints of compound

AP AP & Lat

CNS cl0

AS AU

188

Abbrev. CPR

Meaning cardiopulmonary resuscitation cardiac rate

Abbrev. Etiol ETOH

Meaning etiology alcohol examination extremities foreign body fresh frozen plasma family history frozen red cells full range of motion foot follow up fever unknown origin fracture gall bladder general anesthesia gastrointestinal grand mal genito-urinary Gynecology hour headache hemoglobin high blood pressure bicarbonate hematocrft head, ears, eyes, nose, and throat

CR CSF CTA CVA w-r CXR D D, D/C DL DOA DOB DT D.T.R. DX

exam cerebrospinal fluid exi clear to auscultation FB cardiovascular accident FFP central vertebra tenderness FH chest x-ray FRC dorsal FROM _ dorsal (thoracic) vertebra discontinue danger list dead on arrival date of birth delirium tremens deep tendon reflexes diagnosis ft F/U FUO fx G.B. Gen A G.I. GM G.U. GW. h. H HA hb, hgb HBP HCO, HCT EOM ER extraocular movement HEENT emergency room

ECG (also EKG) electrocardiogram ED EEG E.E.N.T e.g. emergency department electroencephalogram eyes, ears, nose, and throat example

EKG (also ECG) electrocardiogram EMG electromyograph, electromyogram

189

Abbrev. HR Hosp H&P HPI ht HX ICP ICU I&D i.e. IMP inf IOP IQ I.V. K.U.B, L L, It L LE kl. LL LLE LLL LLQ LOC

Meaning heart rate hospital history and physical history of physical illness heart, height

Abbrev. LOM LPN LRQ LS

Meaning loss of motion licensed practical nurse lower right quadrant lumbosacral. liver and spleen liver. spleen, kidney lumbosacral left upper extremity left upper quadrant murmur moves all extremities mandible maxilla Doctor of Medicine muscular dystrophy metaphalangeal moderate magnetic resonance imaging musculoskeletal masses, tenderness motor vehicle accident Negro, normal no acute distress no complaints Neurology Negro woman

LSK history LS intracranial pressure LUE intensive care unit LUQ incision and drainage M m that is MAE impression mand inferior max intraocular pressure MD intelligence quotient MD intravenous MP kidney, ureter, bladder mod lumbar MRI left _ lumbar vertebra MS M. T MVA N NAD N.C. Neuro N/F

lower extremity large lower lobe left, lower extremity left lower lobe of lung lower left quadrant loss of consciousness

190

Abbrev. NKA NL N/M NSR NN 08 O.D. OPD Ophth OR Ortho OS. ou F P. PA P&A Path P.E.

_ Meaninq no known allergies normal Negro male normal sinus rhythm (heart) nausea, vomiting obstetrics right eye out patient department Ophthalmology operating room Orthopedics PM PMD PMH PO post post-op PR PRBC pre-op orn

Meaninq afternoon private medical doctor past medical history by mouth posterior postoperative pulse rate packed red blood cells preoperative according to circumstances as needed prognosis patient prior to admission pulse, temperature, respiration pneumothorax prognosis every day every hour quiet respiration red blood cells right right lower extremity right lower lobe right lower quadrant

prog
lefl eye Pt both eyes PTA post, after PTR pulse pulmonary aorta palpation and auscultation, percussion and auscultation Pathology qh qih physical exam qt through or by R. by mouth RBC PERRLA PH PM PM pupils equal, round, react to light, accommodate past history petit mal post mortem R. rt RLE RLL RLQ PtX PX qd

per
per 0s

191

Abbrev. FVO ROM RR RUE RUL RUQ Rx s S SB SC. semi Sm SOB SIP spont ss. ss stat. subcu temp. T. TLC TM TMJ T

- Meaninq n&out range of motion

Abbrev. T.P.R.

Meaning temperature, respiration treatment traction upper extremity upper gastrointestinal upper and lower upper left quadrant unilateral upper respiratory disease upper respiratory infection upper right quadrant versus vital signs ventricular tachycardia white blood count well developed white female white male well nourished within normal limits weight without years old pulse,

TX regular rhythm (heart) TX right upper extremity UE right upper lobe UGI right upper quadrant U&L prescription, treatment ULQ without unil sacral vertebra URD small bowel URI subcutaneous URQ half vs small vs shortness of breath VT status post WBC spontaneous WD half W/F at once WIM subcutaneous WN temperature WNL total lung capacity WI tympanic membrane w/o temporomandibular _ thoracic vertebra joint YO

192

89

HOSPITAL SYMBOLS

Meaning
female
a 0

male degree increase decrease less than greater than with without half plus times (multiplication) no, none minus negative; no murmurs equal approximately primary, first degree secondary second degree

1
< > C S ss + x 0

tertiary, third degree pounds; fracture

193

8.3. WEIGHTS AND MEASURES

Celsius or Centigrade (temperature): C + 5/9 (F - 32) cc cm cubic centimeter (volume): cm3; 1 ml = 1 cc centimeter (length): l/100 of a meter: cm = in x 2.54 square centimeters (area): cm2 = in2 x 6.4516 F = 9/5 (C) + 32

cm2 F fl 9, gm in in2 kg I lb, # m mg mm OZ vd

Fahrenheit (temperature): foot (length): 12 inches gram (weight) inch (length) square inches (area)

kilogram (weight): 1000 grams: kg = lb x 0.4536 liter (volume): 1000 cm3 or 1000 ml pound (weight): 16 ounces meter (length): m = ft x 0.3046 milligram (weight): 111000 of a gram millimeter (length): l/1000 of a meter ounce (weight): i/16 of a pound yard (length): 3 feet

194

C. DECIPHERING C.l. Prefix a-, anadambianteantiautobicircumcontraMeaning absence of to; toward; near both before; forward against self tW0 around against: opposed against didysectoendoepiex-, eMOextrahemihypertW0 painful; difficult outside within over; upon

MEDICAL TERMINOLOGY PREFIXES Prefix infrainterintraisolumbomacromalmegomicroparaperiPolYpostpre-; proMeaning below: under between within equal loin large disordered: bad great small beside; near around many after: behind before; in front of backward hatf under: below above with, together fast across; beyond three one

retrofrom: without semioutside suboutside of; beyond; in addition to half above; excessive; more than normal below; deficient; less than normal inin; not super-, suprasym-8 syn tachytranstriuni-

195

C.2. ROOTS Root acroadenoangioarterioarthroaudiobiobrachiocardiocephaloceliocerebrocholeochondrocostocranrocystodentdermaduodenoencephaloenterogastroglycohem-, hematoJ&&g extremities gland tube; blood vessels arteries joint hearing life upper arm heart head abdomen myocerebrum nephrobile neurocartilage oligrib OS-, osteoskull phlebsac pneumoteeth pseudoskin puimonofirst part of small intestine brain intestine stomach sugar blood pyelorenorhinoschlerotoxovasolung pelvis; kidney kidney nose hard poison vessel false air; lung vein bone little: few nerve kidney muscle &&t hepatoheterohistohome-, homeo. hydrohysterolaparomammomeningomyleoMeaninq liver other; different tissue same water uterus abdominal wall breast membranes marrow; spinal cord

196

C.3. SUFFIXES

m
-al -algia -asthenia -cele -centesis -cyte -duct -ectomy -emia -esthesia -genie -grade

Meaning pertaining to pain weakness tumor tapping cell to lead or draw surgical removal blood feeling; sensation causing trend; current; progression visual record visualization state; condition

Sunix -aid -0logist -0logy -0ma -0sis

Meaning resemble: like specialist science of tumor abnormal condition formation of opening

-0tomy -pathy -penia -plasty -pnea -ptosis

cutting into disease insufficiency surgical repair breathing falling; downward displacement to burst forth

-gram -mW -ia -IC -itis -metry

--rrhag (e) -rrhag (ia) -rrhea

discharge rupture see urine

pertaining to -rrhexis inflammation -scopy measurement -uria

197

D. LAY TERMINOLOGY

- NASS INJURY SYNONYM LIST

This list is intended as a best fit mapping between commonly encountered laytens and NASS injuries. The mapping presented here does not preclude the use of a dlfferent injury. The ultimate choice of injury is based upon the gg&tt in which the lay term is used. If the context dictates the use of an injury other than those presented below, then use that injury. Some layterms (e.g., bumped, jarred, jolted, etc.) are nebulous in their meaning and further insight as to their meaning should be explored during an interview.

Lav Term abortion (aborted) ache black and blue black eye blacked out bleeding blister (blistered) bloody bored broke bruise (bruised) brush burn bump bumped burst bust (busted)

NASS lniurv result result contusion contusion concussion result burn result puncture fracture contusion abrasion contusion resutt rupture fracture or laceration abrasion abrasion fracture result result fracture result strain laceration transection or severance transection or severance

carpet bum chaff (chaffed) chipped collapsed lung complaint of pain cracked cramp crick cut cut in half cut through

In NASS results are not considered injuries and therefore are not coded. In this list the word result implies that the lay term is not a codeable injury.

199

Lav Term decapitated denudation disconnected dismembered ecchymosis embedded erythema excoriated exposed foreign body gash goose egg hematoma hemorrhage hurt (hurting) hyperextended infection irritation jammed (e.g.,jammed jar (jarred) jolt (jolted) knocked out (head) knocked out (teeth) knot finger)

NASS lnlunf amputation avulsion separated amputation contusion result result abrasion avulsion

laceration contusion contusion result result strain result result sprain result result concussion avulsion contusion

maimed mash (mashed) miscarriage obstruction ooze (oozed) pain parched penetrate (penetrated) perforation pinched nerve

unknown injury crush result result result result bum puncture laceration strain

Exception:

if not anatomic injury of brain.

Results are not codeable in NASS

199

Lav Term

NASS lniury fracture, laceration or rupture dislocation puncture strain or sprain laceration avulsion abrasion burn abrasion laceration burn abrasion laceration crush dislocation dislocation result bum abrasion laceration laceration strafn result result puncture puncture fracture dislocation or laceration strain or dislocation crush result result abrasion strain puncture result result2

popped out pricked pulled P (ripped) ;:z;;;; (integumentaty) roasted rubbed saw tooth scorched scrape (scraped) scratch (scratched) scrunch separated shifted shook up singed skinned slashed slit snapped sore (soreness) spasm speared spiked splinter (splintered) split

squash (squashed) squirted stiffness strawberry stretch (stretched) stuck suffocation swelling

Exception:

code if anatomic injury of brain.

Results are not codeable in NASS 200

-bv
tear (tom)

NASS lniury laceration (internal organ) laceration, avulsion (integumentary) result strain or sprain strain or sprain concussion weakness welt whiplash (to the neck) wrench (wrenched) result3 unknown injury strain strain

tenderness turn (turned) twisted

3Exception:

if neurological deficit due to head injury, AIS may be upgraded for its presence.

201

E. FRACTURES

A fracture is a partial or complete interruption in the continuity of a bone. Definitions of the fractures more frequently encountered in NASS are listed below.

Twes

of Fractures Fracture of the joint surface of a bone; also called joint fracture. Fracture that occurs when a joint capsule, ligament, or muscle insertion of origin is pulled from the bone as a result of a sprain dislocation or strong contracture of the muscle against resistance: as the soft tissue is pulled away from the bone, a fragment or fragments of the bone may come away with it. Oblique fracture of the base of the first metacarpal. Fracture of the floor of the orbit, without a fracture of the rim, produced by a blow on the globe with the force being transmitted via the globe to the orbital floor. Fracture of the body of vertebra. Comminuted fracture in which there are two fragments on each side of a main fragment resembling the wings of a butterfly. Transverse fracture usually in the thoracic or lumbar spine, through the body of the vertebra extending posteriorly through the pedicles and the spinous process. Fracture of one or more spinous processes of the lower cervical or upper thoracic vertebrae. Fracture which does not produce an open wound in the skin: also called simple fracture. Fracture of the lower end of the radius at the wrist with displacement of the distal fragment dorsally: sometimes called reversed Colles or Smith Fracture when volar displacement of the distal fragment occurs in the same location.

Articular Avulsion

Bennetts Blow-out

Burst Butterfly

Chance

Clay-shoveler

Closed Colles

Fracture of radius a) Cokes fracture,

b) Smith Fracture

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Comminuted Compound Compression Depressed Hangmans

_ Crushing fracture in which the fragments are splintered to pieces. Fracture in which the skin is perforated and there is an open wound down to the fracture. Fracture caused by compression and usually involving the spine.

Fracture of the skull in which a fragment is depressed. Fracture through the pedicles of the axis (C2) with or without subluxation of the second cervical vertebra on the third. Bilateral horizontal fracture of the maxilla. Horizontal segmented fracture of the alveolar process of the maxilla, in which the teeth are usually contained in the detached portion of the bone. Also called Guerins and horizontal maxillary fracture. Unilateral or bilateral fracture of the maxilla, in which the maxilla is separated from the facial skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline of the hard palate, through the floor of the orbit, and into the nasal cavity. Also called pyramidal fracture. Fracture in which the entire maxilla and one or more facial bones are completely separated from thecraniofacial skeleton: such fractures are almost always accompanied by multiple fractures of the facial bones. Also called craniofacial disjunction and transverse facial fracture. i

Le Forts Le Fort I

Le Fort II

Le Fort Ill

Le Fort Fractures

Lisfrancs

Fracture-dislocation

through the tarsometatarsal.

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Monteggias

- Fracture in the proximal half of the shaft of the ulna, with dislocation of the head of the radius. Sometimes called parry fracture because it is often caused by attempts to fend off blows with the forean.

1, wggia Y$ Fractures , !

Open Pilon

Same as Compound fracture. Fracture of the distal metaphysis of the tibia extending into the ankle joint. Fracture of the lower part of the fibula and of the malleolus of the tibia, with outward displacement of the foot.

P0ttk

Teardrop

Fracture-dislocation cervical vertebra.

of the cervical spine; compression

fracture of the body of the

Trimalleolar Tripod

Fracture of the medial and lateral malleoli and the posterior tip of the tibia, Facial fracture involving the three supports of the malar prominence, the arch of the zygomatic bone, the zygomatic process of the frontal bone, and the zygomatic process of the maxillary bone.

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APPENDIX A SOURCE OF ILLUSTRATIONS

(1)
(2) (3) (4) (5) (3)

Anatomv & Phvsioloav. Vol. 2 (2d Ed.. 2nd Rev.). New York: Barnes & Noble, 1984. Anderson, J.E. Grants Atlas of Anatomy (p Ed.). Baltimore: William 8 Wilkins, 1978. Anthony, C.P., and Kolthoff, N.J. Textbook Mosby, 1971. of Anatomv and Phvsiolooy (8 Ed.). St. Louis: C.V.

Dorlands Illustrated Medical Dictionary (26 Ed.). Philadelphia: W.B. Saunders, 1981 Dorlands Illustrated Medical Dictionary (28n Ed.). Philadelphia: W.B. Saunders, 1994. Jacob, SW., Francone, C.A., and Lossow, W.J. Structure and Function in Man (4 Ed.). Philadelphia: W.B. Saunders, 1978. PDR Medical Dictionaw (l Ed.). Baltimore: Williams &Wilkins, Smith, G.L., and Davis, P.E. Medical Terminology Tortora, G.J., and Anagnostakos, Canfield Press, 1975. Tortora, G.J.. and Anagnostakos, Canfield Press, 1978. 1995.

(7) (8) (9)

(4 Ed.). New York: John Wiley, 1981.

N.P. Princioles of Anatomv & Phvsiolooy (1 Ed.). San Francisco:

(10)

N.P. Principles of Anatomv 8 Phvsiolooy (24 Ed.). San Francisco:

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APPENDIX SUGGESTED

REFERENCES

This Injury Coding Manual has been designed to provide the nonmedically-oriented NASS injury coder with the tools currently identified and available to extrapolate and interpret injury data, and to assign codes accurately. After this manual has been mastered, the following references provide an opportunity for in-depth reading for coders who are eager to learn more about the history and background of injury coding. This list is not all inclusive, but does represent some of the major contributions to the field.

The Abbreviated Injury Scale (AIS) 1976 Revision, including Dictionary, American Association for Automotive Medicine (now Association for the Advancement of Automotive Medicine), Des Plaines, IL. The Abbreviated Injury Scale (AIS) 1980 Revision, American Association for Automotive Association for the Advancement of Automotive Medicine), Des Plaines, IL. The Abbreviated Injury Scale (AIS) 1965 Revision, American Association for Automotive Association for the Advancement of Automotive Medicine), Des Plaines. IL. Medicine (now

Medicine (now

Baker, S. P., ONeill, B., Haddon, W.. and Long, W. B.: Injury Severity Score: A Method for Describing PatientswithMultiple InjuriisandEvaluating Emergency Care, .lOUANALOFTRAUMA14:187-196, 1974. Baum, A. S.: An Alternative Injury Code for Police Reporting: An Evaluation of the New York State Injury Coding Scheme, PROCEEDINGS, 22nd Conference, American Association for Automotive Medicine, 1978. Calspan Corporation: Advanced Training in Injury Coding for the National Accident Sampling Buffalo, NY, July 1982. Campbell, E. 0. F.: Collision Tissue Damage Record, Traffic Injury Research Foundation Ottawa, 1967. System,

of Canada, National

Champion, H. R., Copes, W. S., and Sacco, W. J.: Major Trauma Outcome Study: Establishing Norms for Trauma Care, (Accepted for publication in the JOURNAL OF TRAUMA).

Committee on Medical Aspects of Automotive Safety, American Medical Association: Rating the Severity of Tissue Damage: I. The Abbreviated Scale, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 216227 -280. 1971. Committee on Medical Aspects of Automotive Safety, American Medical Association: Rating the Severity of Tissue Damage: II. The Comprehensive Scale, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 220:717 -720,1972. General Motors Corporation, Safety Research and Development Laboratory: injury Report, long form PG 2002, Milford, MI, September 1968. Gennarelli. T. A.: Analysis of Head Injury Seventy by AIS-80, PROCEEDINGS, Association for Automotive Medicine, 1980. Collision Performance and

24th Conference. American

Gennarelli, T. A., Champion, H. R., Sacco, W. J., Copes, W. S.. and Alves W. M.: Mortality of Patients with Head Injury and Extracranial Injury Treated in Trauma Centers, JOURNAL OF TRAUMA 29:11931202, September 1989.

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MacKenzie, E. J.,Garthe, E. A., Gibson, G.: Evaluating the Abbreviated Injury Scala, PROCEEDINGS, Conference, American Association for Automotive Medicine, 1978.

22nd

MacKenzie, E. J., Shapiro, S. Eastham, J., and Whitney, B.: Reliability Testing of the AlS 80, PROCEEDINGS, 25th Conference, American Association for Automotive Medicine, 1961. Marsh, J. C.: Existing Traffic Accident Injury Causation Data Recording Methods and the Proposal of an Occupant Injury Classification Scheme, PROCEEDINGS, 16th Conference, American Association for Automotive Medicine, 1972. Marsh, J. C., Flora, J. D., Komfield, S. M., and Bailey, J.: Results of Financial and Functional Consequences of Injury: A Pilot Clinical Study, PROCEEDINGS, 22nd Conference, American Association for Automotive Medicine, 1978. MULTIDISCIPLINARYACCIDENT INVESTIGATION DATA FILE: Editing Manual and Reference Information, Volume l-1976, Contract No. DOT-HS-5-01134, June 1977. Available from the National Technical Information Service, Springfield, VA 22161. Ryan, G. A., and Garrett, J. W.: A Quantitative Scale of Impact Injury Calspan Report No. VJ-1823-R34, Calspan Corporation, Buffalo, NY, October 1988. Sherman, H. W., Murphy, M. J., and Huelke. D. F.: A Reappraisal of the Use of Police Injury Codes in Accident Data Analysis, PROCEEDINGS, 26th Conference, American Association for Automotive Medicine, 1976. Somers, R. L.: The Probability of Death Score: An Improvement of the Injury Severity Score, PROCEEDINGS, 25th Conference, American Association for Automotive Medicine, 1981. 18th Conference,

Spence. E. S.: A Proposed injury Code for Automotive Accident Victims, PROCEEDINGS, American Association for Automotive Medicine, 1974.

Stalnaker, R. L., Mohan, D., and Melvin, J. W.: Head Injury Evaluation: Criteria for Assessment of Field, Clinical and Laboratory Data, PROCEEDINGS, 19th Conference, American Association for Automotive Medicine, 1975. States, J. D.: The Abbreviated and the Comprehensive Research Injury Scales, PROCEEDINGS, Conference, 13:282-294, (SAE 699810), 1969. STAPP

States, J. D., Huelke, Cl. F., and Hames. L. N.: 1974 AMA-SAE-ADAM Revision of the Abbreviated Injury Scale, PROCEEDINGS, 18th Conference, American Association for Automotive Medicine, 1974. Williams, R. E. and Schamadan, J. L.: The Simbol Rating and Evaluation System, ARIZONA MEDICINE 26:886667, 1969. World Health Organization: Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, Geneva, 1977.

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In addition to the above references to scientiiic and technical information on injury coding, the NASS injury coder is encouraged to consult both basic anatomy texts and medical dictionaries for information and clarification on body regions and medical terminology. The following are suggestions only; other anatomic and medical resources may be consulted.

Clinical NeurosuraerY Volume 12, William & Wilkins Co., Baltimore, MD, 1966 (Head Injury Glossary prepared by acommittee of the Congress of Neurosurgeons). Dictionan,, 3* Edition, Hanley & Beifus, Inc., Philadelphia, PA, 1998.

Dorlands Medical Dictionaw, 27 Edition, W. B. Saunders Co., 1986. Grants Atlas of Anatomy, 7 Edition, Williams 6, Wilkins Co., Baltimore, MD, 1978. Gravs Anatomy, Running Press, Philadelphia, PA, 1974. vTerminolopu, 3 Edition, John Wiley & Sons, Inc., New York, NY, 1976.

PDR Atlas of Anatomy, I Edition, Williams B Wilkins, Baltimore, MD, 1996.

Review of Gross Anatomy, 6 Edition, McGraw-Hill, 1996.

Stedmans Medical Dictionary, 24 Edition, Williams 8 Wilkins Co., Baltimore, MD, 1982. Structure and Function in Man, 5e Edition, W. 8. Saunders Co., 1982 (S. W. Jacob, C. A. Francone, W. J. Lossow - authors).

208