Caiss Terms

Caiss study terms

Boxed & Bold Text

Represent AIS coding rules and conventions and contain directives to assist in the appropriate use of specific descriptions.

Brackets

Denote inclusive or exclusive information.

Parentheseses

Include synonyms or occasionally, non-clinical terms and provide a definition for the injury description.

Semicolons

Separate injury descriptors that are comparable in severity.

Bold Type

Identifies an anatomical structure

Italics

Are used for proper-named anatomical structures or injuries, and for OIS grades.

AIS .1

Minor

AIS .2

Moderate

AIS .3

Serious

AIS .4

Severe

AIS .5

Critical

AIS .6

Maximum

Range of AIS severity codes

1-6

Is "DEATH" part of the AIS severity scale?

No

Does a linear relationship exist between AIS severity codes?

No

(T/F) Injuries within the same code may not be strictly compatible.

T

AIS .9

Unknown

(T/F) The AIS single digit severity number indicates the relative severity of injury in an "average person" who sustains the coded injury as his only injury.

T

Average Patient

Adult 25-40 years of age
Free of pre-existing conditions
Free of treatment complications
Receiving timely, appropriate care for the injury

Pre-dot Code

6 digits to the left of decimal point

AIS Severity Number

A single digit to the right of the decimal point.

Body Region

The first number in the pre-dot code stands for?

Type of Anatomic Structure

The second number in the pre-dot code stands for?

Specific Anatomic Structure

The third & fourth numbers in the pre-dot code stands for?

Level of injury within the specific body region and anatomic structure

The fifth & sixth numbers in the pre-dot code stands for?

(T/F) AIS assesses the severity of single injuries.

T

(T/F) The ISS is the sum of the squares of the highest AIS in each of the (3) most severity injured ISS body regions.

T

There are how many ISS body regions?

6

ISS Body Regions

Head & Neck
Face
Chest
Abdominal & Pelvic Contents
Extremities & Pelvic Girdle
External

Head & Neck

Include injury to the brain, skull, cervical spine or neck organs.

(T/F) Asphyxia is assigned to the ISS Head region?

T

Face

Include injury to mouth, ears, eyes, nose and facial bones.

Chest

Include injury to abdominal and pelvic contents, including all lesions to internal organs in the respective cavities and injuries to diaphragm, rib cage and thoracic spine.

(T/F) Drowning is assigned to the Chest region?

T

(T/F) The ISS is the sum of the squares of the highest AIS in each of the (5) most severity injured ISS body regions.

F

(T/F) There are 9 ISS body regions?

F

(T/F) Asphyxia is assigned to the ISS Chest region?

F

(T/F) Drowning is assigned to the Head & Neck region?

f

Abdomen and Pelvic Area

Include injury to Lumber spine lesions.

External

Injuries that include lacerations, contusions, abrasions, hypothermia, electrical injury, whole body injury and burns are assigned to what region?

1-75

The ISS score ranges from what to what?

(T/F) An ISS of 75 can be derived in 2 ways: one AIS .5 injury in each of three body regions or a single AIS .6 injury.

T

Should patients with a AIS .9 code be included in research studies?

No

Underestimation of the ISS score

Assigning injuries to too few body regions can result in what?

Overestimation of the ISS Score

Assigning injuries to too many ISS body regions can result in what?

Injury

The anatomic lesion resulting from a transfer of energy rather than a complication or immediate sequelae is what?

Blunt, Penetration, Burns & Selected other Trauma

The AIS includes injuries from the what mechanisms?

(T/F) The AIS sometime permits the coding of immediate sequelae, but withing strictly defined rules?

T

(T/F) You can code suspected, possible or rule out diagnosis?

F

(T/F) Clinical diagnosis alone are not codable for certain injuries.

T

(T/F) In order to code clinical diagnosis, there must be back-up with a CT, MRI or autopsy documentation.

T

(T/F) Cranial Nerve Injuries or Basilar Skull Fractures are an exception to coding clinical diagnosis.

T

Basilar Skull Fracture

Physical signs of raccoon eyes, Battle signs, CSF rhinorrhea, CSF otorrhea and Hemotympanum are indications of what?

(T/F) AIS allows coding of cranial nerve "contusion" if there is documented cranial nerve weakness/paresis or subtotal loss of function?

T

(T/F) AIS allows coding of cranial nerve "laceration" if there is documented cranial nerve paralysis, or total loss of function?

T

(T/F) Coding a basilar skull fracture based on physical signs or manifestations is only permitted if there is evidence of traumatic head injury or the physical manifestations cannot be related to a peripheral or facial injury (e.g., facial fractures)?

T

(T/F) Complications are coded as injuries?

F

(T/F) Do not assume that a specific injury has occurred simply because a particular outcome occurred.

T

(T/F) Death is an automatic AIS .6.

F

(T/F) An AIS of .1 can result in death.

T

(T/F) Vertebral fractures and contusions are coded separately.

F

(T/F) Penetrating injuries that do not injure underlying structures should be coded in the Whole Area section of the dictionary chapter and assigned to the External ISS body region.

T

(T/F) In penetrating injuries, you should code the overlying skin injury, not just the organ injury.

F

(T/F) Bullet wounds associated with fractured bones should be coded as open fractures.

T

(T/F) A bullet can pass through soft tissue/skin only, completely missing other organs and systems, and cause only an AIS .1 injury.

T

(T/F) The not further specified (NSF) category allows for coding injuries when detailed information is lacking.

T

Open Fracture

Skin overlying the fracture is lacerated.

Closed Fracture

Skin overlying the fracture is not lacerated.

Articular Fracture

Fracture involving the joint.

Comminuted Fracture

Multiple bone fragment fracture

Displaced Fractrue

Fracture in which two ends of the bone are not aligned

Complex Fracture

Fracture with three or more fragments with the proximal and distal fragments not touching

Sprain

Injury to joints

Strain

Injury to muscles, tendons

Crush

Massive destruction of body part with damage to underlying body systems (e.g., skeletal, organ and vascular)

Amputation

Total loss of body part from trauma or burn

Vessel Laceration

Same as puncture or perforation

Minor vessel laceration

Superficial, incomplete circumferential involvement, blood loss less than or equal to 20% by volume

Major vessel laceration

Rupture, transection, segmental loss, complete circumferential involvement, blood loss \> 20% by volume

Thrombosis

Includes any injury to the vessel resulting in its occlusion

Muscle laceration

same as rupture, tear or avulsion

\> 20% blood loss in adults

\> 1000 cc

Nerve paresis (palsy)

Subtotal loss of function

Nerve paralysis

Total loss of function

Transection, Laceration, Contusion & Segmental Spasm, Aneurysm/Pseudoaneurysm, A-V Fistula, Intimal Flap

Types of Arterial Injuries

(T/F) You should code conservatively.

T

(T/F) Foreign bodies are not injuries and therefore not coded.

T

(T/F) You should base the injure severity based on procedure or treatment interventions.

F

(T/F) Multiple fractures to the same bone but in different regions of the bone are coded separately.

T

(T/F) "Crush" should only be used when vascular, skeletal and soft tissue injury occur with an injury.

T

(T/F) If "crush" code is used, you should also code the injuries separately.

F

(T/F) Transection should be coded as a complete transection.

T

(T/F) An incomplete transection should be coded one AIS code less severe than a complete transection.

T

(T/F) If a vessel injury occurs in combination with an organ injury, the vessel injury is not coded separately if it is already included in the organ injury descriptor.

T

(T/F) Branches of vessels are not coded unless they are named vessels and/or are listed within a specific vessel descriptor.

T

(T/F) When more than one injury claims the qualifier "blood loss \> 20%", the blood loss is assigned to the most severe associated injury.

T

(T/F) For AIS coding, penetrating injuries are defined as injuries resulting from gunshot or stab wounds, or from impalement or spearing-type trauma, with or without damage to underlying organs or structures.

T

(T/F) Penetrating injuries that do not involve underlying structures or internal organs are coded to the Whole Body region except injuries to the skull and face.

T

(T/F) You should code all internal injuries for a penetrating injury that involves internal organs and structures.

T

(T/F) If a penetrating injury in the brain crosses more than one region it should be coded to "penetrating major" under the Whole Area section rather than specific site of the brain.

T