Clark, and I'm going to be introducing our speaker for today. The topic is avoiding the headache of coding head injuries. And our speaker is Kathy Cookman. And Kathy has been involved in the trauma field for over 40 years in various capacities from pre hospital emergency department patient care, trauma data management, performance improvement and injury prevention. She is the CEO of KJ trauma consulting LLC, and ICD 10 CM dash PCS instructor, CEO of KJ and JC enterprises LLC, and recently achieved Florida Masters naturalist through the University of Florida. She lives in Florida with her husband john and their three labradoodles Bella tiller and the newest edition, which we just found out the name is skipper. So welcome, everybody and enjoy the webinar. All right, well, welcome, everybody. There's one other title that I have to add to this mix, because we're going to talk about AIS. And I am the triple AM AIS business director and the international technical coordinator. And so when you see me referencing things to AIS, and in the bottom right hand corner, you see the triple AM logo, and the AIS logo, that's because I wear two different hats, actually three different hats, if you think about it. So thank you for inviting me. I always appreciate the opportunity to talk with the folks that are part of TCAA. It's really awesome. I apologize for my laid back kind of atmosphere, my hair in a ponytail looking kind of laid back, but I live in Florida now. So they tell me that that's what you're supposed to do is pick up that beach vibe. Anyway, here we are. Let's get started. And we'll talk about anatomy just for a little bit, because I noticed that some of the questions that came up were related to understanding a little bit better the anatomy of the head and the brain specifically, there were some questions that were related to the face that if there's time, I'll mention those. But I really wanted to focus specifically on the head and the brain since that tends to give us a lot of headaches. Absolutely. So let's think about the bony box itself. All right, this is the head, because it incorporates not only the skull, the cranium, the bony box, but our faces there as well. And when we think about the differences between AIS and ICD, we have to also remember those full pieces of the head, the face, the mandible, all of that comes into play with ICD, but they're separate areas when we're playing with the AIS code. So I like this picture. And by the way, you do get a copy of the slides. It's a PDF version. So all of the pictures that you're seeing here on the screen will be available to you, which is awesome because I like pictures. I'm one of those of you who know me well enough know that I really like pictures because I think it speaks to us a lot more than me sitting up here sounding like a Charlie Brown schoolteacher after a while. And reading literature and reading documents is sometimes difficult to grasp, especially from a health care perspective. It's the nomenclature that we tend to get a little bit out there, 50 cent words as I like to call it. So let's take a look at the various bones here. The frontal bone is in blue, represents here the frontal part of our skull. Your parietal bone you can see is in the larger green area. The occipital is in purple, and that's the backside of our of our skull and also tucks down and under and into the base portion here. And then our temporal bone, we've got different pieces of the temporal bone and we'll talk about those in a little couple slides in advance from now. But it helps to divide certain parts of the temporal area into the vault versus the base. And then of course, we get into the sphenoid here. And then you can see our facial bones, which we're just going to skip over that for now because we want to focus mainly on what's going on with the bony box, the cranium, the skull, lots of different words we use for that. Let's go inside a little bit. So here's the outer layer, the skull, the bony box, the cranium, right directly below that is the dura mater. And we start talking about the periosteal layer, we go to the meningeal layer. And what this does is this helps to protect, it's like the first line of defense to protect the brain from an injury. And dura mater means tough mother. All right, so it's a tough membranous layer that is there to help protect the brain. Then you'll notice as you go a little further down, you've got the arachnoid, the arachnoid mater and the arachnoid below it, look at this little feathery like area here. That's the subarachnoid. Remember, sub means below, submarines go below the waterline. So when we see sub something or other, it's below whatever it's defining. So the subarachnoid, arachnophobia, I have a fear of spiders, spider webs, possibly, that kind of looks like a little spider web area. So that's the subarachnoid area, you then see the pia mater and notice how it kind of layers right here on the brain itself. And that's the final layer before we actually get to the cortex there. And that's the little mother, it's much thinner, but it's again, the last little area of defense. You see the gray mater when you get here into the brain itself, and then the white mater. Okay. Also pointed out in this area are your sagittal sinus, the superior sagittal sinus, you've got your subdural space, so the space below the dura, remember the dura, and then you've got your falx. All right, so that's in the center here in the hemispheres, because our brain is split into two separate hemispheres. That's a pretty busy slide. This one makes it a little more simplistic. Again, same information here, it's just a little easier to try and see from a picture standpoint. So again, the blue is representing the tough layer, the arachnoid, and then the pia mater is in the lighter red, pink or dark pink color, so to speak. If we think about the brain from a lateral position, we know that the cerebrum is the larger mass area. Those of you who have taken an AIS class before know that we stress that the cerebrum is the default. It tells us so in the dictionary or in the AIS coding book. If you happen to have your coding book with you, you can certainly follow along when I give you references to certain things. But in the AIS 2508 dictionary on page 41, the second rule box down the page says use the cerebellum section only if the cerebellum, infratentorial or the posterior fossa are named, otherwise code under the cerebrum. So there's where we get our default is the cerebrum. It kind of makes sense if you look at this drawing here, it has the larger gray area. This whole area is the cerebrum. So if you close your eyes and throw a dart at the picture, it's probably going to land on the cerebrum. It makes sense that if they don't tell us where the brain injury is, they simply say there's a subdural hematoma. It's likely going to be in the cerebrum. The cerebellum is represented here in an orange color. And if the cerebellum is injured, they're definitely going to tell you that. And so you want to make sure that you're really paying attention to how they describe the injury and its location. And then here in the pink area, this is parts of your brain stem, the brain stem. Let's take it a little bit further here. Again, good opportunity to see the cerebrum, makes sense that it's the default. You've got the cerebellum back here. It's kind of like if I took my ponytail and rolled it up into a bun, that's what it would be from a simplistic way to describe it. And then you've got your brain stem. Notice there's a red line that's drawn here. That's called the tentorium. Tentorium cerebelli, actually. And that I always refer to as a line of demarcation that separates the cerebrum from the cerebellum. It's basically a fold. And it's a tent-like fold, hence tentorium. And it separates those two portions. Below the line is referred to as the infratentorial. And above the line is referred to as the supratentorial. So now we're sitting there thinking, well, gosh, we've got the cerebrum, which is also known as the supratentorial. Why can't we just come up with one word and leave it at that? Wouldn't that be nice? But it's not the way that medical terminology works. So we have to be a little flexible. And when you see things documented in the chart, if medical terminology is not your strong suit, look it up. Look it up. It's okay to use Google, as long as you go to a safe site, one that's reliable, because not everything on the internet is true and factual. Or have yourself a good dictionary, a good medical dictionary at the desk side. That would be another place that you would want to go check things out and make sure you're understanding what's being described in the chart. Because let's face it, if you sit at your desk, eight hours a day working on charts, eventually your brain's going to go, you know, I'm really tired. And I think it's this, even after 40 years, I still find myself going, what? I gotta look that up. And it's okay. That's a good thing. Because we should always be learning every day. So let's talk a little bit about the brainstem. Again, I'm just hitting high points here from an anatomy standpoint. With your brainstem, there's the midbrain, there's the pons, the medulla, you've got the basilar artery, and then it goes down into the vertebral arteries. So a lot of high powered real estate there. That's why in AIS, when you look at the postdoc values, they're in fives and sixes. Because if you injure that, it's pretty significant and potentially could lead to fatality. Doesn't mean an automatic death sentence, but it certainly isn't that good of a spot to be injured. All right, so we want to kind of watch for those pieces of information when we're working our charts. And then we've got the lobes of the brain. So we think about the cerebrum, again, that larger mass area. Remember the frontal lobe, we saw it on the bony box part, it's represented here in blue again. And that's bilateral frontal lobes. Because remember the brain, if we were to look straight down on top of it, it has a fissure in the center hemisphere, and it splits the brain into two different hemispheres. Okay, the parietal lobe, the temporal lobe, and then obviously the occipital lobe. And each one of those lobes have a functionality. Now, you don't need to memorize this. And it's really probably something that from a trauma data abstraction standpoint, may or may not be helpful. But I think if you have the information at your fingertips, it might make sense why they're ordering certain types of tests to be performed. I've always had a curiosity, when I've looked at an approach to patient's record, whether I'm the one providing the care or not, I've always approached it as a story. And I want to know the rest of the story, because I'm nosy and curious like that. You know, me and CSI type shows, I really like those things, because I want to figure out who done it, you know, that for lack of better nomenclature there. But if you look at point number one, here in the frontal lobe, that's going to be part of our motor functionality. So depending upon where the brain injury is, you can kind of see why they're consulting speech therapy, or why they're doing swallow studies, or whatever the case may be. So again, curiosity killed the cat. It's good to be curious. So maybe that slide will be helpful to you in the future. Alright, so now let's talk about the fracture parts, the vault, and the base. So we went through the brain, and we have the cerebrum, the cerebellum, and the brainstem. Now the bony box that covers all of that real estate is divided into two areas, the vault and the base. Well, the vault is the default. And those of you who've been in my AIS classes before you know that I get a little slap happy by the time I get to the head chapter, and I'm singing songs, and clicking my fingers going the default is the vault, and you'll never forget it then because you're sitting there going, she's really weird. But again, the larger mass area for the bony box is the vault. So it makes sense that it's going to be the default area for our codes, when all we know is that the skull is fractured. And sometimes that happens in our charts. So the frontal bone, the occipital bone, the parietal, the temporal. Temporal has a little star next to it, because again, we have to split it into two different pieces when we're looking at the fractures there. We'll have linear fractures that can be simple. And sometimes people say, well, linear fractures, that's not a big deal, Kathy, it's just a little tiny fracture line. But remember, right below that bony box, there are a lot of vascular opportunities for injury. So even the most simple fracture of a linear nature could potentially lead to a bleed because of the vascular structure right below that bony box. When we think about depressed fractures, we all get excited about those because they've got some good visuals. If you're looking at the CT results, or maybe they snapped a picture, and you're looking at that, you can kind of go, oh, yeah, the one here on the slide gets your attention, right? But not everybody has a depressed skull fracture. But if we do see that in the chart, we need to know what is the amount of depression. So hopefully, they're describing the amount by measuring it, how deep into the brain did that depression go? And then what is right below there, the dura, remember that tough lining that protects the brain? So what's going on with it? Is it lacerated? Do we have a tear in the dura? Or is the dura fine? The bony box just fractured, and we got a nice little depression, but the lining of the meninges is together. If it's not, and it's torn, now we've got to look to see exactly the extent of it. And it changes our AIS codes based on whether or not the dura is torn. It can lead to a cortical laceration or even hemorrhage. So it's an important piece of info. By the way, on my slides, and some of these down in the corners or on the sides, you'll see little numbers, those are the prefixes for the ICD. So a vault fracture is going to take you to the S02.0 area of your ICD codebook. All right, so that's the reason for those there. All right, so what else? We've got the base. And the base fractures are more difficult for us to actually identify radiographically. And that's because again, you got to flip the brain upside or the head upside down, and you're looking at that lower portion. And it's obscured by a lot of our radiographic studies. So what are the bones, the ethmoid, the orbital roof, the sphenoid, the petrous, the mastoid portions of the temporal bone, see there you go where we split those out. And then obviously the basilar process of the occipital bone. So in the bottom left corner, you can see we're in the S02.0 area. And you'll find that 0.1, 0.8, and 0.9, depending upon the complexity and the location, I should say, within the skull base itself will determine which codes that you're going to use for ICD purposes. Now I have to tell you the next slide that I have is kind of one of those freaky ones. It reminds me of the Chucky doll. But after I put it up here, I thought, Oh, you really shouldn't use that. It's kind of disturbing, I think. But at any rate, it's a good depiction of clinical signs for basilar skull fracture. And what's the most common? Periorbital echemosis. So those little bilateral contusions around the orbits. Okay, what we have to make sure of, though, is that the periorbital echemosis is from a head injury, not from a facial injury, because I can get bonked in the nose like that with a fist. Or you can have a 75 pound labradoodle jump up in the bed and accidentally take his head and hit you off to the side of your nose and end up with periorbital echemosis. That's me. And so be careful. Don't automatically assume you have a brain injury or a skull fracture, sorry. Don't assume you have a skull fracture if you have bilateral periorbital echemosis. Look at the mechanism, determine what was going on. And if there was a blow to the face, either by face planting on a steering column or getting hit with a ball bat or a fist, watch that because it's probably facial trauma. The other things that we need to consider, and they're all on this picture, which is really kind of cool. And that's the bruising here behind the mastoid. So we call those battles signs sometimes. And that same 70 some pound labradoodle and I had a collision with his hard head about a week and a half ago. And I ended up with a basilar skull fracture concussion. I didn't think I had a fracture until I went back for a repeat CAT scan. And so I am sporting around a nice little knot back here. And he's just wound up in seven years of age. And so it doesn't take a car crash or somebody hitting you with a ball bat, it can just be you having fun with your dog. So watch out, first hand person here. So and I'm still having the headaches from it, but it's all good. A perforated tympanic membrane that can happen and be a sign clinical sign of a skull fracture, hemo tympanum, otorrhea, rhinorrhea, a lot of different things that we look for and again, all of those indicators are here in the AIS dictionary. If you're looking for that information, it's on page 49 of the 0508 dictionary. And you'll find it also in the new 2015 dictionary if you are currently using that version. Again, people are on different versions right now. Okay, so we've got primary and secondary injuries that occur. A primary injury occurs directly to the brain upon impact. It stops metabolism, it causes some energy failure, but the things we need to look at from a primary injury standpoint, what was the mechanism of injury? Was it a blunt force trauma by a car crash? Was it biomechanics? What was going on inside? And even think about kinematics. Kinematics, a body in motion stays in motion until it finally comes to rest. So if I'm in a car, and I'm driving along, and let's say I've stopped at a traffic light, and I'm at a dead stop, and a car comes up from behind, playing on their cell phone, don't stop, and they hit the rear end of my car. My car has already stopped, but now it's going to project forward. My body's going to project forward as far as the seatbelt will allow it to go. And then it's going to cradle me into the seat and stop me from moving around like a projectile. But inside, my brain is going to slosh back and forth until it finally comes to rest, including my organs and everything else. So that's the kinematics of a body in motion stays in motion until it finally comes to rest. That's how we can get some secondary type injuries that occur as well. So some of the complications that we can get, systemic complications, you see those hypertension, anemia. So watch for those types of things, just to look at the opportunities of how significant the primary injury is and what goes on secondarily. So again, am I being hit in the head with a ball bat, like this example shows in the upper right-hand corner? I have an acceleration-deceleration, so coup-contrecoup. Again, there's a little space area in that bony box. It's not a lot of room up there. And so the brain sits nice and neatly with a little area around that's full of cerebral spinal fluid, so it allows a little bit of sloshing and movement. But if you have a high impact, or even just something suddenly doing that, you've got to bounce off the front, bounce off the back, and it's going to continue to move until it comes to rest. Sometimes you can have a rotational force, and that's where you start to see shearing-type injuries. And then, of course, penetrating trauma. That's a projectile, so it could be a gunshot wound. It could be an impalement type of a situation where you have a stabbing or a piercing. So again, some examples here on that bottom picture, where you could have a penetrating wound that goes in and stops, goes completely in and out, or maybe it goes in and it starts to ricochet and bounce all around. So again, some pretty significant opportunities there. And then our cranial nerves. What are we worried about in cranial nerves? Again, we need to look at the documentation. Are they talking about paralysis that the patient is suffering? If so, we're going to indicate that as a laceration for the cranial nerves. Paresis or palsy is contusion. And then there's a little rule in the dictionary that says if the cranial nerve is not specifically named, code it as a cranial nerve not further specified. But the important thing I need you to realize is to read the boxes in the AIS dictionary. And if you don't have an AIS dictionary, you need to get a hold of one. Because there are rules and guidelines that are not in your computerized software yet. And you need to understand those so you're picking the right answer. Again, cranial nerve injury is going to go to S04 when we're talking ICD. So we're kind of covering a little bit of both AIS and ICD. There's different types of brain injury. We can have focal brain injury. Those are in localized areas. And again, we think about a focal injury, it's occupying the space within the cranium and there's not a whole lot of space there. And this can lead to swelling or midline shift or even herniation of the brain. So again, if it squeezes and squeezes and pushes things to one side, eventually it's going to look for the quickest way out. If you think about somebody giving you a really tight bear hug, and eventually you're like, okay, this is uncomfortable, I don't want to do this anymore. And you start pushing your way out of that lovely hug that you're getting, you find the quickest way out. And so does the brain when it herniates. And then you have diffuse injury. That's widespread. It's a global disruption of the neurologic function. It's generally associated with swelling. And it increases our neurological deficit. And you'll find that there are usually disturbances in consciousness level. So what are some of the focal and diffuse injuries? Here they are on the screen. Again, in red, you'll see the associated ICD. And I forgot to add the cerebral contusion code. I will make sure that you get that. And if I have a chance, I'll look it up here in the ICD book before the end of the session. Sorry about that. So cerebral contusions, hematomas, all of those are focal. Even though the hematomas will spread, they're still focused and pinpointed to a particular area. Interventricular hemorrhage, some arachnoid hemorrhages, and then diffuse, more widespread type injuries are your concussive opportunities or diffuse axonal injury. That's where you've got white matter shearing, widespread damage to the axons. And it's a pretty significant injury, although not very large on radiographic studies when you think about it. So some of the following pictures I use in ICD training or AIS training with AAAM. And so we're good. We've got permission to be able to share this with you. So look at the difference between an epidural and a subdural. Epidurals have a crescent shape, kind of look like an eye lens here. And it doesn't follow the lovely little sulci of the brain. So those little crevices and the curvatures of the brain, it doesn't follow along with that. And these can get pretty substantially, it's pretty substantial in size and cause a midline shift. So you see this little finite white line here, that should be straight up and down. But because of the way this crescent injury is expanding, you see a shift and that little white line is no longer visible. So that's the midline. And then on the right side, this is a subdural. So below the dura, that tough mother, is where the bleed is occurring. And that actually bleeds into the contours of the brain. And it too can cause a midline shift. The whole idea is symmetry. I should see a line down the center. Both of my ventricles should be visible and look exactly alike on each side. But that's not the case with this one. And then subarachnoid. Subarachnoids are further down in the layers, if you remember the layers of the earlier picture. We don't typically get a midline shift with a subarachnoid if that's the only brain injury that the patient sustains. Now, if they have a subarachnoid with a subdural, you can sometimes have a midline shift. But generally, just a subarachnoid is not going to cause a midline shift. All right. Now we looked at these little bleeds here. All right. When we think about an intracerebral hemorrhage, that's pretty huge. And look at the midline shift. Perfect representation of that. Not so good for the patient, but perfect representation of what that looks like. It reminds me of somebody either throwing a snowball or I've had an ice cream cone and it just went plop and fell right onto that particular picture. Pretty large. And the perilesional edema. So this is actually an MRI. And the perilesional edema is in a brighter white around it. And if your radiology department gives you the measurement of the perilesional edema, you can actually use that when you're trying to make your code assignment for AIS. And if they don't, that would be a great opportunity for you to have a chat with them and say, hey, if you provide the perilesional edema, I can actually, you know, have a better code assignment to represent the significance of that patient's injury. And most radiologists are very receptive to that. If you go to them with a point of, I'm trying to be helpful and I'm curious about, can you provide, educate me, those types of approaches as opposed to say, you know, your charting sucks. Don't go there. They're noncommittal at best. I think they've been sued probably way too many times. So the noncommittal pieces of the documentation drives us crazy. But, you know, let them know what we have to work with. And you'll be surprised how they're going to want to come alongside of you and have better documentation. And then interventricular hemorrhages. Remember, the ventricles need to be symmetrical to one another. And you can see the arrow is pointing out to the interventricular hemorrhage there. You code if it's not associated with the DAI diagnosis. So with the 08 dictionary for AIS, you know, there's two different locations for coding DAI. And there's a rule for coding DAI. And if the patient has a confirmed DAI, you don't code the associated brain injuries with it. So this interventricular hemorrhage would not be coded with it. And that's not me just saying, again, that's in the rule boxes within the dictionary. So speaking of DAI, a lot of questions came about in your questions under your test your knowledge. There were a lot of questions about DAI. And the most important thing that you need to remember are these three items in red. There has to be immediate and prolonged coma. So greater than six hours. So coma is greater than six hours. It has to be immediate. That's why the words in capital letters. In other words, if the patient is up walking around at the scene of the car crash and then collapses and remains unresponsive for more than six hours, that is not immediate and prolonged coma. All right. So that doesn't count. The physician also has to diagnose DAI. So he or she has to write it in the chart that it's DAI. And the third thing you have to have is radiologic or pathologic evidence of DAI. So that could be an autopsy report. It could be an MRI, CT scan. But all three of those things have to be in play. If they're not, you can't code DAI. So that's important. And again, remember, once you have a confirmed DAI, all three of those things are there. You don't code the additional interventricular hemorrhages, the subarachnoids, the subpeels, those types of things. When you're using the 08 dictionary, I need to make sure that you understand that I'm talking about the rules for the 08 dictionary. It changes when you move to 15. And I don't want to confuse you. Those of you who are already using AIS 15, you know what I'm talking about. The majority of the folks haven't moved there yet. So for right now, follow what the rules say in the dictionary that you're using in your registry. Okay. Types of brain injury, concussion. Oh, that's another fun area. Lots of questions here. Lots of confusion for concussion because sometimes they say it, sometimes they don't say it. Can I code it because they did this? Can I do this? And oh, there's no loss of consciousness with it, so I really can't pick it. You need to slow down, take a deep breath, and read the rule boxes. A concussion can occur as a result of a minor head trauma when there's tension or strain. So getting hit by a 70-some pound dog can cause a concussion to somebody. It can also cause a basilar skull fracture, if you really think about it. You might not have a loss of consciousness. I didn't. I felt like I was going to throw up. I got really dizzy and had a headache, but I did not lose consciousness. Loss of consciousness has to be diagnosed and documented by the physician or your physician extender. So like your nurse practitioner, your physician assistant, but they have to document it. You can't make an assumption. You can't go on the fact that the family witnessed it or the patient said they were unresponsive. Those are not things that are reliable. And patients can have prolonged problems as a result of even a minor concussion. So recurring headaches, all sorts of residual effects of a concussion. So we also see documented quite frequently CHI, TBI, closed head injury, traumatic brain injury. The thing about this is it's not definitive enough information. And the rule box is quoted right here on the page. Use one of the following two descriptors when such vague information, including traumatic brain injury or closed head injury, is the only information available. And while these descriptors identify the occurrence of a head injury, they do not specify its severity. Again, this is from the 0508 dictionary. And guess what? It's the same in 15. The only thing that's changed is the location, the page numbers. So closed head injury, traumatic brain injury. Why do we see it so much? Well, think about it. Somebody comes into the emergency department. They were in a car crash and they said, you know, I lost consciousness or the witness said or the medic said. So is there a brain injury? We don't know. We've got to run a CAT scan. So how do we get a CAT scan ordered? We have to have a suspicion of an injury. What are they right? TBI, CHI. That in turn allows for the CT to be performed and reimbursed. That's important. What happens to make our world a little more difficult and challenging is they don't always go back into the chart and give us a definitive if the CT scan is negative. So if all we're left with is CHI or TBI, well, we end up with an AIS code that ends in a post-op nine. And it's not part of our ISS calculation. It's basically a placeholder saying there was something or a suspicion of a head injury, but nothing ever came about. Not a popular spot. And a lot of people want to go ahead and code it as a concussion. And you can't do that because you back it up to the rule. We read a couple of slides back. They have to say concussion, document concussion in order for us to code it. So it's a sticky wicket as our friends across the pond like to say. So different types of brain injuries when we think about blood on the CT scan. And so just showing you some pictures. We talk about acute, subacute, and chronic. Well, that's a challenge, especially when you're reading a radiographic study, because they'll say acute on chronic. That drives me nuts. Well, how much is acute? How much of it's a chronic bleed? And they don't always tell you. That's the challenge. And if they don't tell you how much is acute, because that's what we want to code is the acute injury. If they don't tell you that, then we're forced with using a not further specified code. If they say there's acute blood, we can code the NFS at least. But the chronic, we're not going to code that. Then we get into the discussion. What do we do with subacute? Can I code subacute? Well, technically, subacute is an injury that was within four to 14 days of coming into the trauma room. Acute could be one to three days. That's interesting. So you need to stop and think about what does your inclusion criteria say? So if you're including patients that have been injured up to two weeks to 14 days, let's say, then acute and subacute injuries could be placed in your registry. What are we looking at? Hyperdense to surrounding tissue, isodense for subacute, and there's great pictures on the screen. And then you've got hyperdense for the acute, hypodense for the chronic. So you can see the visual changes. And most of us don't look at the pictures. I like to look at them because I'm just curious. But most of us don't do the pictures every day. We read the content of the documentation or the dictation that the radiologist has provided. But think about those things. Think about what your inclusion criteria is. There's a guideline there for you to go with and do your best. That's all we can ask is do your best. And we talk about intracranial pressure. I didn't cover any procedures in this presentation, but I do want to mention a couple of items. And one is the Monroe Kelly Doctrine. And I can't remember if it's M-O-N-R-O or M-O-N-R-O-E. So forgive me if I have a typo here. It could be without the E. But it basically gives you an equation that 80% is brain, 10% inside that cranial box is blood, and another 10% is the cerebral spinal fluid. So there's not a lot of area in there when you think about it. And this describes the relationship between the contents of the cranium and the intracranial pressure. So this was, again, identified by a couple of physicians, Monroe and Kelly, I can't remember what year the doctrine came out, but it really only applies to adult patients. And then you think about when you have a newborn, the fontanelles are not quite together and the suture lines are open, and it's as they age that those suture lines start to close. So this doctrine and the percentages there are mainly related to the adult population. If you've ever seen this before, if you see a document and now you're gonna know what they're talking about. And so we just wanna kind of think about intracranial pressure because it can be quite devastating. And that leads to opportunities for like an ICP monitor and so forth. Our brain can herniate, and there's just some pictures here on that particular slide of different herniations. You can have a subfalcine herniation, you can have an uncle herniation or a tonsillar herniation. Now, when you think about uncle and tonsillar herniations, that's gonna take you to a G code, G93.5 for ICD. All right, if that clot or that blood collection continues to grow without intervention, the pressure is gonna go up to the point where you're gonna have that herniation. So the brain parenchyma says, I gotta get the heck out of here, I can't stand this tight corner anymore. And it needs to find the closest route out. And unfortunately, down through the brainstem and through the foramen magnum is very popular spot for that. And if we don't treat it, it could actually be fatal for the patient. Another area that you guys questioned was, what's the difference between brain swelling and brain edema? There's an entire page in the dictionary that talks about brain swelling and brain edema. Actually, it's not an entire page, it's a pretty good chunk at the bottom of one page. Honestly, what we teach here in the United States is code based on how they've documented it in the chart. Now, if this was a group that was in Australia or over in say London, England, they were a little more particular about their coding. And page 43 in the 08 dictionary is where you find the differences in the definitions. For the most of us here in the US, if they call it edema, go to the edema codes. If they call it swelling, go to the swelling codes. Honestly, most of the time it's gonna be edema. It's gonna be cerebral edema is the most likely spot. And so SO6.1 is gonna lead you to your ICD proper coding. Brain contusions, SO6.3, I guess I did have it on this slide I just didn't have it on the previous one. So brain contusions, lots of little contusions popping up there, as you can see. They can be all on one side, they can be bilateral and you're only gonna have one AIS code based on its location and the complexity of it. And then penetrating trauma. With penetrating trauma, our primary injury is the soft tissue goes into the bone and then potentially to the brain. Our secondary injuries could be edema. And so the most lethal type of head injury is penetrating trauma. And there are specific rules in the head chapter and it's on the very first page, which is page 31. And it's the third rule box down. And it has basically five different rules in that one box. And it tells you code a penetrating injury to a specific anatomical site, the brainstem, the cerebellum or the cerebrum when you know that's where the injury occurred. So if you've got a gunshot wound that went into the parietal lobe, the parietal lobe is part of the cerebrum. So you go to the cerebrum section and code your penetrating injury there. Again, rule box, bottom of page 31, very, very helpful. So now I've got a case presentation I wanna do real quickly. I gotta be a little more aware of my time here cause I can get on those sidebar comments and sorry about that. This is a real case. It's a 34 year old male. Let me get my notes here, make sure I don't miss anything. It's a 34 year old male who came into the emergency department after being assaulted by thieves who attempted to kill him by hitting him with a pick ax to the head. The patient was asleep when they broke into his house. And guess what? He had mild bleeding around the site of where the ax went in, no loss of consciousness. He complained of severe headache, nausea and had three episodes of vomiting according to this friend who put him in a car and drove him to the ED. You can't make this stuff up, that's the sad part. When they went and did an exam on him and the ED, he was fully conscious, all right? He was pretty well oriented to time and space and complaining obviously of a severe headache. His blood pressure was normal, 132 over 96, little high. Pulse was 118, he had a respite rate of 20 and his intracranial pressures were off the charts obviously. But again, no loss of consciousness. So you can see a rendering there on the left and then the actual radiographic study on the right. And again, this is just another set of pictures here and it's in the left frontal temporal area of the head where he was hit with the pick ax. Now the interesting part is that they took it out surgically and you can see where they're pointing to the area of the depth of the ax. It was about 14 centimeters long and when they extracted it, it left a cavity of about four centimeters in diameter into the parenchyma of the brain. So they washed it out, okay, with normal saline. They did a duroplasty, they closed it with the type of sutures that absorb in. He was extubated, he was stable, spontaneous ventilation at 99% room air. He was fully awake. The only thing that the gentleman had issue with is that he was blind in his right eye, all right. The next day, day two, I think it was, he was taken to step down. He had persistent unilateral blindness of right eye blindness. Ophthalmology was consulted, said it was irreversible. There wasn't anything that they could do about it because he had an injury to the optic nerve. He was sent home on day five and they did a follow-up with him a year later and he was doing great. Talk about amazing. That is unbelievably amazing. So this guy is gonna have a penetrating injury to the cerebrum, to the cerebrum. And that is what we would code. We would go and find our ICD. We would do our procedures, obviously. Now with the duroplasty, just a little sidebar statement about that. Medical records coding rules would not include the duroplasty that was performed, but most trauma programs do because they're interested in that capture of the information. Not only the craniotomy that was done, but also the duroplasty because it was quite significant in this particular case. So it's really no different than those of you who collect the splenectomy and the XLAT codes in your trauma registry. It certainly makes for reporting capabilities much easier when we do that. And so duroplasty is another one of those examples. All right, so then I wanted to talk about your tests and knowledge to kind of give you an idea of how you did. And so your first one was a 78-year-old female who presented to the ED with a fall. Please code the following injuries with the limited information provided to you from x-ray, CT, and ED notes. The first part was a laceration to the scalp. So the majority of you got the correct code for ICD. So good job on that. That's awesome. And then the AIS code, again, the majority of you got that correct. I just want to mention to you, we have no measurements provided to us. It just simply says a laceration to the scalp. So some of you wanted to upcode it to minor. The other thing that I noticed in looking at your responses is several of you used your registry, and it's a collector system, because you don't have the full seven-character AIS code as your answer. And so when you're answering a quiz or looking at AIS codes, it's all seven characters. All right, so notice that means six numbers, a dot, and a seventh number. That seventh number is what's utilized to show the severity of the injury and is potentially part of the ISS calculation. So that's the first thing that jumped out at me. So we have a parafalsine subdural hematoma that was five millimeters thick, and the blood tracked along the tentorium. There was no midline shift and no mass effect. So the code that you picked for ICD was most of you got it right. So good job. Again, along the tentorium, think about our defaults. So we're going to take it to the cerebrum. Now, what about AIS? Again, good job. Look at that. Your responses are well over 70%. Got it correct. Again, subdural hematoma. Some of you wanted to take it to the cerebellum. All right, and how do I know that? Well, anything that is 1404, that automatically tells me it's the cerebellum. Be careful with that because the codes look very similar if you're using the dictionary. And depending upon how your database defaults, it could default to the cerebellum. Make sure that's where the injury is coded though. All right, so this one's going to be to the cerebrum. And then we have a petrous or petrous fracture. Again, tomatoes, tomatoes, how do you pronounce it? This is going to be to the SO2.19XA. The majority of you got it correct. So that's good. And then of course your AIS, you did awesome with that one as well. A few indicators that are a little bit different, the 752400.2, that's a carpal fracture. So I think maybe you just had happy fingers when you were answering that particular one. The 540402.2 is a vault fracture. The 50202.3 is a base fracture without CSF. And technically you could use that code. So when we think about cerebral spinal fluid, if it's there, they're going to talk about it. They're going to mention cerebral spinal fluid. So with AIS, you could technically move to the fact that there was no CSF if it wasn't mentioned. That's one of those little sticky wickets, all right? So technically either the one that's highlighted 150200.3 or the 150202.3 could be utilized, but be careful with the CSF, all right? Definitely they're going to mark it if it happens. And then that 140651.3 at the bottom there, that's a subdural code. And we don't have any mention of the subdural with this particular part of our descriptor. All right, the next one was a 32-year-old with a gunshot wound to the brain stem. So it tells me where that penetrating injury is. They also tell me that the patient died and there's no X-rays to do any confirmation. So there on page 31, we know the anatomical site. It says brain stem. So we're going to go back in our dictionary to where the brain stem codes are at, and we're going to make our code assignment. So page 41 in the AIS-08 dictionary has one code for penetrating injury to the brain stem, and that's the 140216.6. And by the way, there's the ICD code. So that was a neck and neck race with a couple of other ones, but you're coding it to the brain stem. And then again, there's the AIS portion. I got ahead of myself, sorry about that. A lot of different codes here, but please pay attention to the rule boxes. Otherwise you're out in left field on a lot of these. Okay, so we know it's penetrating and we know it's the brain stem. So those are two very key points. Two-year-old admitted to the ICU for coma and the CT reads multiple shear lesion and the patient dies two days later. So the correct answer for ICD is there on the screen. And this is the correct code as long as that's the only injury in the brain. So as long as it's the only injuries are in the brain, that's the code you're gonna pick. Now with the AIS, there was a lot of stuff all over the board. There isn't enough information to code DAI. And several of you wanted to code DAI. 31% of you wanted to code DAI. 31% of you made the correct code choice. So you end up with that shear lesion of the patient. Remember, DAI has to have immediate and prolonged coma. Physician has to document DAI and you have to have radiographic evidence. And what we have here doesn't tell me all three of those things. So we can't technically go there. I know you wanted to, but we can't go there without all three items being available. We had an 80-year-old who arrived with her daughter and the daughter said that mom had loss of consciousness. The ED physician's HMP says concussion and the patient was admitted for concussion and syncope. Again, remember the physician documents concussion, we can code it. Nothing's mentioned in the HMP about loss of consciousness. So you can code concussion without loss of consciousness and you should code concussion without any loss of consciousness indicators because unfortunately the bystander, in this case the daughter, isn't reliable enough to make those code choices. So again, Rulebox tells me what to do with that from an AIS perspective. And you did awesome with the ICD for the most part. And again, 50% of you got this correct for your AIS code. 34% of you went a little bit too far. We can't go there because we didn't have any indication from the physician about the loss of consciousness. Our 75-year-old male that was in the ED has a history of multiple falls, most recently striking the face on the bathtub. There were bilateral subdurals. There was an acute subdural on the right and mixed density on the left, which was acute on chronic. But again, think about what we were talking about previously. We don't know how much is acute. They didn't tell us how much is acute on either side. Okay, so your AI or your ICD, the majority of you got that correct, so good job. But your AIS, and you did good, 73% of you. But again, it's a little concerning because we have some different opportunities here. We've got folks taking things to the cerebellum. Again, pay attention to what they're describing to you. And we don't have any measurements. So a lot of you went an extra step to give measurements. All right, so 1404383 is a cerebellum subdural, not further specified, but it should have been cerebrum subdural, not further specified. Mildly displaced right mandible body fracture. Again, this is not part of the head that we normally talk about, but it is part of the, or it's not part of the skull, but it is part of the head. So I went ahead and put the answers in here just as an FYI. And so it says mildly displaced right mandibular body fracture that extends through the posterior molar and overlying soft tissue swelling and air. And so your correct code for ICD is highlighted. So good job on that. The thing with AIS is that we have some specific rules that say that has to be significantly displaced when it's a fracture in the face. And mildly is not considered to be significant. We actually have you make a note in the book that says greater than four millimeters, and we still couldn't code it because it says mildly. And so I know those generic words like small, tiny, mild, extensive, those words are really challenging when we want a measurement and we don't always get it. And so you have to do the best with what you've been provided. That's the best recommendation that I can give to you. A couple of you wanted to code it to the teeth and use that combination of dislocation fracture and avulsion, but the tooth wouldn't been involved if the mandible hadn't been fractured. So the mandible is the primary and it's extending into, so you're gonna code the mandible and not the tooth itself. All right, so here's my resources and references. If you're interested in reading more about the story of the pickaxe, it's the third bullet point down. Very interesting story and a true story. And I'm just amazed that the young man was able to walk out of the hospital five days later and just ended up with blindness in one eye. What an amazing story. I'm just totally amazed by healthcare these days. And then here are my contact pieces. So if you have AIS coding questions, email me directly at kcookman at triple am.org. And if you have ICD coding questions, you can email kjconsulting at kjconsulting.us. I may not be the one answering your ICD, I might, but we have a couple of other trainers on staff that will probably be the ones answering your ICD coding questions if I don't happen to be available because my major focus right now is AIS at this point. So that's what I have to present. And I know we're almost out of time and I'm sorry, cause I ramble on way too much. But Deborah, if there's anything that we can cover in the next couple of minutes, I'll be happy to. Otherwise we can certainly have them email me your questions that you've written. And I can make sure that the team there at TCAA gets the answers back to you.

coding head injuries

Kathy Cookman

trauma field

anatomy

types of brain injuries

coding guidelines

fractures

hemorrhages

contusions