Well, good afternoon everyone and I guess a few of you probably good morning if you're out on the West Coast. So today we are going to talk about best practice guidelines for coding liver and splenic injuries. And let's get started. So just a little bit first about who we are here at VCU. So we have three hospitals, our VCU main campus here in downtown Richmond, Virginia, and we are a level one state and ACS verified adult trauma center. We are the only ABA verified burn center in Virginia. And we just celebrated our 75th burn center anniversary in December. So that was a great accomplishment here at VCU. And we also have two sister hospitals, one community Memorial Hospital in South Hill, Virginia, which is actually very close to the North Carolina border. And then to our Northeast is Tappahannock, which is a small community hospital. And then we have our children's hospital here in Richmond on the same campus as our level one. And we are a level one state and ACS verified pediatric trauma center as well. And so our volume here is about 5500 patients a year. We have 10 trauma burn registrars. We have three PI nurse clinicians, and this is actually on the adult side. And then our pediatric side, we have our program manager, a registrar, and we also have our PI nurse clinician as well. And then we have a burn outreach coordinator, an adult trauma outreach coordinator, a pediatric trauma outreach coordinator, a falls coordinator. We have a full-time and a half-time trauma psychologist, and we have an EMS coordinator along with our injury and violence prevention program, which employs about 30 people. So we have a very large trauma program here. So the objectives today are recalling solid organ injury grading, recalling the anatomy of the spleen, the anatomy of the liver, describing the coding principles of the spleen, and describing the coding principles of the liver. And so starting off with the spleen. So your spleen is located in the far left part of the abdomen. It's to the left of the stomach. It's very vulnerable to injury due to its position, and it is easily injured because it overlies the overlying rib cage. It's right under ribs nine, 10, and 11 on your left side. It is one of the most commonly injured abdominal organs. It's the most vascular organ in the body. And so obviously, a highly vascularized organ can result in some major significant blood loss, and so that means obviously splenic injuries can be very serious and need to be treated immediately. So if trauma involves the lower left chest or the upper left abdomen, the spleen is likely to be injured. And again, that would be in the areas of the left ninth, 10th, and 11th ribs. And most commonly, gunshot wounds or blunt trauma to the left upper abdomen. And the most common mechanism actually is a motor vehicle crash. So again, that vasculature, you have the splenic artery, which is a branch of the celiac trunk. Your splenic vein, which joins the superior mesenteric vein to form the portal vein. The different parts of the anatomy, again, are the pulp. So the red pulp is that vascular, 80% of that spleen. It's made up of by thin-walled blood vessels. So again, all that vasculature is susceptible to injury and a lot of bleeding. And then your white, which is 20% splenic tissue, and it's entirely lymphoid tissue. And then you have that hilum, which is the place of insertion for the splenic artery and the splenic vein. So looking at a little bit of anatomy pictures here to help you out, again, looking at where the spleen is located there, which is kind of on top of the stomach and to the side of the liver, and again, that red and white pulp. So 80%, as you can see there, is red, and 20% is that white pulp, which is lymphoid tissue. Again, and another, just to look here at a little bit closer, and there you'll see your splenic artery and vein going into the spleen. The red pulp, which is all of that vasculature, your white pulp, that lymphoid tissue, and then that trabecula and the capsule. So you'll hear whether it's a capsular tear or is it a rupture. So that splenic capsule is a dense, irregular fibroelastic tissue, and it actually produces a weak contraction of that capsule to help discharge the blood that's stored in the spleen out to circulation. And that trabecula is kind of an internal support for the spleen, and it carries the blood vessels into the spleen. It's connective tissue, and so again, it all works together and gets that blood where it needs to go. Again, just another look at the surface, so kind of where your other organs touch the spleen, so the gastric, your pancreatic surface, your renal. And there again, you have your splenic artery, your splenic vein, and the hilum, which is where all of that, those splenic vessels, the artery, the vein, the lymph vessels, and the nerves all enter the spleen there at the hilum. So when a patient comes in and you look at their mechanism, that's the first thing they're looking at, and where their injuries are. We all know that one of the first things that we do is a FAST, so a focused assessment with sonography for trauma. So this rapidly identifies free fluid in that abdomen and pelvis, and it's especially useful when you have someone who comes in and they're hemodynamically unstable, so their blood pressure is tanking, and you're looking for bleeding somewhere. Again, your CAT scan, so you come back with a negative FAST, they're usually going to go to CAT scan. If it's a positive FAST, most times they're going to end up going off to the OR. That CT scan can show disruption in the splenic parenchyma. It can show if there's a hematoma, if there's a laceration. Also can show free intra-abdominal blood. And then that physical exam, so they're going to look for tenderness in the abdomen and rigidity. So are those muscles in the belly really stiff, and then maybe they actually stiffen up more when you try to push on them. So that's your abdominal rigidity, and that's usually an indication that there's some blood in the belly. Looking at different treatment options. So treatment obviously is going to depend a lot of times on whether your patient's hemodynamically stable or whether they're obviously unstable. Most unstable patients that come in and they have either that positive FAST, they have that abdominal rigidity, they're going to go off to the OR right away. But your non-operative management, so approximately 80% of splenic injuries are when they're hemodynamically stable patient, they're going to go for non-operative management. So they're going to be getting serial abdominal exams, making sure that they do not end up with some tenderness and some rigidity in that blown up abdomen. They're going to be doing complete blood counts and looking at their hematocrit and hemoglobin and making sure that all of those are staying stable and they're not dropping. Another treatment option obviously is going for angiography and or embolization. So sending them off to IR, interventional radiology. So patients who are hemodynamically stable but have contrast extravasation on CT. So contrast extravasation is a leakage of contrast agents into the surrounding tissue. So when they see that, you know, that contrast is leaking out or sometimes you'll hear that there's a blush, there's a blush on their CT scan. So that is when the patient has contrast extravasation during the arterial phase of the CT. So sometimes you'll hear them say there's blush sign. So obviously that means that they have a leakage somewhere. So you could end up, they could end up going off to the OR or you can end up embolizing in doing an angiography and embolizing. Again, operative management. So hemodynamically unstable patients. So if they have an abnormal or unstable heart rate or blood pressure, they're more often to go for operative management. Again, peritonitis. So redness and swelling of the lining of your belly or abdomen. They're going to look for that. So you know, is something causing that? That's leaking from somewhere. Pseudoaneurysm formation. So that's a tear in the vessel wall intima with blood dissection into a false lumen. So you know, looking for, do they have a pseudoaneurysm? And then again, there can be associated intra-abdominal injuries requiring an exploratory laparotomy. So they may not only have a splenic injury, especially if you're looking at maybe a gunshot wound where they can have a splenic injury, they can have a liver injury, they can have, you know, colon injuries, small bowel injuries, all of the above at one time. Again, with a major MVC as well. You can have, you know, obviously more injured than just the spleen. Here is, I threw this in for reference for everybody. So solid organ injury grading of the spleen. So this kind of shortens up for you what grade it is and then what your AI, sorry, AIS severity is for that. And then a description of what the injury is. So, and that would be imaging CT findings. So if you have that subcapsular hematoma, it's less than 10% surface area, or you have parenchymal laceration that's less than one centimeter in depth, or a capsular tear. That's a grade one injury. Your AIS is two. And then when you get into grade two, it still is an AIS severity of two. And again, you have that larger subcapsular hematoma, so 10 to 50% surface area, or that intraparenchymal hematoma, but this time greater than five centimeters, or the parenchymal laceration, which is one to three centimeters. So just a little bit larger than that grade one goes into the grade two. And then your grade three, and then this is usually when you get into the higher grades as you go up, is when you see them going to the OR, or sometimes having a failed nonoperative management. So the grade three being a subcapsular hematoma greater than 50% surface area, or less than, sorry, ruptured subcapsular intraparenchymal hematoma, or that parenchymal laceration. And then when you get into your grade four, it's any injury in the presence of a splenic vascular injury, or active bleeding confined within the splenic capsule. And again, that parenchymal laceration involving segmental or hilar vessels. So when you get into, it's actually into those vessels at the hilum, that is a much more significant injury when you get into the hilum. And then your grade five, which most likely you're going to take that patient to the OR, is any injury in the presence of a splenic vascular injury with active bleeding beyond the spleen into the peritoneum, or they may call it a shattered spleen. So now looking at splenic injuries, so contusions and lacerations. So something that I found when I was doing some validation was that there was a little bit of confusion between your AIS coding and your ICD-10 coding, because they're not exactly comparable. There's not one code to one code for these. Things can kind of fall into two ICD-10 code ranges, but only one AIS code. So your contusion or hematoma grade one, you only have one ICD-10 code to cover that. But then when you get into your grade two, a contusion, you actually, this falls into a grade one or two for your AIS code. But for your ICD-10, as you can see, you have two different contusions. So less than two centimeters or greater than two centimeters. So again, I kind of made this tool for my registrars here so that they had something to reference when they were coding that made it a little bit easier when they were actually looking at things to know which ICD-10 code matched when there's more than one to choose from. So again, a grade three contusion being that subcapsular or a ruptured subcapsular or parenchymal or intraparenchymal, that is considered a major contusion greater than two centimeters. So again, giving them, you know, what they needed when they get into coding. All right. Getting into the lacerations then. So you have a simple capsular tear. And again, this is a grade one or two laceration. And then you actually have an ICD-10 that fits that. So it's a laceration of the spleen less than one centimeter or minor. Then you get into your grade three and you have no hilar or segmental parenchymal disruption or destruction. So, you know, it's not involving that hilum, but it could be involving those trabecular vessels. And it's a moderate injury. And again, there's your moderate laceration of spleen. So that's one to three centimeters for your ICD-10 coding. And then when you get into grade four, it's involving the segmental or hilar vessels and it produces major devascularization. Again, that's a grade four. And again, using major laceration of spleen for your ICD-10, that includes an avulsion of the spleen, a laceration greater than three centimeters, a massive laceration, multiple moderate lacerations or stellate laceration of the spleen. So any of those descriptions fall into that ICD-10 code. So, again, just pointing out that this is somewhere where your ICD-10 codes kind of don't match that AIS code exactly. So you kind of have to find what falls into it. And then your grade five. So that's a hilar disruption producing total devascularization. Again, like I said, this is most likely going to go to the OR. You have tissue loss. You have an avulsion. It's a massive injury. And again, that's a major laceration of the spleen as well. So, again, looking at that ICD-10 code, you see for a grade four or a grade five, it's the same ICD-10 code, but a different AIS code. So just like I said, something that sometimes trips people up a little bit. So your splenic procedures. So obviously a total splenectomy, which is considered a resection. So that's cutting out or off without replacement all of a body part. So that's a total splenectomy versus a partial splenectomy. So if they're only taking a portion of that body part, so a portion of the spleen would be a partial splenectomy. Majority of the time, it's going to be a total splenectomy. I have only experienced maybe one or two partials. It's usually the entire spleen. And then I threw in here for everybody, your angiography. So your angiogram of your splenic arteries, the beginning of your ICD-10 procedure, and then you would have to obviously find your final code based on exactly what they did. And again, so there's a couple types of embolization. And what I did was I went to our IR physician champion and spoke with him about the differences in types of embolization and maybe why they choose one over the other and what the differences are in them. So the biggest thing that we do here is either a coil embolization or a lot of gel foam. And we've just started with some vascular plugs as well, but the coil embolization is considered permanent. So that is actually an occlusion of that artery. Whereas gel foam was explained to me that that's temporary. So it can last anywhere from hours to forever, just like the coil embolization, but it is considered a temporary measure. So you would use restriction for a gel foam or the vascular plug that is also considered temporary, although it can be permanent, but it is from the eyes of IR when I spoke with them, it is temporary. So a couple of your splenic procedures. So an exploratory laparotomy, so an inspection of that peritoneal cavity. And I think most people in a level one center are definitely familiar with an exploratory laparotomy, sometimes called a coeliotomy. There's a couple of doctors call it different things. Obviously to most in the trauma world, we say X-lap. That's the easy way. Then there's inspection of the spleen. If for some reason they're just going in and looking at the spleen only, maybe they're not actually doing an entire X-lap. And then a repair of the spleen. So they go in for an X-lap and maybe they've got a whole bunch of damage in there. Maybe they're just going to repair the spleen. So that would be, for example, if they were just gonna suture something. And then abdominal packing, which we do code here and we keep track of what they're packing. So are they packing the liver, the spleen, both, where exactly they're packing for control of bleeding. So moving on to the liver. So the liver again is blunt and penetrating trauma. And this, the liver injuries make up about 5% of all trauma admissions. So your liver is obviously pretty large. It's located under the diaphragm and on top of the stomach. And again, large in size relative to other organs. It's in the upper right-hand portion of the abdomen. And the most common mechanism is a motor vehicle crash, pedestrian struck and falls. There are four lobes of the liver. There's two main lobes and each are made up of eight segments that consist of a thousand lobules, which are small lobes. And that is the left and the right. And the right is the largest of the lobes of the liver. And then you have the caudate lobe, which is deep in the liver, in front of your inferior vena cava, behind the three major hepatic veins. And then the quadrate lobe is inferior surface of the right lobe. And I do have some diagrams coming up to show you that. The blood supply. So the liver holds about one pint of the body's blood supply at any given time. So that's about 13% of a person's blood. So obviously the liver again is another area where you can bleed out very easily from with a major injury. So you have the hepatic artery, which delivers oxygenated blood from the general circulation of the body. And then your hepatic portal vein, and that delivers deoxygenated blood from the small intestine, and that contains nutrients. And there is a right middle and left hepatic vein. And again, coming up here, you can see there's that right lobe that is majority there of the liver. And then the left lobe, that's a little bit smaller. And there you see that falciform ligament, which if you've abstracted a lot of the X-lapses you'll hear them very often refer to that falciform ligament. And then there you see in the back, you have your inferior vena cava, and then your aorta, and then that hepatic vein that comes off of the inferior vena cava. And then underneath there, you see that you have your hepatic artery there coming off of the, branched off of the aorta. You have your hepatic portal vein, your ducts, and then your gallbladder with all of their ducts. So there's a lot going on there at your liver and a super important organ of your body, to filter out all of the things you don't want, all of those toxins. So here's a little bit better of showing you the size difference of these lobes. So that right lobe being very large, left lobe, and then you see underneath, where you have the bottom side there of the liver and the front, and then the caudate lobe there is on that bottom side there at the top. And the rear side and the quadrate lobe there, and how small they are in comparison to the right and left lobes. Again, another picture here of all of that vasculature that comes into the liver, and you see there are a whole lot of branches in there. And again, it's a pretty vascular organ. So your diagnosis. So you're looking for trauma in the thoraco-abdominal region. So the thorax and the abdomen. A CAT scan is the best way to identify hepatic injuries. And it also allows for grading of those injuries as well. Blood work, so they're going to look at those liver function tests and obviously a FAST. So looking for that free fluid, that blood in the abdomen. Again, very similar to your splenic injuries that when you're looking for your liver injury, very much the same kind of thing. So 80 to 90% of liver injuries are managed non-operatively, and that's usually grade one or two. A grade six injury is often fatal, so most likely fatal. And liver injuries are the primary cause of death in severe abdominal trauma with a 10 to 15% mortality rate. So that is pretty high. And again, gunshot wounds to the liver or these massive injuries in a really bad motor vehicle crash. You can get a volved liver, things like that. And it's kind of, when it's that significant, sometimes it's just, you can't stop the bleeding. So hemodynamically stable. So a lot of times, especially those grade one, two, even three, is going to be observation. So you're gonna, again, see those serial abdominal exams, making sure your belly is soft, it's not tender, it's not rigid. And then again, your serial CBCs, your H and H, making sure your hemoglobin and hematocrit is stable, everything looks good, it's not changing, it's not dropping. And then you also have that angiogram and embolization, the same as you do with the spleen. So again, looking for extravasation of contrast on CT. And then for patients who are hemodynamically stable, embolization can be most successful when it's used preemptively in a hemodynamic stable patient. So when they have a stable blood pressure, stable pulse rate, and they're really worried about this liver laceration and a re-bleed or bleeding, they will send them for angiogram and maybe embolize preemptively. And it's also used for those patients who have failed non-operative management or in patients with ongoing bleeding or re-bleeding after surgery. So sometimes you'll even see they went in for an X-LAB, maybe they have several injuries. When they leave the OR, they're going to go to IR or some people have a hybrid room, whichever your hospital has. And they will actually then also embolize on top of having done some surgery. In a hemodynamically unstable patient, again, you're going to see that operative treatment, that X-LAB, packing, again, suturing of the liver and ligation of some of those vessels. Again, looking at the solid organ injury grading for the liver, same grade one and two have that AIS severity of two. And then you get into your grade three with an AIS severity of three. And it's easy to remember your AIS severity because a grade three is a three, a grade four is a four and a grade five is a five. So I think, especially if you're going to sit for the CAISS, this is just a hint that that's something to keep in mind to remember when you're looking at some solid organ injuries. So I won't read over every single one of these again, but I put this in for your reference so you have somewhere to kind of look at it. Sometimes you don't necessarily get a grading, but you might actually get a description in a CAT scan or a description maybe in pathology if they removed something. So if they removed the spleen, you might get your pathology telling you what size the lacerations were or the disruption was, same with the liver, if they removed part of it. But looking at the actual description is very important versus just looking at the grade. Because sometimes a doctor can say, hey, it's a grade three, but when you actually read what the injury was, it's actually a grade four. And you can then code the grade four if it meets your AIS coding, you can code that. So looking at your liver injuries again, and again, looking at those, the AIS versus the ICD-10 codes, you'll find, so there is only the contusion not further specified. So they say liver contusion and that's it. Right there are your codes for both of those, your AIS and your ICD-10. Then moving on to a contusion, subcapsular, non-expanding, superficial, it's a grade one or two. And again, that AIS code that goes with it. And that AIS code, or I'm sorry, the ICD-10 code also goes with that grade three contusion as well. So again, looking at that you can have the same ICD-10 code for either a grade two contusion or a grade three contusion. So again, looking at those different coding. Liver lacerations. So I am a big not further specified. No, no, no, we don't do that. So in our center, the registrars will let me know if there is a solid organ injury that is not further specified, that they do not have any pathology, they don't have anything in the op note, they don't have anything in a CT or any other notes that tells them what grade is it or specifies enough detail that they can code it. They let me know and I immediately send out to our surgeon and say, hey, we need to know the description of this injury and the grading. And can you please addend either your op note or your HNP or whatever it is that is on that patient that we need addended. And then they do. And that way we are able to get more specific coding. So I say to everyone out there, please query your physicians when you only have an NFS code, try your best not to use them. It doesn't give your patient the best ISS that there is when you use that. So whether you guys reach out to your surgeons on your own or you have somebody that can do that for you, please make sure that you do that. And then getting into your simple capsular tear, a grade two laceration. And here you'll find that there are two ICD-10 codes that fall into this one AIS code. So again, that's kind of where you actually have to look at your description of what they're giving you, where that comes in to be a little bit more important. And again, then moving into that grade three liver laceration, you'll see, again, you have two different ICD-10 codes that it can fall under. So this again is where you'll find, it's really important to have that grading and that actual description of the injury, super important. And so again, reaching out and letting your physicians know and maybe educating them on how the trauma registry actually has to code these injuries, sometimes helps to get better descriptions. So again, looking at a grade four, you have that parenchymal disruption. And again, you can have multiple lacerations, burst injury, a major liver laceration, and there's your ICD-10 code. And again, that code can also be used for grade three, dependent upon the description. And then your grade five injury and your grade six. And like I said earlier, grade six, most of the time those patients are not gonna make it. That's a complete separation of all vascular attachments of the liver, okay? So, and again, this major laceration of the liver, ICD-10 code, that can be used for a grade four, a grade five, a grade six, and possibly a grade three, depending on the description. So this is where having a reference to really look at, and again, getting those really detailed descriptions of what really is the injury really comes in handy. And then there is a rupture, which is only when a more detailed descriptor is not available. And you'd have to use that laceration of liver unspecified degree for your ICD-10. Again, try not to use. This is another one where I would go out and query our surgeon and say, we need more information, I don't wanna use this. And then looking at your liver procedures. So there's some bypass of the ducts, if there's some duct involvement, and they need to do some repair in their drainage, if they're actually gonna put some drains in, and then an excision. So an excision is a removal of the portion of the liver. And so you might see that as a wedge resection. And so there's the liver, there's the right lobe, there's the left lobe. Again, you go into all the different areas that they might be removing a portion of. And again, I just put in these quick references for you. Again, so suturing the liver, which we see often here when we have a pretty significant injury, and especially when they're in there doing all kinds of other repairs, especially with gunshot wounds to the abdomen. So a resection is a removal of an entire lobe of the liver. So if they're going in and they're going to remove an entire lobe, that's how you would code that resection, okay? Obviously, they're not gonna remove the entire liver because we can't live without a liver. So you also have that hepatic angiogram, and then your embolization, again, the coil, the gel foam, the coil being a permanent occlusion, and the gel foam being a temporary restriction. Oh, and we are gonna get to our quiz. All right, so question one, a simple capsular tear of the liver is a grade what laceration? One, two, three, or four? Okay, so let's see what we got. So our answer, a simple capsular tear of the liver is A, B, grade two laceration. It's a simple capsular tear, K minor superficial. The point of insertion of the splenic artery and vein is called the, as soon as we get the poll, I think she's probably pulling the poll up now. Oh, there we go. All right, good job. So the point of insertion of the splenic artery and vein, it's not there, it's actually the hilum, and you guys did really well with that one. So remember where all of those splenic artery, vein and the nerves come in all together is the hilum. Nope, there it is, I had that fly in. Okay, next question. A hepatic avulsion is described as multiple lacerations in all four lobes of the liver, total separation of all vascular attachments, massive complex lacerations of the right and left lobes of the liver, or none of the above. All right, good job. The answer is B. Hepatic avulsion is total separation of all vascular attachments, a grade six injury. Good job. Okay, next. Splenorhepi is liver repair, suture of the spleen, removal of the spleen, or none of the above. Very good, splenorhapy is suture of the spleen. So splenomeaning spleen, herhapy meaning suture. It's a surgical repair when you are coating it. Good job. A wedge resection of the liver is coded as what type of procedure? A repair, an excision, a resection, or a bypass? Good job. A wedge resection of the liver is coded as an excision. So remember a removal of a portion, a removal of a portion is an excision. A resection is the removal of all of a portion or all of the body part. So resection all, so a total splenectomy is a resection. A removal of one lobe of the liver is an excision, okay? It's not the entire liver. The liver is made up of how many lobes? Two, three, four, or the liver does not have lobes? Very good. The liver is made up of four lobes, the right, the left, the caudate, and the quadrate. A subcapsular contusion of the liver involving less than 50% surface area is A. Grade three laceration, grade one contusion, grade three contusion, or none of the above. The answer is C, it's a grade three contusion. Great job. True or false? If the trauma surgeon documents a splenic laceration as a grade three, however the pathology description is consistent with a grade four laceration, you should code what the trauma surgeon documented, grade three laceration. So the answer is false. So per AIS coding rules, if a grade is documented by a physician, but the pathology or CT scans are consistent with another grade, that grade should be coded. Now, one thing that I will reiterate here is this. If you have a CT scan that says that you have a grade four laceration of the spleen and your trauma surgeon actually does an X lap and goes in and grades the spleen as a grade three, I would then go with the grade three because a surgeon looking directly at the injury versus the CT scan, I would go, would trump a CT scan. So somebody going in and actually looking at the injury and saying, this is what it is, is much better than even a CT scan. So that's where that would be different. But if they go in and they do surgery and you have them saying it's a grade three and maybe they did a splenectomy and the pathology comes back and has a description that's consistent with a grade four injury, I would then code the grade four injury. So again, using a little bit of critical thinking when it comes to what you're looking at. But again, following your coding rules and that list of your hierarchy for your injury and where you're going to take your diagnoses from. Trick question, guys. The spleen doesn't have lubes. Good job. All right, last question. Coil, true or false? Coil embolization of a vessel is a temporary measure. False. Coil embolization is permanent while gel foam embolization is temporary. Good job. So questions and also my email there and my contact information. If anybody has any questions or suggestions or anything else, you can always contact me. I'm always open to helping anybody out or anything at all. That was a great job, Robin. There were several questions that came through during your talk. So I'm going to go ahead and ask those. So it's my turn to ask questions of you instead of you asking us. One of the questions, when there is a laceration and a hematoma on the spleen, do you code both injuries or just one? That's a great question. So per the AIS coding rules, you would code the laceration unless they were distinctly two separate injuries. So saying that there was a hematoma on the far right of the spleen and there's a laceration that's on the far left. If they are completely separate injuries, you would code both. But if they are together, you would just code the higher AIS, the more severe injury. Yep. Okay, perfect. And the next question, how do you handle a pseudoaneurysm and a splenic injury according to the OIS update for 18? Um, I'm not quite sure what they're asking. Like how to treat it? That's not an area of expertise. Maybe how to code? How to code the pseudoaneurysm? Maybe. I'm not, I guess whoever asked the question, if they could maybe specify what exactly they mean. Like, I don't, you know, are they asking? Okay. What? And I'm not sure who asked the question. Okay. So maybe they're still listening. Okay. Um, one of the other questions is what if a radiologist says, uh, one grade level, but the image that you showed doesn't support that. Okay. In other words, what you showed doesn't support that grade. So according to your AIS guidelines as well, um, you can, as I referred to, you can code, you should code no matter how, whatever they say, if they say it's a grade four injury, but the details of it, or, um, the descriptors fall into a grade three, that's where you would go. So again, same, same, same thing with that is, you know, if, if they say it's a grade three injury, but the description of it is a grade two injury, you would code grade two or vice versa. If it was, they said three and the description was a four, you'd go to the four. So you would code whatever that description, if they give you enough for that description. Yeah. Okay. Uh, can we code for abdominal packing in addition to an X lap and trauma cases where we initially pack and the, and then patient leaves the OR. Okay. All right. So I think I know what she's saying is, um, she's asking, do you code the packing if they don't leave the packing in? I think that's what she, is that what she's asking? Like, you know, they'll do an X lap, they'll pack everything. Then they'll go back to it and remove the packing. So we only code the packing if they leave it in. So they, they pack up the liver real good. And then they may, they throw an Abthera on and they're going to bring them back the next day and they're going to, you know, then we would code the packing. However, if they just pack, um, and remove the packs, do everything, close them up and go, then we would not code the packing. So it would have to stay in. Yeah. Okay. Yeah. That's the way I interpreted that question. Uh, in the new 2018 rule of OIS, it says you can upcode and, um, was curious as to how they hand, you handle that at their institute at your institution. Okay. Uh, I'm not quite sure what she means by you can upcode, uh, upcode in a, uh, or she or he, I should say, um, in a, you know, um, you can upcode if, if your injury supports, you know, if you have the description that supports it, or again, when you have multiple lacerations, uh, you can upcode. Okay. Again, that's an AIS. Yeah. Okay. Uh, the liver fructure is showing to code as S36.113 in the ICD-10 on the slide. Um, the participant is asking for the rationale of why you chose an unspecified degree for ICD-10 on that liver rupture, or was this a typo? I'm going to look right now to be sure. Uh, liver rupture, liver rupture. So, um, maybe that's a, maybe that's a new code. Let me just quick look. I want to see, maybe it wasn't, couldn't have been a typo, but I think so. I think, um, we've always used rupture as a, um, not further specified or unspecified because it doesn't tell us what's ruptured, what's the degree, what's, there's no description of the injury. So we actually go back to our physicians and say, this is not, a rupture doesn't work for, for, um, our solid organs. Like we want an actual description of what do they mean by rupture? So this is how we have always done it, but I am going to look right now, uh, and see if there's a better code. And, um, and I will definitely, um, send this back to, um, Deb and April, um, this question and, um, and yeah, definitely let me do a little bit of research. And if there is a better code by all means, uh, I think that's, that's how we should do it. All right. Perfect. I am seeing a lot in the chat about this was a great presentation. Uh, very appreciative of the, the information and very appreciative of getting the slides ahead of time so that they can take a look at the slides ahead of time. So lots of that information. So thank you again, Robin, appreciate everything you've done today. I know you're busy and, uh, thanks for spending an hour of your time with us. Absolutely. And again, if anybody has any questions or anything else, feel free to always reach out to me. All right. Have a great day.

coding liver injuries

coding splenic injuries

best practice guidelines

VCU

spleen anatomy

spleen injuries diagnosis

splenic injury management

grading splenic injuries

ICD-10 codes