Good afternoon, everyone. I want to give everyone a welcome. And thank you guys so much for joining us for today's webinar. I am Callie Crawford. I'm a trauma educator at JPS Health Network in Fort Worth, Texas. We're a level one trauma center. And we're going to get started with today's webinar. Without further ado, I want to welcome back Kathy Cookman from Triple AM. And everyone, enjoy the presentation. Please feel free to write any questions or comments in the chat. And we'll make sure that everything gets asked at the very end. Thanks so much. All right. Thanks, everybody. It's nice to be back. I do not have my camera on because I just had a catastrophic emergency happen. I was trying to share the screen and it gave me a message that my PowerPoint was unstable. So we've decided that I'm not going to be on camera just in case that has some sort of a conflict. I wanted to put this educational statement up on the screen for everybody to remember that the TCAA is approved by the California Board of Registered Nursing. The disclosures are listed here. I'm Kathy Cookman, your presenter, and you can see any of the opinions, the little statement down at the bottom, and you guys can read that on your own. The slides are available for you as a PDF document. So nobody needs to worry about that. You don't need to ask that in the chat. It will be made available to you. Three basic objectives. I'm going to try to discuss the impact of documentation, evaluate the effective, accurate AIS coding based on documentation. And you will hear my clock in the background. So my apologies for that. And then we're going to identify the impact that accurate coding has on our TQIP submissions, as well as preparing for an ACS survey. Now, some of the slides you have already seen if you've taken an AIS course. So just sit back and relax. I just want to do a little bit of review. I do like this slide because it tells us that it's more than just hospital based folks who use the AIS scoring system. Clinical trauma is probably what 99% of the people on this call right now are involved in. And that makes sense that you would be here at this wonderful opportunity to learn. We use AIS and ISS when we're thinking about the triaging over and under of our patients. We look at probability of survival. We look at outcome majors, evaluations, we do research. There's all sorts of things that we utilize AIS for in our day to day workings within a clinical setting. Obviously, motor vehicle crash investigation through the National Highway Traffic Safety Administration and our Department of Transportation. They have used AIS since its inception. And actually, they were part of that original group that got together to put together AIS as a whole. They look at frequencies of injury patterns, distributions, mechanisms of injury, vehicle design, and things of that nature. They go even so far to recreate crash scenes to determine the pattern of injury. And I know that most of you have probably seen the commercials every now and then where they show the crash test dummies inside of the vehicle when they're running them into buildings and whatnot. And that is valuable pieces of information, as is the information that you collect and put in your local registry. And then you probably send it off maybe to a regional, the state system, and then on to the national system. So a lot of people have an opportunity to look at your data and use it. Health research, epidemiology, and our military as well, is a very heavy user of AIS because we want to keep our men and women in the armed forces safer. And so they look at protective systems and they evaluate those and their effectiveness and the patterns of injury. So even the most simple abrasion or contusion that a patient can sustain is just as important as a bleed or a aortic transection. So every little nook and cranny, as I say, when I'm teaching that has a boo-boo is important to somebody. And that's why we want to do the best that we can in collecting that information and putting it into our registries. And then on the bottom row, you've got policy and industry decisions. And that's another key factor as to why we have to have valid, accurate data. Policies are being made and changed based on this information, clinical practices, and how patients are cared for. And just as I'm sure everybody on this call would want their loved one having the best trauma care, well, we need to start back to the beginning again of how is it documented? And how are we picking that up and putting it into the registry and coding it? And so again, and some of you we've heard this before. So just just bear with me for a second. We do use AIS, the concepts and the purpose are to rank the injury by severity and it's relative to the whole body. Notice that I have the word attempts in quote, I've been saying that a lot more lately. It is a standardization of terminology, but once in a while, we don't always think about a global perspective. And I'm referring to the AIS-15 dictionary where we added the word peppering. Peppering is not globally understood, believe it or not. Here in the States, yeah, pretty much standard thing. We know what that means. And so that's why I'm saying attempts to because that's the whole purpose is that we're speaking the same language. It is definitely usable for multiple injury causes. It describes our injuries anatomically, and it's more than a threat to life scale. This is the definition of what AIS is. And I don't need to read that to you. Those of you who have been coding AIS, or have at least been introduced to it, you're very familiar with the definition of it. We do describe things anatomically. And so we have to know our anatomy. That's the key factor there. So AIS descriptors identify the damage to the anatomy. And it's from a transfer of energy, and it's not the physiologic response. So knowing your anatomy, knowing your medical terminology is key. And that's why if you've ever signed up to take a class before, that's one of the primary questions that you're asked. Have you had an anatomy course? Have you had medical terminology? Have you had at least six months experience working with AIS? Because when you don't have that experience behind you, it's difficult sometimes to truly understand the AIS system. So anatomic measurements, they're not variable based on physiologic measures. So you know, the golden hour of getting that patient stabilized into definitive care is still important, but it doesn't change the code or the AIS code that we use for that injury. We rank these things in numerical order using an ordinal scale. And again, this looks pretty common to most folks on the call. It goes from one to six, minor, moderate, serious, severe, critical, and maximal. And maximal used to be defined as not survivable or not treatable, and that's not the case anymore. So the nomenclature changes as the code changes and the code changes, because medicine has changed and the way that patients are being cared for and the survivability is quite amazing from when I first started back in the late 70s. The post-dot value, that's what we refer to that last number in the string, is going to be what we use to then go and calculate an injury severity score. If you end up with a post-dot nine, that means there's not enough information in the documentation. It's just not adequate enough to assign a more definitive number. For example, closed head injury. We see that quite often, generally in patients that come into the hospital and they're not acting quite right in the emergency department. And so the physician has a suspicion that there could be a head injury. And what do they do? They pull out the protocol, they order a CT scan of the head, they write closed head injury in the documentation. That now allows that CT to be performed and reimbursed. But what happens when we're coding and the CT scans negative? We're stuck with closed head injury. And that's okay. It's a placeholder, but it does not have an impact on injury severity. It's important to know what version of the dictionary that you're using, because as the dictionaries grow, they change sometimes in their post-dot values, new codes are added, some are retired. And so when you're doing reporting, such as trending, or you're involved in a research project, it is extremely important to make sure that your reports are showing when you changed versions. So for example, if you're doing a study on concussive injuries, and you are looking at the number of patients that have had concussion diagnosed, it changed post-dot value into the new 2015 dictionary. It's now a post-dot value two. Over the years, there's been an increase in the number of codes that are in the dictionary. If you look back to 1990 version of AIS, there was just a simple little 1300 codes. Now we're over 2000 codes. And as you look at that second column, the count and the percentage of AIS three and four post-dot values, again, those are the serious and severe type of injuries. Those also have increased 619 of those, which is 31% of the code for 2015, and 43% or 43, meaning 2% are lesser in the AIS nine values. And so we try to encourage you when you're reading documentation, and you're trying to pick the most appropriate code, try not to use the ones that end in a post-dot nine. But of course, if the documentation doesn't support something better, that's what you're stuck with. And that's okay. You have that placeholder to show that there was a suspicion of an injury, it's just not going to be counted in the overall scheme of things. So when you go to a chart, and you're looking at it for the first time, whether you're working concurrently or retrospective, try asking yourself these questions. When you're reading through the documentation, what part of the anatomy is injured? So think about that for a second. What part of the anatomy is injured? What's wrong with it? Is it fractured? Is it contused? Is there a bleed? Number three, how serious is it? So if it's a fracture, excuse me, is it comminuted? Is it open? Is it displaced? How much is it displaced? And then number four, what additional information in the documentation is going to help me to choose the most appropriate AIS code? So when you think about those types of things, I always use the example of a fractured mandible body. Yeah, a mandible body fracture, comminuted mandible body fracture, I'll get it right. Comminuted mandible body fracture. So the anatomy is it's the mandible. What's wrong with it? It's fractured. How serious is it? It's open. And what additional information? It's comminuted. So again, breaking it out chunk by chunk, it's a little less overwhelming. So I hope that those four steps are helpful, especially if you're fairly new to AIS coding. Documentation. Wow, that's a huge thing. And that's, that's the purpose of talking about how important it is to communicate with the physicians, nurse practitioners and physician assistants who chart in the patient's medical records. Just looking at closed head injury, I mentioned that before, it's not definitive enough to give us an AIS postdoc value other than a nine. Traumatic brain injury, same situation, not definitive enough. Concussion, now we're talking, but the doctor has to write the word concussion in the chart so we can use it. And then the same thing with loss of consciousness, that's helpful. Again, physician has to document loss of consciousness. That's why you see things in quotes in the rule box within the AIS dictionary. So I want to run through a couple of examples. It's not, you can play along with this if you want to, but that the purpose of this was to just kind of talk through some things. And these are common items that I get questions on every single day. When I signed on to this, I still have 235 emails to answer just from yesterday and today. And there are a lot of folks who ask questions and I encourage you to ask questions. I just ask that you be patient so that I can get back with you. I'm just doing my best. But it's interesting to keep track of the types of questions that come in because they're very similar. So that helps the content subcommittee to determine is there a need to change something in the dictionary, the way that it's worded or how it's collected. It's helpful to the faculty to know that maybe we need to stress this more in our training from this point forward. And so example number one, you've got a CT scan impression that says multiple acute brain contusions. And if you only read the impression, when you're looking at the CT scan results, that doesn't tell you a whole lot. It tells you that the brain has contusions, but where, how significant, what's the size, those key things that we need to know the details so that we can pick the best code. But if you read the findings, it says there's multiple focal areas of hyperdensity within the cerebral cortex that are consistent with acute brain contusions. And sometimes we get hung up on the word consistent, because we're like, well, is that really true? Or is that like a probable statement? Well, if they're describing something to you, and it's consistent with what they're diagnosing, then of course, you can pick it up and use it. It also goes on to say the largest measuring 2.5 centimeters in diameter, located in the right frontal lobe, with smaller contusions noted in the left parietal and temporal lobes. So when we go to the dictionary itself, and this is the screen snip, we know this is a cerebrum, right? Because it says it was the cerebral cortex. That's the other thing, where in the anatomy is the injury occurring? Because you have different codes for cerebellum versus cerebrum. So you need to make sure you're in the right part of the anatomy in the dictionary. And so here in the cerebrum, these are the contusion codes. And as you're reading through there, indented underneath, and again, we refer to the bolded area as the parent of the code group. So cerebrum is the parent of the code group. Indented underneath that, we have a child named contusion. And indented underneath the children, you got some grandkids, single, multiple, multiple on the same side, multiple, at least one on each side. And then yet again, even more specificity underneath each of those sub subcategories. So when we break it down and look at those individual sections, and we go back to what our findings said, we have cerebral contusions on both sides. So that's how we work down through the dictionary to get to the answer of 140622.3. Cerebrum, contusion, multiple, at least one on each side. But we have to go with this small semicolon, superficial semicolon. Remember, semicolons mean equal in severity to one another. Because as you keep reading through that line, it gives us the severity of one to four centimeters in diameter. Sometimes folks will want to jump down and go to the large, because it seems like it's in a larger area, mass area, but it's not. It was specifically talking about 2.5 centimeters being the largest. And so that's what takes us back to that 140622.3, as opposed to going to the large, because large would need to be greater than four centimeters. So again, working it out, reading the whole content of things, and sometimes you'll get discrepancies in your documentation. Who knew? So what do we do? We look at what radiology has, we look at what the operative report states, and if there's a discrepancy between radiology and what the neurosurgeon writes, neurosurgeon's taking care of the patient, that documentation takes precedence. Anytime there's a measurement that takes precedence over a generic word like tiny or small, always look for those key factors. Example number two, the CT scan says there's a skull fracture. Okay, well, that's awesome. It's a linear fracture. It's noted involving the left parietal bone. It's five centimeters in length, there's no intracranial hemorrhage or mass effect, and there is soft tissue swelling noted overlying the fracture site. I just want to focus on the fracture for a second. You know the skull is divided into the base and the vault. The vault is the lighter shading that you see here on the slide, and that's directly from the dictionary of AIS-15. And so the vault gets the default. And in the bottom right corner is the rule box that is there in the dictionary. And guess what? That rule is the same thing in AIS-08. So if you're still using that version of the dictionary, it hasn't changed. Skull fractures are divided into the base and the vault. Code all the fractures under the vault, unless it's specified as the base. And so a linear fracture, five centimeters in length, that's what we're going to pay attention to. So we know it's the vault. We look at the code choices that are available to us. We have a vault fracture that's not further specified. Well, we can't pick that because we have a measurement and we know where or what type it is. So it's linear. Look at that second line down, 150402.2, closed, simple, undisplaced, diastatic, and linear. Now, no measurement in the line with linear. So keep reading to make sure there isn't something more appropriate. And then we get into comminuted, open, but the dura is intact, well we know we can't play on that line. Our fracture was never described as being open. Even though there's measurements there and measurements on the last line, notice it has to be equal in severity. It has to be depressed in order to use the 408.4. And so always make sure you read through the choices that are available to you. Back it up and pick up the one that is the most conservative, unless you can justify that fracture and that measurement according to what's there available in your dictionary. So this one is 150402.2. That's what we end up with. Autopsy reports. Now sometimes those are few and far between. If a patient expires, you have to wait a while to get an autopsy report if one was performed. But you also have to be careful when you do receive it, that you are taking a look at what is provided. The autopsy findings are consistent with a single gunshot wound to the head. It entered into the cerebrum and exited the cerebellum, resulting in fatal traumatic brain injury and hemorrhage. Well when you look at the internal examination though, it talks about a communuted fracture of the skull, tells you where, talks about the entrance wound. It then talks about the brain showing the trajectory path from the left parietal lobe and then traversing through the frontal lobe and exiting through the cerebellum. The cerebrum talks about extensive lacerations and contusions along the path of the bullet. Then the cerebellum says that it exhibits large irregular defect that's associated with hemorrhage and contusion, consistent with the exit wound. And then the brainstem says there's no significant injury to the brainstem identified. Hmm, well that's interesting because sometimes as you read further along, you will find where that documentation has changed a little bit. There, and it actually, notice in the brainstem it says it exhibits a large irregular defect consistent with the exit wound. So as you're reading through this, it is a single gunshot wound, but it's almost like execution style. It went in the cerebrum, through the cerebellum, and out the brainstem. And if you're just skipping through real quickly, you could miss those types of things. So this is the rule box at the bottom of page one in the AIS 15 dictionary. There are five different rules in this rule box, and this has to be the number one set of questions that I get most often with regards to, I have a patient with a gunshot wound to the head, but I need to be able to code the bleeds and the fracture of the skull and all that other stuff with AIS codes. Well you can't. You can't. You can list them on your ICD diagnosis or on the diagnosis screen and put your ICD codes in the diagnosis screen of your registry, but the rule box tells you specifically to code a penetrating injury to a specific anatomical site, the brainstem, the cerebellum, or the cerebrum, if the site is known. If the site's not known, if it just says gunshot wound to the head and that's all you ever get, or if more than one site is injured, like this example, all three of those are injured, then we have to use the codes at the bottom of the screen. So you only get one AIS code for that entire incident of a fracture to the skull that's open plus the bleeds and the this and the that. One code identifies it all. In this particular example, it would go to the 116006.6. That's a huge challenge and I think where we get messed up a lot of times is trying to determine what's the driving force of our diagnosis screen in a trauma registry and when you're hung up on, and I don't mean this disrespectfully so please don't take it that way, when your focus is all on ICD, ICD, ICD, ICD, you lose the opportunity to pick up the severity of your patient's injury because as you've heard me say before, ICD and AIS do not have a one-to-one match and the rules in ICD and AIS are not always compatible. So if your registry is there to look at outcomes, severity, probability of survival, it doesn't matter what your ICD code is. Doesn't matter. But it does matter that you're following the rules of AIS and assigning it appropriately. Now can you list those individual bleeds and things if that's something you need internally? Go for it. But 116006.6 would show up on the first line of the diagnosis screen for the AIS value and the rest of the AIS fields would have to either be blank, listed as not applicable, or 999999.9 and that's going to depend upon how your registry is programmed. Most of your registries will allow the entry of NA for not applicable, but you can't repeat that AIS code 116006.6 multiple times because now you're over-inflating the severity of that patient's injury and not following the rules. I know, rules. I don't like them either, but they were there for a reason. Example number four, surgery report. You have an indication for surgery. You have a surgical diagnosis. The indication says the patient sustained a right ankle fracture following a fall. The diagnosis, right ankle fracture. But what do the guts say about this? It talks about the incision that was made, it talks about the exposure, and it says there was an isolated lateral malleoli fractured just below the ankle joint. And remember the rule box says you can't fracture a joint. And what do we have in ICD? We have an ankle fracture code. We have an AIS code for ankle fracture, but we encourage you and teach you to look for what bone is broken. Because what bone is broken is what we're really interested in, not what happened with the joint. Okay, so look at your fibula page where you've got your lateral malleoli, and it's below the ankle joint as it says in the documentation. So you end up with an 854453.2 code. Fibula fracture below the ankle joint, infrasyndesmotic, isolated lateral malleoli, a Weber A. Again those little semicolons, those are equal in severity to one another. I guess what I'm trying to stress here is when you're reading and you're trying to analyze the chart that the physician has written, look at the full content. Don't just rely on the indications or the quick little snapshot that's on the surgical diagnosis or the discharge summary. You need to look at the full content to get to those details that are ever so important. Next to gunshot wounds, pelvic fractures are my number two leading cause of questions that come in on a daily basis. So example number five, we have a CT scan that shows multiple pelvic fractures that are displaced. Incomplete disruption of the SI joint, fracture of the left iliac wing that's displaced, an LC2 lateral compression fracture with overlapping pubic bones, widening of the pelvic ring, a massive pelvic hematoma that displaced the bladder anteriorly. There's no evidence of an intra-abdominal organ injury. So as we're looking through that particular example, the rule boxes come to mind. It's divided into two anatomic structures and the ring only gets one code. So here we go again, just like what we talked about with the gunshot wound to the head and having bleeds and open skull fractures and all that other fun stuff from an ICD perspective, it's the same situation that we have here in the pelvis. There are multiple different ICD codes for the pelvis. There's also a multiple fracture of the pelvis ICD code. If your facility is okay with using that one, then that solves your problem because you had one ICD and one AIS and life is good. But that's not always the case. So when we think about lateral compression fractures and we're thinking about the pelvis, the little highlighted yellow portion of the posterior part of the pelvis, the SI joints, are where we determine the stability of a pelvic fracture. And whenever those areas are involved, now we need to look at blood loss indicators. Well, nice enough, it's describing a massive pelvic hematoma. Massive pelvic hematoma. So that when we get to the dictionary page about pelvic ring fractures, it's divided into three segments. Stable, partially stable, and totally unstable. And I know it's kind of hard to read, but you all have a dictionary that you can look at. And the middle rule box mentions lateral compression fractures. So that's a starting point for us. Again, go back to your findings, read exactly how the physician documented it, look at the rule box, see how close it aligns to one another. You know, sometimes I'll have students say, well, my physicians don't use these words that are in the dictionary. Well, sometimes you have to interpret, are those words meaning the same thing? And if so, you have your answer. Because they're not required in their documentation to use the nomenclature is exactly as it is in AIS, nor are they required to use them. And sorry, I'm losing my voice. They're not required to use the nomenclature that's in the ICD coding book either. And although AIS doesn't code, PCS, you know, our procedural things, when you think about a neurosurgeon who's taken a patient to the operative suite to evacuate a subdural hematoma, evacuation, we're all used to that. That makes sense. But the technical word is extirpation. And I don't see a lot of neurosurgeons saying that they extirpated the subdural. Maybe they do, but it's probably not as frequent as evacuating the subdural. So there we need to understand that those mean the same thing. And it's the same with AIS and the documentation. And I know that's a challenge sometimes, but how do we alleviate that challenge? By communicating with our doctors that we're working with every single day. So again, to give you a visual, just like when I was talking about the gunshot wound side of things, we'll pretend that this is your diagnosis screen in your registry. And those are of course made up ICD codes, but you've got your three different lines. One could be for the skull fracture, one could be for the bleed, another one for a contusion or something that was identified. You don't get to repeat the AIS code three times. This happens to be the pelvic fracture code. So if we have these things that are listed here in that original fracture grouping, we would only pick the one that identifies the significance of the blood loss indicator. We don't get to repeat it three times. So the proper entry most cases would be the AIS code in the first line and then NANA and the other two subsequent codes. And will it be accepted at the at the college level? Absolutely. What I don't know is what your particular software permits. Some of your softwares, like I said a minute ago, allow the NA. Some of you have to put nines across there. Some of you have to leave it blank. And so you'll need to determine that by working with your own software, but just don't repeat it, okay? And why is that so important? When researchers pull data, and even when you're trending data internally at your hospital, sometimes people will ask you for questions on what's the frequency of lateral compression fractures. That's looking at the number of occurrences of that type of fracture, not the number of patients that had it. But what's the frequency of lateral compression fractures? What's the frequency of? That's when you're counting the number of occurrences of something, not the patients that have that. All right, let's look at our autopsy report. This actually is in one of the slides that is in our clinical documentation for AIS course that is strictly for physicians, nurse practitioners, and physician assistants. And so this is one of those practice things that they get to do. There's a lot of hands-on practice. They'll have a listing of some generic wordings. They have to go into the AIS dictionary and find the most appropriate code, and then we talk about it. And it was kind of fun. The last class that we did, one of the trauma surgeons said, well, but I know that it was blah blah blah. And I said, I'm sure you do, but did you document that? And he said, well no, but I knew it. And I said, but I don't know that because it's not in the chart. And then about the second time we had that same conversation, he looked at me and he said, point well taken. And so I think he probably changed his coding practice, or not his coding, but his documentation practice after that. But let's look at the first paragraph. External examination shows a body was received in a body bag, the clothing is present, and there's a right radius and ulna fracture. Well, what kind of fracture? Is it open? Where? Is it the proximal portion of the long bone? The distal? The shaft? See how we're missing some detail? The facial bones show fracture. Okay, what bones? There's a tattoo present. That's always helpful. Can't code it though. The back shows some abrasions. Multiple skull fractures. Hmm, the base or the vault? So if we don't know, we have to default to the vault. There's a posterior scalp laceration that's five centimeters long with exposed brain tissue. Now you're talking. That's some good detail. But no leg fractures are noted. They went on and did the internal examination and the body is open in the usual Y-shaped incision. Subcutaneous fat measures three to four centimeters. Multiple rib fractures. Oh, that is my least favorite piece of documentation of all times. When you're looking at something, whether you've opened up the body or you've taken a picture of it, you know how many ribs are broken. So which ones are broken? Because it makes a difference in the post-op value. It makes a difference in the overall severity sometimes. The heart shows a rupture through the pericardium. The spleen shows a rupture. The aorta is ruptured. Is it thoracic or abdominal aorta? The liver has some lacerations. Um, how, what about details? And the cause of death? Motor vehicle crash with multiple blunt force trauma to the head and chest. Yeah, that one's not helpful either. And the matter of death is accidental. So again, as we look through that, we do the best that we can when we're trying to assign AIS. The sad part is, is once an autopsy is performed, there's no communication opportunities to go back and say, could you be more specific? Because if they didn't document it in those, in that first blush, there's no way of going back and knowing the specifics about that unless there's some other detail throughout the autopsy report. That's why engaging the coroners, the medical examiners ahead of time is so important so that they understand because maybe they've never heard of AIS or maybe they've never taken a class or seen the dictionary. And so that's up to us to help to continue to educate folks about what it is that we're looking for. There's always unique challenges. You know, here in the U.S. we've got different laws, depending upon what state you're in, as to how the investigation of a death occurs. Is it a coroner? Is it a medical examiner? Do they have to perform it? Do they not have to perform it? And there's always the right of refusal from the family. Lots of different variables that are in play. So there's not consistency in that regard. And the details sometimes, if they're just doing an internal or an external review, obviously we're gonna miss out and we see a blunt or multiple trauma a lot, which again is not helpful. But these are some of those things that, as we look through these slides, maybe you can take a copy of that to your next trauma committee meeting. And if you have a representative from the coroner's office, do a quick little presentation about a patient's record and show them the importance of the detail and what ISS score you end up with. And one of the other things that sometimes happens in a trauma program is that they think they, meaning people in general, that if a patient dies it should automatically get the highest post-op value possible, which is a six. But that's not the case. You have to earn the six. You have to follow the rules in order to get to that six. And so just because they died or just because, you know, they had one injury that was a six, we don't stop coding. We code every little nook and cranny that has a boo-boo. So accuracy is the key. And your accuracy is by paying attention and coding correctly from the documentation. It begins, though, with the documentation. And how do we get folks in that capacity to better document? Well, it's education, education. Whether it's a conversation, working concurrently, and collecting your information. I know that's a challenge to some trauma centers, but it can be done. There are multiple level one trauma centers across the United States who work concurrently. If I come in as a patient today, you start my chart tomorrow, and you follow me throughout my stay. So if there's a documentation issue where somebody types something incorrectly and then it's copied and pasted throughout my stay, nip it in the bud. Go up and say, hey, could somebody correct this before the patient's discharged? Then can you be more specific with what ribs are broken? Can you tell me where the cerebral contusions are located and how big they are? Is there perilegional edema? You know, those types of questions are absolutely okay to ask and so it's a group effort. Make sure that you feel safe and that you can have a voice to share your concerns. We all put our shoes on the same way and so it's a good opportunity to be a good solid team. And again, different summaries here that I just want to make sure that we cover. It was specifically developed, AIS was developed to code traumatic injuries and to look at those severities. We're not dropping bills. We're looking at an individual anatomic injury and assigning a number to it because that number speaks what the definition of words means. That's the equation there. We do revise AIS to stay up to date with the current medical treatments. They're already working on the next dictionary. When will it come out? I don't know. That's not on my docket at this point to know. There are some discussions that they're going to try to keep up with things on a more regular basis, but what that number is and the number of years or months, I can't say at this point in time. AIS is not the only coding schema. Different databases use different things for different reasons and it's okay to collect ICD. Just don't try to marry them together with AIS. It doesn't work. All right. And make sure that training is obtained and I'm not trying to sound like a commercial, but make sure you have the resources that you need. Use your dictionary. Read the rule boxes. Your computerized systems up to this point don't have the rule boxes programmed into them, although I know it's coming, but you still need to read those rule boxes when they are programmed in. So here I'm on my soapbox. Can you hear me preaching? Oh my gracious. It's a good thing you can't see me because you'd see me with my hands in my air going just, you know, but that's how I am and most of you who know me, I'm pretty emphatic about education. I think it's so important. The other thing to remember is where do your AIS codes go? They don't just live in that little box that you work on every day. You run reports. People look at them in your community and house. They look at it in a regional and state system and goodness knows the national looks at it. You know, we got these little things called benchmark reports if you're part of TQIP and you want that accurate data so that your benchmark reports are true. Your PI is good and true that you're really looking at the severity of injuries as they need to be looked at. All right. So let's look at some examples. There's different databases. I think I skipped that part in here, but the different databases. Again, TQIP, folks that aren't part of TQIP, they submit to NTDB. There's also NISQIP. There's things in Europe and all sorts of different large mega databases where data ends up. And so what are the details that our physicians, our nurse practitioners, and our physician assistants really need to pay attention to along with our gentle reminders from time to time? Measurements. What size, the CC, the thickness, the depth, the blood loss, all those types of things. Is there loss of consciousness? Document it. You don't have to witness it, but document that you corroborate the fact that the EMS said the patient was unconscious when they arrived at the scene. Descriptive details. Oh my gracious, that's so important. The neurologic deficits. What's the percent of compression of a vertebral fracture? Are displaced fractures significant? If so, how much? What's the measurement? Where is that long bone broken? Proximal, shaft, distal? And then how do they describe burns? If you collect burns in your system, how are they describing those? All right. Share the importance of their documentation, not only from a medical record coding standpoint and the importance of billing and reimbursement, but also remind them of the need for specificity and coding injuries. Work concurrently so that you can keep up on the questions and get the clarifications that are necessary so that the chart can be updated and reflect those details before the patient goes home. That's not only going to improve your severity scoring, it's going to improve your reimbursement too, I would almost guarantee. Provide a 10 to 15 minute injury list comparison of what was documented in the chart versus what could have been helpful if it had been better represented in the patient's injury in the documentation. Please don't include the name of the patient or the physician identifiers. Keep it generic. Just say here's patient 1, 2, 3 and this patient, from what we could gather in the chart as it was documented, we were able to code this, but if we had just had a little more information such as what ribs were broken, the size of the subdural, the da-da-da-da-da, here's what the ISS could have been. And it's important to know that you're taking care of really serious patients and you're doing a good job of it because you need to pat yourselves on the back from time to time because enough people have fingers you know shaking at you when you do something wrong. Let's pat ourselves on the back too. Make sure you explain the importance of solid detail oriented injury descriptors. It does impact your benchmarking reports if you're a TCLIP center and if you're not a TCLIP center it still impacts your program. So here's my commercial part. There are courses and workshops specifically for clinicians. They can of course participate in a regular AIS 2015 course. They're available two days in a row virtually, eight hours a day. There are four days in a row, four hours segments, I can't talk, segments that are and these are virtually. There's in-person two-day trainings and at the TCLIP pre-conference is a really good opportunity for your physicians to come in a couple of days early and sit in on the class. We've had coroners, we've had radiologists, trauma surgeons, neurosurgeons sit in on the class and every time they do their evaluations have been very positive. I wish I'd have taken this earlier and so really be encouraging to them because it's a win-win situation. And then the number two point here is we have a clinical documentation for AIS workshop. It's again only available for physicians, nurse practitioners and physician assistants are the ones who are actually documenting in the chart. And we can do a virtual group setting and we just need to coordinate the dates with the faculty and all the providers. We can do or they can do an on-demand and how that's set up is it's available for one month. They sign up for it and then they can log in and do the on-demand at their leisure. So if three o'clock in the morning they can't sleep and they're on call and they want to work the modules they can, that's fine. And then we always have an office hours where they could you know connect in like a zoom session like this and ask their questions and with a faculty member and get things resolved that way. So just know that those are there and then AIS coding resources. If you have questions email me directly. If you stump me on a question I usually go out and poll the faculty. If you stump the faculty then I pull the content subcommittee. So somebody is gonna come up with an answer and then we'll get back with you on that. And just remember that if you are publicizing anything that uses AIS make sure you give AAAM a citing as part of your references. It should be there because you're using that copyrighted system and so this is this last slide is showing you how to reference the citing, how you would put that in your sources. So I wanted to make sure to include that. Not everybody does publications and things to that nature but just in case that you do in the future or if you are actively involved in those types of things make sure you give the citing because you're using that copyrighted material and also give yourselves credit as well individually if you're working on a project together. Make sure that there's accolades for your work as well. All right that's all I have. We'll open it up for Callie to ask any questions and I know I kind of wait a little bit longer than I had anticipated but thank you for your attention and I'll turn it over to Callie. Yes we got a lot of questions coming through so I am hopeful that we'll get to most of them but there are quite a few so this is a good group good questions. The first one I have is AIS 2005 head section page 44 cerebrum contusion codes 1 4 0 6 0 6.3 to 1 4 0 6 1 8.5. It states descriptors of midline shifts and the measurements of the shift for different codes. If contusions are not noted in imaging but midline shift is can we still use these codes? Well I love it when you give me chapter and verse and I don't have the dictionary open. So can we hold that question and send it to me so that I can get my dictionary out to answer you and then what we'll do is we'll respond and we can share my responses to everybody that's on the call today if that's okay. That sounds perfect. Okay the next question I do have is patient has an unstable cervical fracture not moving the left arm or left leg died prior to getting an MRI. Diagnosis states as severe spinal cord injury and has symptoms of paralysis. Patient's cervical CT scan noted a C1 posterior arch fracture, C1 to C2 subluxation, acute displaced posterior odontoid type 3 fracture, possible ASIA C. Not documented as such what is the AIS score? It depends upon what version of the dictionary that you're using because in the AIS 15 version the cervical the spine section not just cervical but the spine section has been totally revamped and so there are some codes that would be appropriate to look at because the paralysis is if they died before the the paralysis was able to be confirmed and it was just a suspicion of probable of there is a code that we can use now but in O5 that codes not available and again very specific question I appreciate that but I think for the sake of time let's make sure that we answer that one as the group as well. Okay are you able to code a concussion at the discharge diagnosis states close head injury with positive LOC but the discharge instructions are given for concussion? That is an excellent question the physician as the rule states in the dictionary must use the word concussion in the diagnosis so if there's a concussion protocol that's an adjunct that's not a diagnosis you need to look for the physician's diagnosis and if the physician diagnosed traumatic brain injury or closed a head injury and they did diagnose loss of consciousness you at least have the loss of consciousness codes to use but you can't code concussion based on that protocol of giving them discharge instructions the physician has to say concussion. I believe this one was when you were talking about a skull fracture if it says Fox can you code that as unilateral or bilateral? I'd have to have more specific details because if it's along that area they're gonna say if it's bilateral so if it doesn't specifically say bilateral I would not code it as such so I would I would encourage that person to look at their CT scan again to make sure there isn't specific documentation about bilaterality. Next one is an autopsy report in the injury section states that the right kidney was pulverized but down in the internal organ section states both kidneys are intact and smooth can we go with the injury stated or should we not code the injury because of the conflicting information? I would code in the detail section of it and not in a summary so again the summaries are sometimes very vague and the detail is more specific but I would go with this always go with a specific description of the injury. And pulverized is a pretty significant thing it's like in AIS 15 we have a code now for shattered which is the equivalent to pulverized it's in multiple pieces it's kind of like you put a banana in the blender and you turn it on and it's no longer in its solid form it's all these little multiple pieces and so to have that vast difference I'd be real careful with that one and remember when in doubt code conservatively. For sure. Next one firework injury to the hand a couple of amputations couple of fingers are hanging no wrist involvement would you code as an amputation an open fracture or both? I would focus on my amputations. In cases where a patient has an epidural and doesn't have any neurological signs but does have a fracture how do we capture the fracture since we can only go with cord contusion in the AIS book says the rule box can says coexisting injuries to the spinal cord and to the vertebral column are coded as a single injury and only assign one AIS code. Well I'm glad that you specified that we were talking about the cord because I was instantly thinking head when you said epidural that's another thing I didn't mention today is making sure that when we're talking about things or reading through a chart and it says epidural subdural those can be in the head or in the spine and again it depends upon what version of the AIS that you're using because in AIS 15 there is a new code that is radiologic findings without neurological impairment it includes edema epidural subdural hemorrhage within the spinal canal and we don't have that in the O5 dictionary so just keep that in mind. Excellent how do we code a distraction injury in AIS? Neuro access imaging demonstrated an acute distraction injury at C4-5 an acute combinated fracture of the bilateral C4 lamina and spinous process C5 superior implant minimally displaced fracture and central stenosis most severe at C4 to 5. So stenosis is not something that's codable if you have a distraction fracture that's the equivalent of saying a chance fracture because a distraction fracture is it's kind of and I'm not on camera right now but it's think of yourself sitting in the back seat of your car and you only have the lap portion on your seat belt you don't have the shoulder harness attached and you're in a car crash from behind your body is gonna project forward your face is your nose is gonna go down towards your knee and it's gonna distract back and snap like that that's a distraction fracture so that's the equivalent of a chance fracture generally causes a horizontal fracture of the vertebral body so when you see distraction fracture think about chance and if I misunderstood the question I'll look at it when I get the question sent to me and make sure that I've answered that appropriately. Perfect next one so if you somehow have a penetrating injury to the cerebrum less than or equal to two centimeters the AIS is a three but you have a subdural that is small which is a four isn't that a misrepresentation of the AIS score if you can't code the subdural. So the question is what's the mechanism of injury? That's a good question. That'll be that'll depend so whoever asked that question if you could pop in the chat a little more detail because that makes a difference okay and then we'll get back to that one as well. Okay regarding the GSW to the head if the GSW enters the cerebrum and exited the cerebrum and injuries include hemorrhaging and skull fracture when we use the AIS code eleven six thousand four point five for major greater than two centimeters of the brain if it was greater than two centimeters penetration and code the hemorrhaging and skull fracture as well if it does not. That was what I mentioned in the example if it's a penetrating injury to the head you may not code anything but one code related to that penetrating injury so when you know the bullet went into the frontal lobe that let's say the frontal lobe is part of the cerebrum you go to the cerebrum penetrating injury code section there's three codes there and then if it's greater than two centimeters you pick that one code that's the only AIS code that can be assigned. Your hemorrhage can be collected on your ICD but it will not have an AIS value. Next one you can't fracture a joint so code the fracture however what about fractures that have an inter articular extension those are actually more severe than the fractures that only involve a bone. That's correct and when you look at your dictionary depending upon what bone we happen to be talking about there are call-outs so I just flipped open to my only have my 15 dictionary here in front of me I just flipped open to the distal ulna and there's a line for extra articular which means outside of the joint partial articular which is into the joint and complete articular meaning the entire joint surfaces involved so just make sure you're reading down through your code choices because articulars are listed when they're applicable. Great I know that we may have time for one more on example number four that you gave in your presentation what do you code if the op report doesn't state whether the fracture is above or below the joint? Then you have to use your NFS code yeah that's that's what sucks about it if they don't give you the location detail then you're stuck with using the NFS which is not the ideal but again we can't make stuff up. And correct me if I'm wrong do we have time for to continue for more questions? It's at the top of the hour we can do one more. Okay let me go to this one fractures that extend into another bone code both or only the main fracture? Again it's going to depend upon the rule box so add in a specific example and then I'll be able to answer your question with more detail. Okay well thank you so much for everyone for hopping on thank you Kathy for imparting your wisdom I know that I learned a lot and it looks like everyone else did too and everyone thank you so much for putting in your questions we will get all those questions sent over to Kathy to have her answer them and then we will get them back out to everyone that was in attendance. Thank you all so much again I hope everyone has a great rest of your week thank you again Kathy and TCAA for giving us this amazing webinar.

accurate documentation

AIS coding

trauma injuries

anatomical locations

injury severity

healthcare communication

coding workshops

trauma registry

coding support