I'm the chair for the TCAA's Education Committee, and I'm going to be your moderator for the day. Welcome to today's webinar. This webinar is going to address the differences between coding with AIS and using ICD-10. Just a quick housekeeping item for everyone, we're going to hold questions today until the end, but feel free to put them in the chat and I will bring them forward once Robin has finished her presentation. It is my privilege to introduce today's speaker, Robin Schrader. Thank you for joining us. Thank you, Robin, for giving up this time. Robin's background includes over 34 years in the healthcare industry, with 16 of those years spent in trauma registry. She's worked as a trauma registrar, she's been a PI coordinator, she's also been a registry manager, and she's done this for several level one adult, level one pediatric, and ABA verified burn centers throughout those years. Currently, she is the trauma registry operations manager for Virginia Commonwealth University Medical Center in Richmond, Virginia. She also works for the Pennsylvania Trauma Systems Foundation as a contract registry auditor and educator. She is the former chair of the American Trauma Society CSTR prep committee. She is also the educator for the Association of Virginia State Trauma Registrars. She does have a voice for the trauma registry in many organizations. She does that as a member of our TCA education committee, as well as for the American Trauma Society. She is on their CSTR leadership advisory council, part of their CSTR mentor program, and on the TRDC committee. Last but not least, she is an ICD-10 coding instructor, so she brings a wealth of knowledge and expertise to today's discussion. You probably already have heard Robin talk, because she's spoken at many conferences, she's hosted several webinars for the ATS, the TCA, as well as TRAM. She's done a revenue cycle education podcast, she's done topics such as PI and hospital events. In her spare time, although I don't know where she finds spare time, Robin enjoys spending time with her husband of 31 years, their son, and their three dogs. So with that, I will hand the webinar over to Robin. Thank you. Good afternoon, everyone. It's a pleasure to be here. I hope everyone is doing well today, and had a wonderful, safe holiday weekend. So today we are here to talk about AIS versus ICD-10 coding rules and differences. So we all know that there are many differences when you're looking at coding rules, and it confuses people often, where do we go, what rule do we follow, etc. So let's take a look at some of those. And like Kim said, you can type questions as we go in the chat, but we'll hold questions till the end, and we will have plenty of time to answer those questions. All right, the TCIA educational statement, so again, regarding your CE that you will get for attending this, as well as their own disclosure, okay. I have no disclosures. I will say that prior approval for use of AIS information was obtained May 23rd from AAAM from Kathy Cookman in order to do this presentation, because as we know, we must get permission from AIS in order to present anything related to their information and dictionary. So our objectives today are to explain some coding differences between AIS and ICD-10, explain what rules take precedence over the other, and when to use additional codes in AIS and ICD-10. So looking at, first of all, you know, AIS and ICD-10 coding, why are they different? What's the difference between the two of them, right? Important I think for everyone to understand is the AIS or abbreviated injury scale, your severities are one through six, and the intention of the AIS is to share information on injury type, location, and severity. So AIS is anatomically based, so meaning that you have different types of injuries and it's based on those anatomic sites. So you may have, like we all know, a subdural hematoma in the head, a liver laceration in the abdomen, a femur fracture in your extremities. So we know they are based on the anatomy versus your ICD-10, which is not anatomically based, okay? So severity is determined once, and it's not affected by the outcome. So we all know the severity is what it is, right? And if the patient lives or dies, it doesn't change the severity of the injury. And so that's important. In that ISS, that injury severity score, we know we have our AIS severity of one to six. And then when that's calculated, you have your injury severity score of one to 75. And that also helps and gives us the probability of survival. So the reason that the AIS is based anatomically, okay, it's also consensus derived and it's global, all right? So this is meaning that it has been derived from people from different areas, and they may agree to disagree on certain things, but they've come up with this AIS scale. And the advantage is that, so anatomically measuring injuries, the variables such as the physiologic aren't affected the way that they could be in other coding systems. So we know that the scoring system is what it is. It doesn't matter if the patient had maybe had, you know, their age may make things a little bit different, or maybe their time to treatment, how long did it take them? Or what pre-hospital treatment did they get? So those things don't really play into that severity. The severity is what it is by the injury type, okay? And again, if you want more information on that, you can go to the AIS coursebook and you can get a little bit more in depth as to all of that information. Your ICD-10 diagnosis and PCS procedure codes, they were developed to classify diagnoses and symptoms for medical billing and reimbursement, right? So two completely different systems used for two completely different things. They're not anatomically based. There's no severity score. You can't predict the probability of survival, right? If you have a whole bunch of ICD-10 scores from that, you don't get any type of severity of the injury or their probability of survival. It captures diseases, signs and symptoms, and then of course we use it for our external cause of injury as well. So how do I know which coding rules to follow, right? You can, you can't, you can, you can't. So trauma is its own beast. I say this, especially with teaching ICD-10 for trauma, because as we know, it was created for billing and reimbursement, and we aren't coding for billing and reimbursement, right? We're coding to look at the clinical picture of a patient. How severe are their injuries? What did we do to diagnose those injuries? What did we do to treat those injuries? So completely different. So we code, what do we code for? We code for performance improvement, for research, you know, so many different things, but not billing and reimbursement, right? That's a whole other part of the hospital, has nothing to do with us in trauma. So the AIS rules take precedence over your ICD-10-CM rules for trauma, okay? So when you're coding your diagnoses, AIS rules are your number one rule, okay? Again, we're not coding for billing and reimbursement, so obviously your ICD-10 rules come into play after you followed your AIS rules. We always want to follow every AIS rule, and we want to try to follow every single ICD-10 rule that we possibly can, but there are a few that end up getting, I say, bent or splintered, and a few of those get completely broken. More so on the PCS side than the CM side. All right, looking at some specific rule differences, penetrating trauma to the body. So penetrating trauma to the body, we know in AIS, if you have an open injury to an internal organ, you code that injury only, right? So if we have a gunshot wound to the abdomen, and we have a liver laceration, which is considered open because it was a gunshot wound, but we don't have that open term, right? So you're going to code your liver laceration. And say they also have a diaphragm injury, a diaphragm laceration. You're going to code that diaphragm laceration, right? And they have, say, a gunshot wound also to the upper arm, and they have an open humeral fracture. You're going to code the open humeral fracture. Penetrating injuries, your entry and exit wounds are coded as one injury. So you code that as one injury. If there's a, say they have a gunshot wound to the lower leg, there's nothing else involved. It's just through and through, soft tissue only. You only code one penetrating wound, okay? Your entry wound, you're not going to code an entry and an exit wound. Looking at ICD-10, if you have an open injury to an internal organ, you code that injury, but look at your instructions. Code also any associated open wound. So you have to read your rule boxes in your ICD-10 when coding. So injury of intra-abdominal organs. So you have a code also. Code also any associated open wound. So you have a gunshot wound, and you have a splenic laceration. You are coding the splenic laceration, and you will have an AIS code to go with your splenic laceration ICD-10 code. However, ICD-10 is telling you to also code the open wound to the abdomen. But we know AIS says, no, no, we don't want that. All we want is that internal injury. So technically, the correct way to assign a code to this, so that would be is to code also that open abdominal injury, and your AIS would get the NA. So it would have an ICD-10, but it would have no AIS code, all right? So would you want to follow this as a trauma registrar? This is one of the most common ICD-10 coding conventions broken by trauma registry professionals. And why is that? Because you learn to follow your AIS. But I think that we're starting to do a little bit more of, hey, if there are things that you can code with that ICD-10 code, you can also code that. You just have to remember, no AIS code gets attached to it. It gets an NA for that, all right? So again, an example, stab wound to the abdomen, no penetration into the peritoneum, but maybe there's a laceration of a vessel. So the open wound would be coded and the laceration of the vessel. But AIS, you're only going to code a lacerated vessel, right? No open wound. Now, the question may be here is, well, my software doesn't allow me to do that. So I have worked in several institutions, and I can tell you that I've worked in one DI product where we couldn't go in and change anything. And that is with the tricode encoder, which I am not a fan of. And those of you who've heard me before have heard me say that it does not teach a registrar to code accurately. So that's a whole other soapbox of mine. But knowing that everyone will soon be getting new coding or new registry software will eliminate that. And that's great because all registrars should know how to open their books and code from their AIS book and their ICD-10 book, not type something in and hit go and move on. Those codes need to be verified, and you should be able to go in and edit them as well. So coding in a lot of the systems, you're looking up both your AIS and your ICD-10 code separately and entering them into the system. So that allows you to put an NA. If your system does not allow you to do that, then you should contact your vendor and talk to them about the ability to do that. All right, penetrating injuries to the head. Everyone loves this. AIS, you get one code, right? You're penetrating injury to the head. That encompasses everything. It encompasses your open skull fracture. It encompasses if they have a subdural, a subarachnoid, an intraparenchymal bleed. Everything is just all one code. That's the proper way to AIS code. However, in ICD-10, you would have several codes. So guideline 19.B in your ICD-10-CM, if you look at your guidelines, it tells you that additional codes are required. So if you have an intracranial injury, you see here S06 is where you're going. So it includes a traumatic brain injury. Code also. There's that code also again. Code also any associated open wound of the head and or skull fracture, okay? So again, there you have it. You would code in AIS one code, right? You get that penetrating injury, whether it's cerebrum, cerebellum, brain stem, or not specified, you know, greater than two centimeters, less than two centimeters, whatever it happens to be. You're going to code that. But in addition, in your ICD-10, you are able to capture the full clinical picture of the patient. So that's the difference. In ICD-10, when you're looking at that whole clinical picture of that patient, clinically, where do they stand? Well, we want to know that they have an open skull fracture. They have a subdural, a subarachnoid, an epidural, an intraparenchymal, et cetera, et cetera. And they've got open skull fractures as well. Everything gets coded. They all get the NA except for that one AIS code, right? So again, that's important. The other thing that's really important in ICD-10 coding with all head injuries, that is, is your LOC duration. So they had a loss of consciousness. What was the duration of loss of consciousness? That always needs to be coded as well. But you see, with a penetrating injury to the head, you may have one AIS code, and you may have 10 ICD-10 codes that go with it. And again, you're going to have NA for those additional injuries that are not codable in your AIS. Superficial injuries, another difference here for superficial. So ICD-10, you have guideline B telling you that superficial injuries, such as abrasions or contusions, are not coded when associated with more severe injuries of the same site. So my question here, and I don't have a poll. I should have probably had a poll, but would the trauma registry professional want to follow this rule? Well, no. Because why? AIS takes precedence over your ICD-10 guidelines. And AIS tells us that a superficial injury is coded in addition to other injuries even at the same site. So for instance, a fracture of the right ulna with a right forearm abrasion, both are coded in AIS, but only the ulnar fracture would be coded in ICD-10. Now remember, the difference here for this is open fractures are only one injury as well as penetrating injuries for AIS. This is a superficial injury in addition to a closed fracture, not an open fracture, but a closed fracture. Same with a hematoma. So you have a femur fracture, and you have a thigh hematoma. You're going to code both of those. It doesn't matter. But in ICD-10, they're telling you, no, you wouldn't code that hematoma or that contusion. So again, that's one that also is normally broken, because we want to capture that because AIS tells us to. Again, those solid organ injuries. So this is really important. I have done, if you've seen this, I did a webinar for TCAA, I think, two years ago, on coding of splenic and liver lacerations and contusions, so injuries, and talked about this and said, hey, your ICD-10 and AIS are not a one-for-one code. So again, even when you're looking at your fractures, they're not really always a one-for-one code, because the AIS kind of groups things together where the ICD-10 has things separated out a bit more. But when it comes to your organ injuries, you have to read the descriptors in both your ICD-10 and AIS book. So an example is a grade 3 splenic laceration. So in AIS, there's no hilar or segmental parenchymal disruption or destruction, or greater than 3 centimeters parenchymal depth, or involving trabecular vessels, or moderate. They may say it's a moderate splenic laceration. That qualifies under that grade 3. When you look at your ICD-10 codes, you have a moderate laceration of the spleen. Now, it's telling you laceration of spleen 1 to 3 centimeters. However, if they tell you moderate laceration of the spleen, you would use that grade 3, because it's moderate for AIS, and you would use moderate for ICD-10 as well. However, major laceration of spleen, avulsion of spleen, laceration greater than 3 centimeters, massive laceration, multiple moderate lacerations or stellate laceration. So it could fall into that one as well, depending on what they're giving you. Three centimeters, right, is three centimeters in both. So in this case, you have one AAIS, but two possible ICD-10 codes. So you always have to read your entire description to choose the most accurate specific to your injury. All right, it's a little bit different. And also, as we look at those solid organ injuries, your AIS codes are based on clinical description first. All right, so what that means is they're based on clinical presentation or description first. So if the physician gives you a good description because they're doing surgery, or maybe they didn't do surgery, but there's a CT scan and it gives you a good description. And at the end, it says it's a grade three injury, but the clinical description is a grade four injury. You would code it to the grade four, okay? You default to what the surgeon says if the clinical description is not available. So again, these grading rules are different on ICD-10 and AIS, because ICD-10 follows the AAST guidelines, which allow for an upgrade if there are two or more injuries within the same organ. And AIS does not allow for this. So say you have a splenic laceration that is a grade three, and then there is also a second grade one laceration, they're gonna allow you to upgrade that to a four, but AIS does not allow for that, okay? So they're a little bit different. But remember that if you have a clinical description of that solid organ injury, that is your first description to go by and code. So you would look in your AIS book and match up that description, and that's what you would use. It doesn't matter what the surgeon necessarily says if you have a clinical description. That's the rules and the way that AIS follows, all right? If you don't have a clinical description, you're gonna have to go with whatever grade the surgeon gives. But that's why the description is always nice to have as well. But just remember that these are two different grading systems. If you go into the AAST, there is a link to look at all of the injuries that are graded throughout. So it's every organ, and it gives you actually the grades for the contusions, the grades for the lacerations, and how it works, the descriptions of each. So it's really a nice reference. I should have put the link in here, and I will get the link to Deb so that we can send it out. I'm just making myself a note so we can get that out to everyone. All right, so AIS body parts that are specifically listed may not be specifically listed in ICD-10. So this is something that you're looking at. So in AIS, you have omentum and mesentery-specific codes, right? But in ICD-10, that codes to an injury of other intraabdominal organs, all right? Same with some of your facial fractures. So the mandible, your alveolar process is part of the mandible. There is no, in ICD-10, alveolar fracture. It codes to the mandible. So there are things that you may have very specific in AIS, and you don't have very specific in ICD-10 and vice versa. Pneumocephalus, pneumocephalus has a specific AIS code. And of course, it has to be directly related to a head injury. But in ICD-10, it's an other specified intracranial injury. So kind of knowing some of these that fall into that other category versus having a more specific code, even though they have one in AIS. Another one that differs is a fracture of the frontal sinus. So in AIS-2008, it codes to the vault. So it codes to the frontal bone vault. It's the frontal sinus, so it's not really the frontal bone, right? It's the frontal sinus. In AIS-2015, it changes, and it codes to a facial bone fracture. But what I want you to understand is in ICD-10, it actually codes to the S02.19, other fracture of base of skull. So look at the difference. In 2008, it's a vault, but it's a base in ICD-10. And in 2015, that's going to change to a facial bone fracture, but in ICD-10, it's a base of skull. I guarantee you, if you use Tricode and you put in there a frontal sinus fracture, it is not going to code to your ICD-10 base of skull. It is going to give you a vault fracture in both. That is incorrect, and that ICD-10 code should be changed. So this is why I say, even if you're using some kind of an encoder like that, you really need to make sure that you are double-checking all of your codes and that they are correct, because I guarantee you, you're getting some not-further-specified or unspecified, not-further-classified, whatever it may be when you shouldn't be. Super, super important to double-check all of those. And that is the end of the slides. I really wanted to have about a half an hour to talk about questions, because I believe there's going to be a lot of them. So thank you very much, Robin. And yes, the questions have been coming in. Actually, interestingly, there's been a lot of discussion in the chat about pneumocephalus, so I thought it was great that you brought that up. Great. Some discussion about using the medical G93 code. No. Okay, so no. No. So the medical G93, are they talking about, and now I'm off-handing this, right? Are we talking about compression? Are they talking about herniation and compression? Let me pop it up real quick, because I got to see what... So it's G93.89. Thank you. Yes. All right. They were very gracious of you, Tara. Yeah, so that is not. That's other specified disorders of the brain, post-radiation encephalopathy. So, yeah, that is not a code that we would use in trauma registry. That is a medical code. And what's nice is that they've been adding some nice new codes to help us out with those certain injuries that we didn't have specific codes in ICD-10 for trauma. Again, and that was the herniation and brain stem compression, and then this pneumocephalus, which now actually does code to an other specified intracranial injury. Fantastic. Thank you for the clarification. That's actually helpful for me as well. One of the first questions that came up, does the code associated with an open wound, when you're talking about open wounds, does it apply to organs only, or is it just open fractures? Or is it assumed that an ICD-10 that had an open fracture has an open wound, and therefore the open wound doesn't need to be coded separately? That's correct. Open fractures do not count for that code also coding an open wound. The open fracture is the open wound in both AIS and ICD-10. It is pretty much when you have something like a penetrating wound to the abdomen or the chest, and you have an internal injury that you're coding. We know in AIS we only code those internal injuries, but in ICD-10 you also code the associated wound with that, and with the stabbing as well. Same kind of thing. So you were just that good. That actually was a segue to the next question that you just went and answered. So thank you so much. To head injuries, for ICD-10, if a patient has multiple brain bleeds and a positive loss of consciousness, do you code all of the brain bleeds with a positive LOC, or just pick the highest one and then do the rest of them without? Nope, you can code them all with LOC. Absolutely, yep. All right, fantastic. So when you're talking about the differences and adding the ICD-10 sometimes and not other times, somebody had asked, do you think that adding this penetrating part of the injury in addition to the internals, like a splenic LAC, like you were talking about, is confusing? Or do you, so any clarification on that? Yes, okay. So I'm going to tell you that yes, I do think that it is confusing. I absolutely 1,000% agree that it is confusing, okay? So when you're trying to teach somebody, and I've experienced this just teaching newer registrars here, that sometimes I leave out those pieces in the beginning and figure let's get them trained on their main coding rules, and let's leave out those kind of additional ICD-10 things until they're at a really good place and they're well-trained and they're understanding and they're, because I do think it's very confusing. There's no doubt about it. You've got two sets of rules. And so I think the newer they are, the harder it is for them to kind of grasp all of that concept, especially AIS coding, because someone can come in with a wealth of ICD-10 knowledge, right? Maybe they were a biller. Now, the first thing you have to do is break them from being a billing and reimbursement and bringing them into trauma because we have our own set of rules, and then is teaching them AIS. So it's kind of, you've got two sets of rules and it's kind of, it is confusing. There's no doubt. Do you have any tips about how to explain or sort of clarify the importance of this to the new registry team members? Yes. So I guess what they have to understand is that for the most part, a lot of these ICD-10 codes and your AIS codes are used for research, right? So a lot of researchers will pull from ICD-10 codes, right? Sometimes it's easier to pull from AIS codes, at least on our end, because instead of having, you might have five instead of having 50, right? So it's easier to make a report with five codes than 50, but there are certain things that you really want maybe something specific, really specific, and you have to go to your ICD-10 codes. Well, if you are looking for a penetrating, if someone's doing research on penetrating head injuries and all they have is one AIS and you have one AIS and you have one ICD-10 and you don't have everything coded out, and maybe they want to do research on a certain type of injury from penetrating. Well, you can't pull it, right? If you don't have all your ICD-10 codes. So it is super important and it's kind of a good example or a way to put it. Fantastic. So there's been some discussion about epistaxis. Somebody had brought up that it's not an S code in ICD, it's an RO4.0. And then another member of the audience also brought up that there is an epistaxis for ruptured mucosa vessel and vessels, which is the SO9 code. Any other recommendations about that? So I think that I can say that we don't end up coding that too often because usually it's not kind of the only injury, right? Usually when they have that, they've got a nasal fracture. Not always, mind you, not always. So it's not one that we use a ton, but again, that's another one where you go, oh, there's not really a great code for this, right? There's just not. I would probably fall with that nasal mucosa to get an S code rather than just the epistaxis. That would be where I would go with it. I always want to get us to a trauma code and not use the other ones because they kind of really don't apply to trauma. That's your first thing that you want to do is, you know. Because those codes don't get submitted then. They don't get accepted. No, correct. That is correct. It's excluded, yeah. Right, right. Some specific anatomical questions, and I know that this comes up in my registry too, is the fracture dislocation thing. So if a patient has a broken angle, so a broken tip fib, do you also code for subluxation dislocation, assuming that there's documentation saying that? Of the same associated area, ICD-10 says it's not necessary. So thoughts on that? Correct, but AIS tells you you code both. You code a subluxation or dislocation in addition to the fracture. So we're going to code both. It's not necessary in ICD-10. You don't have to, but it's not wrong if you do, if you code it together. Because you have to code them separately in AIS. There aren't any combination codes. So you code both. Yep. So also in the line of those kinds of fractures. So for avulsion fractures in AIS-08, do we code those as ligamentous injuries, like in AIS-15, or do we still code them as a fracture? In AIS-08, actually avulsion fractures are excluded. Well, that's interesting. An avulsion is excluded. Yep. Another cross-check about head injuries. So for a penetrating head injury, you'd only assign the one AIS code. None of the other injuries, such as a subdural subarachnoid, would get an AIS assigned to it. So just one? It's just one. It is only one. And that is your penetrating code only. So you have your penetrating injury to the skull, not further specified, which means we don't know where, what part of the skull, like where it penetrated. But then you also just remember to make sure if you're in the cerebrum, you're in the cerebrum. And if you're in the cerebellum, you're in the cerebellum. And if you're in the brainstem, you're in the brainstem. But they all have a less than or equal to two centimeters and a greater than two centimeters deep, or not further specified if you don't know. But it is, you are correct. It's one code. So AIS is one code only for a penetrating injury to the head. So everybody remember that. And I know that there are plenty of people who I know have coded an AIS code like 10 injuries, if it's 10 injuries, and that is incorrect. It is one code only. Again, you can add all the others with an NA for the ICD-10, but AIS is one. What would be the ramifications if you did include all of them? Well, obviously it's not going to increase your ISS or anything like that. But you're submitting those codes and they're incorrect. Fair. Okay. If a patient has multiple abrasions and contusions to an extremity, can we code all of the ICD-10 codes for the different areas like shoulder, elbow, hand? Do we need to assign the AIS code to each or is assigning it to one of the areas sufficient? You would code them all. You would code them all. And abrasions, contusions, those things, if you have, you should code them as specific as you have documentation. So I know places where they'll just put in, you know, they'll just code the, it's a T code and it's like scattered abrasions or whatever it might be. That's incorrect. If they tell you it is, you know, the right lower leg, the left lower leg, bilateral thighs, bilateral forearms, you should be coding all of them, every last one. Individually. Perfect. So in the past, we, I know that we've had this discussion in our organization as well, but we've been told that AIS coding classes that you code a minimally displaced fracture as a non-displaced, unless the displacement is significant. Is that still the case? Okay, that's in the face. Okay, you're mixing, that's in the face. That's not everywhere. Okay, so if it's a minimally displaced femur fracture, it's displaced. If it is a minimally displaced nasal bone fracture, it is non-displaced. The face, the face needs to be significantly displaced in the face. Okay, interesting. That's the rule. That's the rule. I don't know why, I didn't make the rules, but yes, it's the face. Perfect, that's good to know. Question about carbon monoxide. Do you capture carbon monoxide exposure? And if so, how would you code the cause code? That's a great question. So I think there are some places who do capture it, and there are, I think probably a majority of places who don't capture it. So that's a really good question. And I captured that years ago, mind you, years ago. And I wanna say, if I'm not mistaken, it's a T-code for that. So if you're picking that up, if those patients are getting admitted, where I worked previously, we admitted them to the burn service for a month, so that's why we picked them up. Here, we don't do that. So we don't pick them up here. Even though we have a burn service, that's not where they go, we don't pick them up. So that's a really great question and let me get that back to Deb because I actually want to look at it a little bit before I answer it. Perfect, thank you. So here's another question, can plural effusions ever be encoded as an injury? No. You need a little more than that. So getting back to how do we educate our new registry professionals, what feedback would you have for newer registrars who came from ICD training and want to code every procedure? What is your sort of stick line for that? So I think the most important thing is that they sit through a ICD-10 course for trauma, because your ICD-10 course that you have in college or to become a certified coder or whatever it is that you want to do is very different from what we teach for trauma. Of course, your guidelines are the same, but some of them we break and bend, as I said, or we splinter a little bit. But I think there's there is a lot of information in that course that really helps everyone. And I know that the ACS wants, so if you have a newer registrar, for instance, and maybe they just graduated and they have their RHIT and they went through coding in college, and it's been within five years, the ACS doesn't want the certificate from that class. They want the certificate from the coding for trauma class. And that's because it is specific. So when you're sitting in that other class, because I've been in all of them, it is directed at reimbursement and billing. It is not directed at all at trauma. So you're learning the true conventions and guidelines for everything. And it's so different. There are so many different little nuances to trauma that you really need to know. So number one is make sure that they get their ICD-10 for trauma course. Super important. I don't care if they just had their course six months ago. They need to sit through a trauma. And then, of course, AIS training, which you have to be working six months to be able to sit through the AIS course. But it's super important. And I do think that sitting with a well-experienced registrar, and I always say five years or more, and actually letting them take them through that AIS book and kind of explain a little bit so that they at least have some knowledge of it. Because people who haven't worked in trauma, they don't know anything about AIS. We're the only ones who use it. So I think it's important, definitely. Kathy Cookman had instructed us to code avulsion fractures as ligament tears. Okay. Is that not correct? Well, that may be in a document. So let me, I'm going to ask her. Avulsion equals ligament tear. And I will ask her, and I will send that back, too. Perfect. Thank you. Yes, Kathy. All right. Perfect. Yep. So for penetrating injuries to the head, this is actually a great question. Okay. Will just coding a single AIS code impact the NISS by underscoring? Well, again, it may very well. However, the guidelines in AIS tell you it is a one code, and that is it. So again, I'm not quite sure where they, you know, where that all came up with, but it is one code for penetrating injuries. And again, Kathy went through my slides and verified everything before to make sure that they were correct, so that I wasn't, you know, speaking out of turn or telling anybody anything that was not correct. So again, that is the way it is. So it could. I mean, there are different scores, I think, that can be affected. But when you're looking at your total ISS, right, if you've got one injury to the head or 10, it doesn't matter, right? Now, so, you know, now, yeah, if you're looking at the new ISS, and you can have three, but the rules for coding a penetrating injury to the skull, to the head, are one AIS code. So that's all you would have, even with that score. That's all you would have, even with that score. You wouldn't be able to code anything else. Now, maybe that'll change in the future. I don't know. Great. Thank you. Pelvic fractures. This is a great question. So we've had conversations around ICD-10 codes available for the pelvic fractures. There are codes under the S32, so .81 and .82 that state multiple fractures of the pelvis with or without disruption of the ring. So how do you feel about using these as opposed to using an individual code for each? Well, you shouldn't. Okay. So that's a great question. All right. That's a really great question. So technically, right, you've got an AIS code that encompasses everything, right? Your fractures of the pelvic ring with or without disruption, stable, unstable, blood loss, no blood loss. Like you've got it all. You've got one code that encompasses everything, right? So in that instance, I would use your code that encompasses all of that. Your multiple fractures, whether there's disruption or there's no disruption, that would be the code that you would use to cover that. If your specific center, on top of that, wants each individual thing coded out, you can do that, but you would have to NA all of them in AIS. You would still have the one AIS and that one ICD-10 code with the multiple. That is how, technically, that's how I would do it. That's how we teach. That's how we teach the course. It's the one and one. So you have an open book pelvic fracture. You're going to have the one AIS to that one ICD-10. So I do know that there are people who want to code everything out, which if you want to do that, you can do that. Of course, you'd have to NA everything, but technically the correct way to do it is the one and one. Perfect. Thank you. What if the penetrating injury is through an eye socket with an associated skull fracture, secondary to like a bullet ricocheting around? That's a great question. That's a really great question. So they have a skull fracture, but they don't have an out. Okay. So they don't have a skull fracture from the outside in, right? It's from the inside out. Is that what you're, is that kind of what they're saying? Not specified, but I think that that might be part of the intent of the question. Okay. So that's a great question. It's going in through the eye socket. So it's not really open, right? Because that's a natural opening. Orifice. Yeah. It's a natural orifice. It's open. So I really, that's a really great question. I would have to really read that and decide that's one that one of, one of the registrars might bring to me and I would have to say, geez, I have to think about this and like really if it didn't penetrate from the outside in and it did the, I mean, I guess my second question is did the bullet actually leave the skull then, or did it just ricochet around and cause a skull fracture, but it's not open? It just said, yeah, she just said skull fracture secondary to the bullet ricocheting around. So, so effect. Yeah. So, I mean, then I wouldn't code it as open. In that case, if it went through the eye socket, there's nothing open and it didn't exit anywhere. If it just bounced around and caused some fractures, that's a really great question. It's fantastic questions. This is, this is great. A great conversation. Oh, this is, this is the debate of all debates on something relatively small. So do you code a skin tear as an abrasion or a laceration? Okay. So this is a really great one. The direction for skin tear is to code it as a laceration. Okay. That is the absolute direction that you get for coding it. However, I, I, there are times when you've got it documented as a skin tear, as an abrasion, as a, you've got a whole bunch of documentation for the exact same thing. Right. And you're like, well, what is it? So we usually say, go with what the best descriptor you have of it is. So there are occasions when we kind of get a little bit of that mishmash and then we go with the abrasion versus the skin tear. But if all you have really is skin tear, technically the rules direct you to code it as a laceration. Yep. Perfect. So is a seatbelt sign an abrasion or a contusion? That again, you would have to like, I like to look at our diagram. Do they have it listed as an abrasion or do they have it listed as a contusion? Cause I think it can be either or, or both. It depends on the, the you know, what they document. That's, that's what I would go to is what are they documented on? So for spine fracture, so now we're moving down to the spine. Say it's a transverse, a TP or an SP fracture. So it's a transverse process fracture or spine fracture. Is that coded as unspecified in ICD-10 or as an other fracture? Other. Other. It's specified. So think about it. It's specified, right? Not unspecified. It's specified what it is. You just don't have that choice. You have that choice in AIS, but you don't have that choice in ICD-10. Right. Right. Perfect. Back to the head. The head is always a challenge, right? Okay. So would you code an intraparenchymal hemorrhage under the cerebrum as a hematoma, not further specified? What are your recommendations on the IDH? An intraparenchymal hemorrhage. So it is coded as an intracerebral contusion. The only way that you could code it as a laceration is if you had that it was a laceration. So the hemorrhage is like the descriptor, right? It's the descriptor of it. So you would have to know, but yeah, it would be, it would be a contusion unless you had that it was a laceration with a, with a hemorrhage. Yeah. Perfect. DAI is a big conversation with coding all the time. I'm actually surprised it took this long to get here. How would you code DAI when there's a How would you code DAI when the neurosurgeon is calling it DAI, however, clinically it doesn't meet the AIS requirements? You cannot code it. So here's the thing. There are three things you need. Now, AIS 2015, that changes. We are not using 2015 here yet. So I can't even tell you what the rules are for 2015. Cause I'm not sure. I know it changes and it's easier to code it. But in 2008, currently you need to have immediate and prolonged coma. So a loss of consciousness must be immediate. At the time of the accident, they cannot regain above an eight, a GCS of eight for at least six hours. All right. And that means that when EMS arrives, they can't have been had a, had a, a GCS of 11 for a little, and then went and tanked back to that totally disqualifies them. It has to be immediate, prolonged, meaning at least six hours. And then it needs to be confirmed on an MRI or a CT and then confirmed by your neurosurgeon as well. So you need to have those three things in order to code it. If any of them are missing, you can't code it. Perfect. Thank you. How do you code a traumatic arthrotomy like an elbow? Lauren here gives us a very specific S51.002A. So that's unspecified open wound of blank. So elbow, for example, but with AIS, there's, it's a joint capsule rupture tear. So what is your direction on arthrotomy? That's all you have. You don't have anything but an open wound in, in there is no, no type of code for an arthrotomy. There is none. Again, you wonder with the thousands of codes, why they're missing a few that you think would be so simple to add. Right. But yeah, there is, there is not one for that. Perfect. Can you just elaborate a little bit on unstable, stable versus partial, complete disruption of the pelvis? Can you offer any pearls for the pelvic fracture, the degree of injury? Okay. So you need to have documentation, right? That's what you need to have. So the other thing is, is also kind of having your reference of the different types of the different types of pelvic injuries. So whether it is a, you know, vertical shearing injury, whether it is, you know, an APC, what kind of, what kind of injury is it? And then what each of them encompass. And I can tell you that if you talk to your orthopedic department at your facility and ask them to even do just a, a very general type of in-service for you guys, for the registry, I think it's great. And usually you'll get somebody, maybe one of the, you know, advanced practice practitioners that'll do it for you, but they'll do it. They they'll make a little sheet for you, all kinds of things like that so that you know where you need to code. But it's really comes down to that documentation because you can't decide whether something is stable or unstable, right? You've, you've got to look for the documentation that that's the kind of injury it is and it's stable or it's unstable. So you've got to look for that injury specifically. Perfect. Just looking for clarification for ICD-10 codes for a spinal epidural hematoma, is this a concussion and edema of the spinal cord? That's a great, great question. So if you are looking for a, I'm sorry, you're calling me off to look at a code right off the bat here. So, so you, I'm sorry, she said a epidural hematoma? A spinal epidural hematoma. All right. So you've got to look for, okay, first of all, I guess my question is, where is it? It's not necessarily a concussion or edema. It could be a, you know, a contusion, a lesion. Like I'm kind of like, did they have central corn syndrome? Did they have, like, you know what I'm saying? Like you've got to, I'm kind of, you need, I need a little bit more info because a contusion, you know, could possibly be coded as the concussion and concussion and edema, but it could be something else as well. Like just that in, in itself. Yeah. Right. Very good. Yeah. We only have a couple more minutes left for today. So I'm going to just go through a couple of these other questions. And if I don't get to your questions, I apologize. There really truly have been a ton of questions in the chat, this, and we, Robin absolutely knew this was going to happen, but if a shaft fracture is described as green stick, where would you code that in AIS? Say, and there's an example. So if it's a radial green stick, does it align more with simple oblique transverse or wedge butterfly fragment or complex comminuted segmental? I want to answer you. I'm not allowed to answer you because it's an AIS question that is not in my pre-approved. So let me green stick. What I'm going to do is I'm going to just send, I can send any AIS questions directly to Kathy with my reply. She will approve it and I will send it to Deb to send out. Perfect. Perfect. So I'm doing that as well. Cause I have to get permission. Understood. Cause it is proprietary. I did see somebody ask what exactly is a spinal cord concussion. I just saw it pop up when we were talking. Okay. So it's kind of like, all right, when you think of a concussion in the brain, right? So you have a concussion, there's no bleed, there's nothing, there's nothing there. Right. But you have like a disturbance. So I don't know how else to, I'm trying to like put it into, you have a disturbance there, just like a concussion of your brain. You don't, nothing shows up on the scan, meaning there's no CT, there's no, but maybe you had, you know, I want to call it like a stinger. They call it, you know, you lost sensation in your upper arms or they got heavy or whatever. That's kind of what I would put as a concussion. And Kim, you can probably. Nope. I completely agree with that. Yep. And that's actually what our neurosurgeons have said as well. Yeah. When they talk about that as well. So we are absolutely at the top of the hour, Robin, thank you so much. You are as always a wealth of knowledge. There's a ton of gratitude in the chat for you taking the time and sharing all of your knowledge with us. So we thank you very much for joining us today. And I know that she has, is always in demand. And so we'll see if we can rope her in for another webinar, maybe later in the year to give you some more, more tips and tricks and making sure that all of our data is accurate. So once again, on behalf of the TCA, I want to thank you very much. Thank you, Robin, for joining us and thank you everybody for your engagement in today's presentation. Thank you everyone. It's always a pleasure. You have my email. If anybody needs anything, just shoot me an email. Thanks. Thanks everyone.

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