Good morning. Welcome to today's presentation of Once-Bitten, Twice-Shy Coding Complexities of Dog Bites. Our panelists today include Joyce Burt, Dina Moore, and Maria Penrose. This is Deb Myers. I will be moderating the session. Thanks to Kathy Cookman for continued support to us as well as reviewing codes for the cases. We have no disclosures. We do have a disclaimer. The panelist, Noor, myself, is an ACD-10 or AIS-trained faculty member. We bring together over 80 years of registry and coding experience. Today's presentation, we like to differentiate between penetrating and blunt trauma, practicing coding procedures found within a complex dog bite, as well as identifying ICD-10 codes associated with this case. Today, we start out with the scenario of a 10-year-old who presents to the emergency department by EMS with a complex complaint of a dog bite to the neck and a left ear involution. Trauma alert activation did happen. Joyce, would you go ahead and start talking about the trauma types for dog injuries and what we should be looking at? Sure. First of all, I can clearly understand why some were unsure. I will tell you from my experience being from the pediatric world and working in the adult world, we had two different trains of thought. Penetrating was what we would use for mostly the pediatric patients that I may have coded with these injuries. In the adult world, blunt was primarily the choice we would make. One thing to remember is that there are some AIS coding rules that tell you that penetrating injuries are defined as injuries resulting from a gunshot wound or a stab wound or from impalement or spearing-type trauma. Another thing to keep in mind is that if you are reporting to the National Trauma Data Bank using the National Trauma Data Standards, they use the CDC ICD-10 external cause code matrix, which interprets all the codes that we glean from our coding books and lumps them into either penetrating or blunt, at least in what we're looking for. In that case, this type of injury with the coding of a dog bite as your external cause code would map out as a blunt injury. For your internal purposes, for your own facility, you may want to track that a little differently, knowing that your blunt and penetrating data element is just staying within your own facility. Thank you. Maria, how would you code this in your facility and why? Well, I agree with Joyce. So I'm currently at a pediatric center, and at a pediatric center, we currently code these to penetrating. When I was at the adult centers, we did code these to the blunt. One reason that we picked our trauma type of penetrating is we follow our matrix of the hierarchy of the NTDS and then the state and the region dictionaries. We know that when our data is downloaded to the NTDS, that they do not get the actual trauma type. They don't get the trauma type of blunt or penetrating. They get the actual code of the dog bite that they do their data with. And so that is for our own internal purposes that we follow the penetrating rule in our facility. Thank you. Dina, what do you do at your facility? We also mimic what the other two had said. In regards to this one specifically, we would have put it as penetrating due to the underlying damage that took place. Now let's transition over to a little bit to some of the pre-survey results that were taking place before the webinar today. So thank you to those who participated. And Maria, go ahead and talk about some of these results we're seeing. When you look at a lot of these results, they're all over the place. And the one thing that I want to preface is that we always try to follow whatever rules are in either the ICD-10 or in your AIS or in your trauma dictionaries. And as I spoke to earlier, here in Ohio, we have three different dictionaries. We have the NTDS, which is our top priority. We have our state and we have our region dictionaries. As well as we have also incorporated into our own facility, we have created our own facility dictionary that incorporates all three of those dictionaries and any procedures in which we want to track internally either for PI, quality, or research. So if you're looking at these procedures here that you guys did on your pre-survey, and you follow the NTDS dictionary, the actual definition in there of procedures to code are operative and selected non-operative that are essential procedures to the diagnosis, the stabilization, or treatment of a specific injury. And so with that, we know that some of these can be combined because they're already assumed in the procedures that they're doing to either stabilize or to treat the actual injury. So Dina, we just looked at multiple ways of coding some of these procedures, a long list of them. What are some ways that you can stream down some of these coding to save a little bit of time? What do you do in your facility? What have you done in the past? In our facility, we follow the NTDB and PQIP as our primary and then our additional data dictionaries, the state and regional. With that, every facility always has what it seems like to be additional procedures that they would like collected. That's what trauma registry is for, to collect what is needed. With that said, you have to remember we're collecting what is utilized and what is needed by your facility. So we often get in the habit of we've collected it forever, so we're just going to continue to collect it. So in our facility, we cut back on the procedures that we were collecting that were not required by any additional entity that utilizes our data. And we really dove in to see if we needed to collect as many as we were. So we did cut back quite a few. And we went back to the basics of following the definition of including the ones that are pertinent for the trauma injuries as well as the complications that the dictionary states. My registrars are weird, and most registrars are very type A, so it was very hard for us to not want to include the whole picture of what happened during that whole visit and to cut back to what was going to be utilized in our facility and the other registries. Thank you. Maria, what about you? We do the same. We only code those that are essential for us to get the picture and to follow the NTDB. We do have specific ones that are for, we are from a level one pediatric trauma center that is high in research. And we have a lot of process improvement indicators that we also include into our data. However, we regularly check those, and we have lots of meetings with our PI coordinators to determine which ones we still need to collect and which ones we can just track and trend if we see a problem happening again. So we try to list and keep those to just what we need to make the picture for the patient. Thank you. Joyce? Well, I pretty much agree with Dina and Maria. My facility has done the same thing, primarily trying to follow the NTDS guidelines and making sure that we're collecting the data based on the patient's injuries and complications. One thing to keep in mind, too, is there's also in your data dictionary for the national, you know, there's a notation that you do not need to collect multiple procedures that are such as diagnostic CT heads. That is not necessary. However, if it's something your facility would like to collect, yes, you may collect that and it will be uploaded into the National Data Bank, but not essential to collect multiples. So that's another thing, too, to remember is there's a reporting code set that is given by the TQIP, those that participate with TQIP. I like to review those and make sure we are capturing the procedures. Most of them are OR procedures, but just to make sure that you're capturing what would be on that reporting code set that TQIP provides for us. Thank you. Once again, be consistent so that you can run some really great reports on your data. Dina's going to talk about some of the different codes that were found in this case and why she or she would not put these in the registry. So we'll go down the list here briefly. So the fluid bolus, again, this is one that we used to collect on every patient and it was one that after further review, it's not required by any entity that we submit to and it was not being utilized in our being pulled from our registry for any research. With that, we also have a fluid table where we collect if the patient received fluid. So we finally realized we're double collecting and we did not need to take the extra time if we're already collecting it in another field in the registry. So we removed that one from our procedure table. For the antibiotics, again, this is another one if you're a TQIP facility, they're now asking you to or having you enter in the specific process measures for open fractures. So that one potentially could be double collected. And then the insertion of the endotracheal tube, if you want to collect that one for research purposes, additionally, the OG tube is also one that's not required. But if your facility is going to be utilizing it, and we can keep going down here, if the vent days, that one is asked by TQIP to be entered as a procedure code. The Foley and the nasal feeding tube are not. And those were additional ones we were putting in. So again, it goes back to you want the whole picture, but you also, procedures, frequent procedures are part of the standard of care. So you're going to see most patients are getting a Foley, most are getting a nasal feeding tube. So do you need to collect those additionally and determine if it's being utilized or not? Thank you, Joyce. Well, looking at this list, there's only one, two, three, four that my facility would collect. And it would be antibiotic, intubation, vent days, and Foley. And I like them on my procedure table, how my database is set up just for reporting purposes. Even though, like Dina said, some of them are collected, antibiotic is in process measures. I still like to use that information off my procedure table. And then I also do some edits based on what's on the procedure table. So in order, so if a registrar has not documented an antibiotic and the patient had an open fracture, I have an edit that flags them that you did not put an antibiotic on the procedure table. Kind of the same thing if they're intubated were their vent days. So I do use them, even though they may be a double entry, but it's primarily for ease of reporting. Thank you, Maria. So I am a little unique as I come from a level one pediatric trauma center and a level one pediatric burn center. And so we have incorporated in our database both a burn and our trauma patients. So some of these things are collected on our just our regular trauma patients, and some of them are collected on just our burn patients. For instance, fluid boluses is something we would collect for our burn patients because they watch how much fluid resuscitation is given to the burns, whether they're under resuscitated or over resuscitated. We have incorporated in our facility to we do not actually capture in the procedure fields the vent days, but they're calculated out as a number so that when it's downloaded to the NTDB, it's we have it cross mapped to that's what goes out. And then the same thing with the feeding tubes. We don't put those on our trauma patients, but our burn patients, we do because they like to get the feeding going as soon as possible. So they do have that as an indicator that our burn coordinator watches to make sure that the two feeds and the two feeding tube was inserted and the feeds were actually started in a timely manner. So those are included in our procedure tables. So it goes back to the same thing. What are you putting in? And if you're putting in the procedures, are you utilizing them with any type of data reporting, whether it be for research PI or for downloads to the state or region or the national level? And if they're not, we don't do double entries and we don't put things in that we're not actually looking at. Thank you. And as we close out 2020 this year, this might be something you might want to run a report on. Maybe a quarter of your data is what kind of procedures you are putting in your registry and have those conversations with your trauma team PI to decide in 2021, is there anything you can clean up or is there other ones you need to add? Next, Joyce is going to take us through just a reminder, a refresher on how to build a procedure code. Yes, and this is, you know, when this first came out, the ICD-10 procedure codes, this was difficult for me, but I learned to understand what the root operation definitions were. I review them frequently before I decide what that root operation should be. And then I begin to look at my index. I can't stress enough how important and how helpful the index has been to me. So just a little example of somebody that has done ICD-9 and then into 10, when ICD-9 and ORIF was an open reduction of an internal, with an internal fixation for a bone fix, I could not get reduction out of my head. So, but every time I went to the index and looked at reduction, it took me to reposition. So it helped me to use the index to find where I needed to go. And then as time went on, I learned the root operation definition better and made it even easier. So in this case, we're going to code, this is the repair of the left ear lack of this patient. So we went to repair in the index and went to ear and went to left. And then you get your first four digits of that code in the index. So right now I've already got four digits, the 09Q1. So at that point, I need to finish my code. So then I actually go into the NED Surge section of my book, my coding book, and I find the 09 section. And then I follow through and go to Q1 and realize my next code is going to be the approach, which would be external, since this is an external ear. And then my device is a Z and my qualifier is a Z. So those are basically placeholders, because in other codes, you may need to fill in an actual digit or character that's not a Z or a Z. So again, the thing I would like everybody to learn from this is that use your index and use, if you have a document that has your root word, root operation definition, use that too. It's very important. Thank you. I would like to ask the presenters if you could speak a little bit louder for us. We have a few that are having trouble hearing us. And this is just a nice reminder of either printing out your root operation words or to have those on hand so you can actually figure out exactly what they're doing. And Deb, can I just say, because I had written a note about this, about that particular slide, is if you look at excision and extirpation, this is where you could get into the wrong path of finding your code. They're similar, but they're not the same. So I would just, that's why it's important to understand the definitions of these root operation words. Thank you. We're going to take a few minutes and look at that fifth character, the contrast. So we're going to go a little bit into the high and low and how to figure out which one your facility is using. So the two are the high and the low. High osmorality is basically, it's five to eight times what a human serum, whereas low is less than three. High is usually given through gastrointestinal or cystourethral, and low is usually given through IV. There's a couple of the name brands listed there. So the important part is when they do say contrast is knowing what kind is given. In this case, it was clearly identified to us the type and the amount, and so it was very easy to pick low. And sometimes the CAT scan reports may just say it was given by contrast. And if that's the case, you'll need to go back to your trauma team or radiologist to identify which type is using so that you'll know in future coding how to code this out. The sixth character, I have to admit, did give me a lot of headaches when we went to ICD-10. There was not very much written about it. I wasn't quite sure how, when to use this. But since then, there has been more research out on there and more definitions. So basically, it is going to come out looking like a CECT on your report, and this is not going to be something that's done initially in the trauma bay but maybe down the road for more diagnostic procedures on your patients. And this exam is used to highlight specific tissues, tumors, or a specific part of the body, and it does use a more different type of contrast, and there's a couple names there. So in most cases, you're going to be charting as an unenhanced in your CT reports. So, Maria, when we were talking in this pre-survey reports earlier, there was some difference of these. So if you could explain these for us, that would be great. Yeah, so when you look at the different codes, we do know, as Deb talked, this specific case did use the contrast. But this head CT specifically states they did not use the contrast on the head CT. So when you look at the codes that were given here, we have the other characters that go along with the root operation. We're all in that same area of the BWs, BW2s, but when you look at the 9, per se, it says it's the CT of the head and the neck. Well, we know that they did the head, but they didn't do the neck with this specific procedure right here. I think they did a CTA of the neck later on. And then the B020, we know that that is the high enhanced and unenhanced. So we just spoke to that about using enhanced and unenhanced, and we knew that this one was the low contrast that was used. And the other thing is, is that that was a CT of the brain. So we're looking at the CT of the head. And so when you go to the BW2A code, that is encompassing both the brain and the bones within the body or within the head. And so we felt that the BW2A was the better code in this scenario here. And because they did it without contrast, then you would have BZZ at the end. Thank you. You're welcome. Dana, can you talk about the angio of the neck? Yes, so the BW2FZZZ, that was the CT scan of the neck code, which does not include any code pertaining to the vascular portion, but it does encompass that the neck was scanned. The 290ZZ, that one is the high osmolar. And as Deb said, this chart reported that it was the low osmolar contrast that was used in this patient. No one selected the 29Y. And then we also have the BW2F1ZZ, which was the scan of the neck using the low osmolar contrast. So that one reflects the correct contrast that was used. On the next screen, we discuss further regarding if you break it out by coding just the scan of the neck or if you code it to the different vessels that are viewed during that scan. So you could potentially have three codes that you would add for the one procedure of the CTA of the neck. In our facility, we spoke with our medical director and he, post our discussion, we decided we were only using the one common carotid artery code for when we track our CTAs because we know that they're viewing the other vessels. And for our reporting purposes, we wanted to just pull it off of that common carotid code. Thank you. Here's some of the other procedures that were identified in the case. It was noted during the pre-survey that on the CT of the cervical spine, 2% did code this a cervical spine CT as CT of the neck. And just a reminder, the neck part is looking at the soft tissues and more of the internal organs. Although this would have been something might have been done for this patient because we have diagnosis of soft tissue injuries, the initial CT was CT of the cervical spine. Maria, can you talk a little bit more now about the chest? Yes. So on this, we noticed that they did the procedure of the CT of the chest with contrast. But you can see some of the codes here. And when you go to your ICD-10 book, when you're actually looking under the CT area, there is not a specific code for chest and chest alone. It's chest combined with the abdomen. So a great method to figure out of whether you're going to use the combination code is was there any mention or any inclusion of any type of abdominal organs within that CT scan? Sometimes they'll get the upper portion with the CT and they'll make some comments about that. Then I would lean more towards the combination of the CT chest and abdomen. However, with this one, there was no mention of the abdominal organs. And so you have to remember that another name for the chest is the thorax. And there is a code in the ICD-10 that is a CT of the thorax. And so that's where we went with this one being that it was just of the chest. So that would be the BP2W using low contrast. Thank you. We're at this time going to transition to more of the surgical procedures. And Joyce is going to talk to you about the first one. OK. Yes, we found that the patient had this microlaryngoscopy. So I see that on the pre-survey results, we had varying differences of which code to use. And in this case, we decided that this was an inspection because they were going into the larynx with a scope and they were inspecting because of the wounds that this patient had. So that took us to inspection of the larynx. And of course, it would be a natural or artificial opening by an endoscopic. So in this case, we picked the code that Deb has the arrow attached to and felt that it was the best code to represent that procedure. So this kind of follows that whole ICD-10 rule of not coding more than what you need to code one and then knowing what exactly are they trying to do in this procedure. So we know that he had a carotid artery dissection that needed to be repaired. And when we looked at the surgical OR report, the actual report that they did or what they did was the repair of the right common carotid artery with a reversed femoral vein interposition bypassed vein graft. So what does bypass graft mean? This is where your anatomy and your knowledge of knowing what exactly they're trying to accomplish will take you to the right procedure codes. So the definition of a bypass graft is it takes the blood vessel from another part of the body and attaches it above and below the injured area. So we know that they harvested the right femoral vein to put to the carotid vein or the carotid artery as a bypass. And so this is one that we would combine those into the one. And if you look at the codes here, replacement of the right common carotid artery with autigulous tissue substitute open approach. So, autogulous is meaning they took it from that person itself. It's something that was in their body that they used to repair another portion of their body. So in this instance, they took the right femoral vein and bypassed it to the carotid artery. If you go to your ICD-10 books, and you look at the top, where it gives you kind of a definition and a path to look, the 03R was the putting in or on of a, either a biological, meaning it came out of their body, or synthetic material. But if you look at the 03Q, and I can see where people would have gotten kind of a little confused about that, it says, use only when the method to accomplish the repair is not another root operation. So that goes back to Joyce's point of knowing what your root operation is. What is the root that you are looking for? And so, you can see that it would be just off by a little bit, but that root operation, knowing what they're doing is the key to, is the key in success to surgical procedures. And I'd just like to add too, even though the OR report did say repair, that is more of an ICD-9 word, and so that we have to really understand what the surgeon's doing, and sometimes convert this back into an ICD-10 root word to get us where we really need to be. Next, Joyce is gonna talk to us about another surgical procedure. Yes, this was, I didn't know what the thyrohyoid membrane was, and so that made it difficult to even try to code this particular procedure. But with a little Googling, we have a definition here for that membrane, and it actually is part of the larynx. So, in Googling and determining that that's where the procedure was actually done, was the larynx, we were able to go to our root operation word of repairing, and going to the larynx, and going to open approach. So, then we got the code that you see there. So, I think this is just another good example too, of how you just have to use Google, and find out what is this body region, what is this, you know, you could look at that and think it's your thyroid. There is a hyoid bone that we can code for injury, but some, I believe, were leading to the thyroid, which in this case, it's simply the membrane, the cartilage, the membrane that connects the thyroid cartilage to the hyoid bone. So, that's where we got this code. Thank you. Tina, you talked about the repair of the partial ear, and this was the result from the survey. Yes, there were 37 results. From the top, we can kind of narrow these down to which ones we would exclude. So, the first one said unspecified open wound, and we know, based off of the operative reports, and the additional notes, that it was, part of the ear was amputated during the attack. So, we can narrow it down to a specific type of injury. The second one, with the 34%, was a laceration without foreign body of the left ear, and based off of the documentation, he had part of the ear brought in with the patient, or he or she, sorry, part of their ear was brought in with them. So, it was not just a laceration. The SO1.311A, that was of the right ear, and this injury was the left ear, so that automatically would be excluded. Jumping down to the SO8.129A, that was of the unspecified ear, so again, that one would be excluded. And then the last code is a T-code of an unspecified body region, which we know that it was the ear that was, for this diagnosis, injured. So, 49% chose the partial traumatic amputation of the left ear. So, that is the code that we decided to, would be appropriate for the ICD-10. Moving over to the AIS, we have the avulsion not further specified, which 43% chose to code to that one. And then we have a minor superficial, but we do not know what size this piece of ear was that was brought in. Then we had one that was entered as a typo. We had major, greater than 25 centimeters squared, which again, the size was not specified. And then we have an ear injury not further specified and an avulsion not further specified of the external region, the 910800.1. So, we chose to go with the avulsion not further specified at the top, the 210800.1, due to not knowing the size. Understandably, the ear is a small portion of the head, however, it was not specified to the size. And I feel like in the ones that were coded to a major, that's where we kind of put our emotions into play with, we felt like it was a major injury, a major avulsion because it was part of the ear missing, but we truly did not know the size. Thank you. Some of the other surgical procedures we had are listed here, and we're gonna go into next, some coding injuries. And Maria, go ahead and talk about this epiglottis injury. Yes, so they talked about, Joyce talked earlier about that whole thyroid-hyroid membrane. Well, it's the same thing with the epiglottis. If you look into your AIS coding book, there is not really a code for epiglottis. So, you have to get creative, you have to know your anatomy. And so, what we did after going through all of these, if you look again, we're all over the board. One thing I do wanna mention here is to remember your code ranges. So, we know that specific trauma injuries in ICD-10 normally fall within the S and T codes. So, we have a JO5.1, but that is epiglottitis, which is the inflammation of the epiglottis. So, it's not the actual injury. So, it didn't fall into that S and T codes. There are a few that are exceptions, but this was not one of them. But we get creative and look, again, you have to know the anatomy. And so, when you Google the epiglottis, it is a flap-like structure attached to the hyoid bone anteriorly in the larynx. So again, you're gonna go to your ICD-10 for the larynx. But then in your description, and I don't know how at our facility, we do not go with whatever is automatically programmed in whatever software you're using. We hand type in our own description of the injury next to the ICD-10 code. And so, this one, in our facility, we would ICD-10 code it to the larynx, but then put in the details that it's a laryngeal laceration, including the rupture of the thyroid hyoid membrane and the epiglottis. So that way, you're encompassing all of the injury and able to code it correctly while still describing the entire injury that the patient has. This is just an example of where Maria took the coding to, as well as a nice anatomy of what is considered in that larynx. Thank you. Joyce, you wanna take on the common carotid artery? Yes. So, this was described as a dissection, and immediately my brain thinks, oh, more severe. But I started to do some digging, and of course, we have, again, different codes for 10 and AIS. Going back to what Maria said, some of them don't fit the trauma codes, but you can see what the choices were there. But in this case, when I was thinking about the codes, and I started with my AIS severity score first, I wanted to see what I would find for my AIS code. And I realized with some additional digging in the AIS clarification document and some of the other rules that the dissection was actually an intimal tear, intimal tear meaning it's inside the vessel that the tear is or the damage to the vessel is. And it can be severe, but for AIS coding, it can only be coded as intimal tear. If it was disrupted, you could code it higher, but you see that the code we chose, and I'm sorry, I have my screen small. I can't read it for the AIS code dev. It says no disruption, the top code there that we chose. So be careful and use all your resources because those will help. Something that sounds severe like dissection may not be coded quite as severe as you might think. So then whenever we found our 10 code, we, again, it matched with what we had decided for our AIS code and more of a minor. And in this case, because it wasn't disrupted, the patient's acuity, as far as how severe that, of course it needed to be repaired. And we know that, but it's a minor lack of the carotid artery. And again, code conservatively. We've got the notes down there. Those are just reminders. Thank you. Here's a few more of the injuries that were identified on this patient. I would like to put in that we did find the carotid artery thrombosis. And that's important if you're coding, especially for performance improvement, if you're looking for any of that stroke complication due to a carotid injury. So this might be something you wanna make sure you're coding on if you're running specific reports based on a stroke complication due to a carotid injury, which we see a lot of times in with ATV accidents. As we close towards the end of our program, we'd like to finish off with the importance of validation and then also some tips for coding. You can see that this had some complex injuries that occurred due to this dog attack. This is a great one that you can use as a validation tool chart in your facility. It's interesting to see how based off of the documentation, we do have different codes assigned, both ICD-10 and AIS for a few of the codes. So this is a great one to have discussion on. And as Maria and Joyce mentioned, there were some injuries that occurred that are not common injuries. So it's great to review further where the anatomy actually is to make sure you're assigning to the correct code. And again, it's great for discussion with your team to make sure that you're all coding consistently. Additional, this was me, correct, Deb? Yes. Okay, sorry. Additional tips for tackling difficult cases like this. First off, avoid distractions as much as possible. As we know, distractions can be frequent and they get you off track. So if you're deep into reading the operative report, that may end up where you miss an important component that would affect your coding. We also thought that a hot cup of coffee and some chocolate to get you through a chart like this would be helpful, keep you going. Other tips that we came up with was when there's complex cases, it may be helpful to just do a overview of the chart to see what you're getting into with regards to what injuries you may need to be looking for and that may help in the long run as well when you're going through the chart. We recommend to not take the billing list as your list of injuries for the coding. Again, you can use it as a guide, but it's not a true injury list for accurate trauma codes. And we code for a different purpose than what the billing does. So you have to keep that in mind that they are not coding for the severity like we are. Their purpose is different. It was also suggested as a practice for in your diagnosis coding to code the AIS first and have that help drive your ICD-10 code of where you will choose, be able to identify the appropriate code. Always query if necessary. You can create a template for querying or that way you'd have a form of documentation to go back to if there's further questions. And that way you also have received the correct diagnosis so you can assign the correct code. Track the diagnosis as you find them. That way you don't have to go back and say, where did I see that in the chart? Collect them as you find them. And then sift through multiple pieces of the documentation and follow the diagnosis definition hierarchy that's in your dictionary. And that will also get you to the most appropriate codes. Additionally, review the diagnosis documented so you're not double coding the same diagnosis that are described two different ways. So that could also affect your AIS code. And again, that goes back to the anatomy of knowing if they're referring to the same diagnosis, they've just mentioned it in the documentation in two different ways. Thank you. Moving on to some more suggestions from Joyce. Well, since I've been doing this for a very long time, I started out with paper abstracts. And so that, I don't use them anymore. But when I have a difficult case, I use a short abstract where I can write down kind of like what Dina said, you make note of the diagnosis or the procedures as you see them. Reading the case over and in its entirety, and then going back to those and getting the fine detailed pieces of each of those, whether it's the diagnosis or the procedure. And I find a paper helps me a lot. And while you're writing these things down, one of the things I like to document is where did I find that diagnosis? Intimal dissection of the carotid artery. I'm gonna make a notation next to my paper on my paper so that when I go back to all the progress notes and all the OR reports and all the notes that I have in my EMR, I'm gonna remember, oh, I saw that on the CT, but then I also saw that in the OR report. And it helps me to go back to that to get my final decision on what I'm going to code for injuries or procedures. I guess that's pretty much all I had in that for coding difficult cases. Okay, thank you. Let's move into productivity. Is there things that we can do to help reduce our time and maybe increase our productivity? Maria, go ahead. So I would say the first thing to do is to always review your data elements at least yearly. We do this at Nationwide Children's with the release of a new dictionary. We take an entire day that we do not abstract, we don't do any PI, we don't do anything other than go through the data dictionary page by page and compare it to the previous year along with the change log that is given to us through the NTDS and compare all that to see are there data elements that are no longer required or needed? And that starts with the NTDS. And then we move on to the other dictionaries. We also hold meetings on a regular basis with our researchers. Our researchers are well incorporated into our trauma program. They not only know what data elements we have, we educate them on AIS, we educate them on ICD-10 and how data is entered and pulled out from our database. And so we know what researches are going to be happening in the upcoming year. There are a few that will pop up mid-year that we weren't aware of, but we have an idea of what data elements we have or what data elements may be needed for that research policy or research project. And then, or if maybe we don't collect a certain thing one way, we may have it another way. So we talk about those things on an annual basis. Again, remember to lump procedure codes together where you can. So like, for instance, that bypass that was done on this kid on the carotid artery, instead of coding the two codes and trying to figure out where to go in the book and putting the two codes, put the one code in. Validate your data on a regular basis as well. At Nationwide Children's, I know it's not around everywhere, but at our facility, we are very fortunate and unique that we are concurrent. So anything that any patients that came in yesterday, we are abstracting today, and then we follow them through and we meet with our data clinical coordinators. Our data coordinators, we meet on a daily basis and we huddle and we talk about any procedures or PI indicators that had fallen out on that patient. And so they're entered in in real time. And that is a time saver than having to go back 30 days or 60 days later to try to put all these indicators in and then review these charts. So that's a helpful hint. Just remember that good data in is good data out. And so you wanna autofill elements that can be autofilled so that you don't have different data fields that are being put in differently. And always have education with your data coordinators or your registrars within your facility. We try to do it on a monthly basis. When I close out the month to do the monthly reporting, I do a little extensive validation and things that I pick up on, we speak to then the following month or within a few weeks of me closing out that data to discuss the things that we found. And so we're able to keep our inter-rater reliability and we're able to keep our consistency going within our own institution. Thank you. So Joyce is gonna talk about how do you grow your team to make them a little more interdependent on themselves and learning as well as how do you grow yourself? Well, I think one of the things I've learned over the years is just knowing my resources. That eliminates a lot of guesswork, eliminates searching for information, just like using the AIS clarification document, using your AIS course training book, using the rules in your AIS coding book, understanding things like ICD-10 route operation words. Being a lead in my facility, I get the questions all the time. What should I count as a complication in this case? So I have to divert the registrar to the actual data dictionary. So if they were more familiar, I mean, I'm trying to get them there, I'm trying to get them to be more familiar. So when they become more familiar with what the data dictionary definitions are on their own, I think that's the best teacher for them. Then they know where to look, they know what they've read in the past and they can troubleshoot that question the next time themselves, rather than coming to me, which I don't mind, but I want them to also be independent. So I think one of the biggest things is just knowing your resources. Don't have to know them verbatim, word for word, but know that that's where you're going to find some answers that you really need. Again, I'll stress, I love using the ICD-10 books index for most any of my coding, as far as ICD-10 identification of diagnosis or procedure. So that in a nutshell is my suggestion. Thank you. Okay, we moved on to the question portion. Please put questions in the questions and answer. If you would like to submit a difficult case from your facility to have a panelist review and webinar on, please go ahead and put that in the chat and I will follow up with you following the presentation today. So some of the questions we have so far is on the dog bite. Which should we report to TQIP? I say blunt based upon the ICD-10 coding rules, an evulsion to a blunt action. Well, this is Joyce, and I think that was part of my, one of my slides. But again, you can report what you want in your facility. Trauma type is a separate data element in my database. So I can flag it as blunt or penetrating. However, what the NTDB is going to see as it's mapped over to them from the code that you choose, if you're coding correctly and coding it as a dog bite, cause, external cause code, it will go out to them as blunt. So when you look at your report that you get from TQIP, NTDB. NTDB, when you submit your data, your blunt and penetrating numbers are not going to match because if you're counting it as penetrating, they're seeing it as blunt. So, I mean, you can code it, you can report what you want in your facility as a separate field, but it will go out as blunt. Thank you. Next question is, I always thought enhanced and unenhanced meant they did the CT with and without contrast. Is that incorrect? And that's how I used to look at enhanced, unenhanced till I really dived into some of these research articles because there is a choice for high, low, and no contrast. And then the next one is enhanced, unenhanced. So I do believe that goes more to that new procedure, the CECT. Next question is, I see 10 guidelines state chest and abdomen means and or. So I think the CT chest abdomen is appropriate for just the chest. They're going to look into the rule to be more 100% certain. Any comments on that one or is that one we need to follow up with? Well, I would just say I'm always learning something. So if that is true, I appreciate knowing where that's at or that that is a rule. I would also say that I do believe that is a guideline, but you have to also make sure you are able to pull the data that you want from your procedures. And then I would just say, follow up with that to say, we're not saying one way or the other is correct or incorrect. These are how we coded them based on our experience and how our facility does that. The main takeaway from this is to, however you choose to code it at your facility, that you are consistently consistent at your facility. Does that make sense? Another question would be, when physicians will say both an abrasion and small laceration for the same injury, how should we code? Well, go ahead, Maria, go. I personally take those as lacerations because if you look at the NTDB rules again, I don't believe that superficial injuries are included in downloads, correct? Correct. So I would take that as a laceration versus an abrasion personally, whether that's right or wrong. Right. And I also would just be mindful of what physician is documenting that. You know, your facility, maybe one of your physicians is more of a hierarchy for certain injuries or data to collect. And so of course, like with neurosurgery, I'm gonna go with the neurosurgeon's report versus maybe somebody else's note. So yeah, it's subjective. Another clarification on the blunt and penetrating. I believe we covered this, meaning the trauma type you select as whether blunt or penetrating and the actual what's going out to TQIP is gonna be based on that injury code. So most likely it's going out as blunts, but in many centers, they're using penetrating as to be able to track down the dog bites. Right. And you know, the other thing is, is that is a CDC matrix. So it's out, actually I think it's on the NTDS's website that you can link to that matrix that shows you that the dog bite code will be interpreted as blunt. And just a little other piece of information, a few years ago, it used to be mapped to other. So that changed. I'm not sure exactly the date that it changed, but it's been, it was changed to blunt a few years ago. But that matrix is very helpful to me to understand what the NTDS is seeing, what they're gonna see in their data bank.

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