All right, well, good afternoon, everyone. My name is Chris McEachin. I am the Trauma Program Manager at the Henry Ford McComb Hospital in Clinton Township, Michigan. It's my privilege to be the moderator for this session, the first TCA session of 2022, from a webinar perspective at least, Pelvic Fracture Features. So we appreciate everyone joining us. It's also my pleasure to introduce our speaker, Kathy Cookman. Kathy has been involved in the trauma field for over 40 years in various capacities, from pre-hospital, emergency department patient care, trauma data management, performance improvement and injury prevention. She is the CEO of KJ Trauma Consulting LLC and an ICD-10-PCS instructor. She's also CEO of KJ and JC Enterprises LLC and recently achieved Florida Master Naturalist through the University of Florida. Kathy has been AIS faculty since 2003 and is currently the Business Director, International Technical Coordinator of AIS. She lives in Florida with her husband, John, and their three labradoodles. Kathy, I hand it over to you. All right, thanks, Christine. It's a pleasure to be with you guys today from sunny Florida. And those of you who are up north in the snow and the ice, I used to live in Ohio, so I get it. And you can throw stuff at me if you want. It was 49 degrees here this morning in Fort Myers. And those of you who are below zero are throwing things at the screen right now, so that's okay. I'm gonna talk with you a little bit about pelvic fractures. Not one of our favorite subjects, it seems like. They're challenging, to say the least. I think they're okay when you put them together in their individual compartments. You know, ICD do the thing with them and then AIS do the thing with them, do our procedures. But when you try to marry them together, those of you who've heard me speak before know that AIS and ICD do not have a good relationship to be married and see eye to eye on everything. And pelvic fractures is a perfect example of that. So when we think about the mechanisms of injury, obviously you can get a pelvic fracture from a lot of different things, motor vehicle crashes, to name one, motorcycles and so forth. But the most common mechanism of injury, as I'm preaching to the choir, is false, obviously. So points to ponder when you're at a chart, you're reviewing that particular chart. What types of injuries did the patient sustain when they fell? Was there loss of consciousness? Is there a TIA, a dysrhythmia? Was it a seizure going on? All of these other questions come into play. And then we start thinking about the surroundings of where that patient fell. Was the ladder not secured? Did the foot get caught underneath a rug that didn't have a good glue section underneath or some sort of skid resistance surface protectant there? Was it an icy sidewalk? And again, those of you who are in this ice and snow storm, be super careful because it doesn't take much to lose your balance and slip and fall. And we certainly don't want you having a pelvic fracture. So in your AIS dictionary, in the new AIS 15 dictionary, let me clarify that. There is a section on page 145. If those of you online have already transitioned over to using AIS 15, then you can turn to page 145 in your book and you'll see the table that I have here on the screen. Those of you who have not transitioned yet, this is still helpful to you because it's a table that describes common terminology that describes pelvic ring stability. As you know, when we're talking about a pelvic fracture, what's the important thing that we need to pay attention to? How stable is that fracture? So what's going on in the posterior portion of the pelvis where the SI joints are? Do we have stability there? And so the first column on your left-hand side are all nomenclature items that would be pertinent to a stable fracture. So things like a pubic rami, the ilium, the ischium, the sacroiola, the iliac crest, very common type of fractures, inferior and superior pubic rami, another example there. So things to think about stable fractures. There's also reference as you see to tile classification, OTA, the Orthopedic Trauma Association has a classification, Young and Burgess classification. So all of these physicians and organizations that have gotten together and really studied pelvic fractures have come up with these different classification or scales for the complexity or the severity of a pelvic fracture. The second column is showing you what a partially stable fracture would be. Again, the first column stable fractures, it's gonna hurt, but you're gonna be able to get up and move around, have some mobility, probably still dance a little bit if you want to. The partially stable column, now we're getting to the point where it's, yeah, you're probably slow dance a little bit, not gonna do the tango with that. But again, having a little more instability there in that posterior section of the pelvis. And then the third column to the right of the slide are your unstable examples. So this is your fracture dislocation at the SI joints, obviously. So vertical shear. Vertical shear, when you think about the pelvis, as I hold my hands up here, the pelvis being vertically sheared, literally shears up and off of the connection points, okay? And you're not gonna get up and dance around any point in time with that as well. So I have a little scenario. I have an 87-year-old male. He came into the emergency department by ambulance and he fell from his wheelchair. He was in the bedroom of his private residence. Now, wouldn't it be nice if our charts were that detailed? Well, make life much easier that way. But I wanted to be as helpful as possible in this scenario. He did complain of left hip pain and he struck his head, but there's no witness loss of consciousness prior to him coming into the emergency department. He's alert and oriented. His vital signs are there on the screen. His GCS is 15. He does have a laceration to the occipital scalp that's six centimeters long and it's into the gilea. And he has a 10 by 10 centimeters squared hematoma also on the scalp, and there's no bony deformity, all right? So there's the skin injuries that he has, no loss of consciousness. So they whisked him off and they decided to do some procedures. They did a pelvic X-ray. Now, not everybody collects X-rays within the trauma registry procedure section, and that's okay. You know, that's where we differ a little bit. But if you do collect the X-rays, then of course you could always look up the procedure code if you wanted to play along. They did a CT of the abdomen slash pelvis. So they're looking at the abdomen and the pelvis together. And as you know, when you're in your ICD book for procedure coding, under imaging, you've got the choice of items that are separate. You've got abdomen and then you have abdomen slash pelvis. The slashes always also mean and and or. So keep those things in mind. And if you forget about the rules, the front part of the ICD book always has the rules and guidelines that you can refer to in case you've forgotten. They did do a head CT because he bonked his head and they did it with contrast, which is kind of interesting. Initially coming into the emergency department, most of our CT protocol is not with contrast. However, he's 85, he fell out of a wheelchair. So maybe they're concerned about a stroke opportunity and that's why they use the contrast. He was also given nine units of packed red blood cells and four units of platelets. So again, if you're keeping track of those things in your database, that would be something that you would want to look to code. So I've highlighted items in red to kind of give you a little bit of a leg up on things that you're looking for. So as you're analyzing the record, you're looking at a lot of different pieces of documentation. So we've looked at the emergency department. We've probably looked at the medic report if it was available to us. We're gonna look at our radiographic studies. So this is the result of the pelvic X-ray. It says a bilateral pelvic radiograph was positive for left pelvic fracture. Displaced fracture with interruption of the acetabulum at the level of the ischium with medial displacement. And then it goes on to talk about how the symphysis and the sacrum were intact and all of that fun stuff. And so those are positive things that make us go, yay. We don't have multiple things happening. And then a little more definitive than the X-ray, obviously they did the abdomen and pelvis CT scan. This showed an acute comminuted fracture. So remember comminuted, little tiny fracture fragments, bits and pieces like a jigsaw puzzle of the left pelvis involving the acetabulum. So if the fracture line has gone into the acetabulum as well, fracture planes involve the iliac wing extending through the superior medial acetabulum. There's also hemorrhage in the left hemipelvis and it has so much hemorrhage going on. It's having a mass effect on the central pelvic structures. So remember, we can't really open the patient up and measure how much blood is going on because pelvic fractures bleed. You've always heard that in any training that you've been to, whether it's ICD or AIS, you've always heard how much pelvic fractures bleed. And so this is right on. And so we look for what's the hematoma doing? How big is it? And is it getting so gnarly that it moves the bladder out of the way? It doesn't necessarily hurt the bladder, but it just grows and grows and grows and things have only so much space and it starts to push things out of alignment. So those are the types of details that we're looking for when we're abstracting a record, especially with pelvic fractures. The CT of the head was a negative. There were no abnormalities shown. And so ponder those things for a minute. You're going to have a handout. I don't know if they've already given them to you or not, but the items that I have here on the slides are available to you as a PDF. So you can always go back and play and try to find your codes. If you want to look for them now, you can, that's perfectly fine. I'm going to do a little bit of review though on the anatomy of the pelvis. And so those of you who have this memorized, you can kind of take a quick little nap and we'll wake you back up here in a minute. So the anatomy, when you think about the pelvis itself, it looks like a ring. It has a ring-like structure. And it goes on to tell us in the left side what they refer to as the pelvic girdle. So each side contains the ilium, the pubis, and the ischium. And that circular area is called the pelvic girdle. All right, the sacrum and the coccyx, as you see here in the picture, this is the sacrum and the coccyx, you can't really see anything but the top of it. That's all part of the pelvis. Even though it's connected to the spine, you know that we include it in the pelvis anatomy when we're making our assignments of injuries for AIS purposes. Now, I am emphasizing AIS a lot today, not just because of the hat that I wear with regards to my work with AAAM and AIS, but you have to stop and decide how is your program going to reflect the best data for the patient population and how seriously injured they are? And I always tell folks, I can't tell you how to run your database, but what I can give you are some things to think about. So if I'm looking at AIS, my AIS values are going to help me to understand probability of survival. It's gonna help me to look at outcomes. And again, that survivability and those numbers that make that equation are based on certain sets of vitals, the age of the patient, the AIS, the ISS, and nowhere in there is it mentioning ICD. And I'm not trying to say ICD is not important, because it is, it's extremely important. But in the trauma registry world, we're not dropping a bill. We're looking at how seriously injured are the patients. So I'm looking for the detail and what is the most appropriate definition or description of that patient's injury. Those are the things that I'm really looking for. Not so much, is this the right ICD code, but is my AIS code gonna drive that probability of survival and the research that you might be involved in at your facility? So this picture shows us the greater and the lesser pelvis. Maybe you've heard it called the false pelvis or the true pelvis. And so you can see in the green, the green is a greater or the false pelvis. And then the yellowish area there is the lesser pelvis or the true pelvis. All right, so again, just giving you some of that nomenclature that some of you may see in your documentation. And so this'll be a good reference point to you. And when I put slides together like this, I always want people to know that it's extra information because each one of you are gonna become a mentor one day. You are going to, without knowing it sometimes, you're gonna help somebody be better at what they're trying to accomplish in the world of trauma. And so if you've got some tools together and you get a new hire coming on board, now you've got a little extra information and you don't have to dig so far to find out some of the definitions that you can share this particular presentation with them. The pelvic outlet. Now that's another thing that you might hear. It's located at the end of the lesser pelvis and the beginning of the pelvic wall, all right? And so the posterior portion is the tip of the coccyx. Then the lateral portion is there and the anterior goes to the pubic arch. So you can see we've kind of given you some color, some definition, and then the connect the dots, where does all of this put together to become the outlet? We talked about the brim already, all right? So that's pretty much that circular area, the ring-like structure. And then the little smaller circles are the obturator. Those are also sometimes called rings. And then our anatomy of the pelvis. So what's going on in and around it? Well, there's organs related to the digestive system, reproductive organs, the bladder, the urethra. So there's lots of opportunity when that pelvis gets fractured to have organ damage as well. So you should always be looking for, don't assume that there's an injury to the bladder or to the digestive system, but you should always be putting that detective hat and looking deeper to see, is there really just a pelvic fracture or do I have other things going on within and around that particular part of our anatomy? Now, I like this slide because check out that runway of arteries and veins. No wonder pelvic fractures bleed, all right? So blood vessels run through and around. You've got the right and left iliac arteries that come from the aorta. You've got the right and left iliac veins that return from the legs and blood vessels that supply the pelvis and the tissues around. Then it gets even better. My husband says that this slide reminds him of the electrical panel of the house that we bought here in Florida in 2010. It had been wired by, I don't know who, wasn't a professional, but that's literally what the electric pumps look like. All these wires, colors going in and around. No wonder pelvic fractures bleed, okay? 80% venous injuries, common source of hemorrhage, shearing injury of the posterior thin-walled venous plexus. All of this leads to retroperitoneal hematoma. That's why AIS rules say you can't code retroperitoneal hematoma because we know that the blood's coming from this pelvic fracture because of all of this runway of arteries and veins, okay? It is uncommon, however, for arterial injuries to occur in a pelvic fracture. It's only about 10 to 20%. And then down in the bottom of the picture, remember in AISO 8, those of you who have taken that class, we had you write in the dictionary about blood loss because the blood loss indicators are not in that dictionary. So we have you write it in, and it's here at the bottom of the screen. Again, it's all about the size of the pelvic hematoma. So if the size of the hematoma is described as small or moderate, then that is gonna be equating to less than or equal to 20% blood loss. And if they describe the hematoma as large, extensive, expanding, then we're gonna look at greater than 20% estimated blood loss because the patient can bleed to death if we try any other process or any other method to determine just how serious that is. On the AIS-15 dictionary, page 146, you don't have to write them in anymore because they're already included in the wording within the dictionary for AIS-15. So if you have 08, make sure you've got a note in the dictionary so that you can be sure to make the appropriate code assignment. And so blood that's supplied to the pelvis, again, all of these items are listed here for you, including that you can have up to four units of blood could be lost from bony structures when you have a pelvic fracture, and it increases if the blood vessels are damaged, obviously. Now, when you look anatomically at the difference between the male and the female pelvis, you can see that the female pelvis is larger and wider and has a more rounded inlet and the bones are thin and lighter. That's because a child buried, obviously. The iliac crest, however, of a male pelvis is higher than what the females are. The sacrum is also longer than the females and it's a little more narrow, okay? When we think about the functionality, what does it do? Well, it helps to balance the weight of our legs when we're sitting or standing. The majority of us are sitting right now and where is the weight riding? Right there in that posterior portion of the pelvis. It also helps to protect blood vessels and organs and it forms the connection for different types of muscles that we use for locomotion, for posture, which my posture right now is pretty poor. I'm not sitting up straight in my chair and that's hard to remember to do. And it provides that attachment for our reproductive organs that are external and our associated muscles and membranes for that. So that picture is kind of hard to realize, but here's the sacrum in the back. There's the upper part of the start of the spine and down here is your pubic symphysis, kind of give you an idea of the angle of that particular picture. So quick little review, pelvic ring. It's likely to separate in more than one location. It's like trying to break a pretzel in one spot. You can't do it. So the superior and inferior pubic rami fractures are shown here and those are considered stable fractures. So I'm giving you references as to where you would find the codes for that in AIS-08 and AIS-15. So depending upon what dictionary you're using, you've got some reference pieces there. If we think about the iliac crest, that's a very common spot to do a bone graft from. It's really not gonna hurt anything. You see, it's not anywhere near the SI joint because this portion back here, I don't know if you can see my mouse moving or not, but this portion back here is where the stability is at. And so iliac crest fractures, those are stable fractures. They're not gonna have any bearing on us being able to get up and dance. And then your lateral compression. Now, this is a little more challenging. This can be partially stable, but it also can graduate to an unstable fracture. And those are sometimes described in the chart as an LC fracture, L for lateral, C for compression, and then there's a grade to it, LC2, LC3, those types of things. And the more serious the impaction is, the higher the number is. Now, if I have a lateral compression, that's a three, LC3, that pushes in and rotates hemipelvis. So it pushes in like this and then rotates itself. That's when it becomes unstable, unstable. So horizontally oriented pubic fracture and the forces from a side impact. So think about somebody sitting in a vehicle. Let's say I'm in the driver's side of the vehicle and I get T-boned onto the driver's side. And my pelvis is not intended to go that way. It's not intended to smoosh in. And so that can cause a lateral compression. And then this little guy gives the most challenge for people and that's the open book pelvic fracture. People wanna code it as an open book and because they see the word open, it's not. It's the type of fracture. And lately I've been teaching in AIS classes, think of open book as a doctor's name. And I know that sounds really stupid, but think of it as a doctor's name because you've got Winquist fractures, you've got Schatzker fractures, Lefort fractures, all these docs get things named after them. Just pretend open book is a doctor's name because it's a type of fracture. Look at the picture. If we go back a slide, see the pubic symphysis here, how nice and close together it is. And then we go to the open book. It's because now that has been splayed open it's not as though you were opening a book. It's not supposed to be that wide, all right? But it doesn't make it an open fracture unless the bone comes out of the skin. So just play tricks on your brain somehow. The symphysis pubis, again, what's the width? Should be no more than five millimeters in adults. And it looks like my picture's taken away some of the writing there, sorry about that. Children, the width could be up to 10 millimeters. All right, anything that's greater than five millimeters in an adult indicates a disruption. And so that's a pretty significant space. Maybe you see straddle fractures. That's not very pleasant at all. It's a double break of the anterior pelvic ring on both sides. That's still partially stable. And you look at that and you go, huh? But again, look at the posterior portion. It's not completely stable because that ring has been impacted, but it's technically not a totally unstable fracture. Now, this guy that's highlighted in red, that's a bucket handle fracture, and that is unstable. And if you look at how it sheared off at the SI joint, and then also here at the superior and inferior pubic rami, that's generally caused by a high force, like a blow to the pelvis, a fall from a height, a really high-speed car crash can occur with that as well. Hemipelvis rotates again. It's not supposed to do that, and it looks like a handle of a bucket, all right? And they say it can rotate internally up to 40 degrees. I've personally never seen any radiographic studies of that significant of an internal rotation, but I believe somebody's seen it at some point in time. And then this is a nasty fracture. And if you're into injury prevention at all, and you see people with their feet up on the dashboard, riding around, chilling out, taking a nap, I used to do it, can't do it anymore. What happens when that airbag deploys? What happens to those feet, and the leg, and the femur, and the pelvis? You can end up with a vertical shear. Airbags come out pretty darn quick, pretty darn quick, and you're not going to get up and dance around with this. These are also sometimes documented as a Malgany fracture, so maybe you've seen that nomenclature. That is definitely an unstable fracture. And then avulsion fractures. This one always gets a little controversial in discussion. This is when the ligament or a muscle is pulled away from the bone. And I always use the example of if you were doing archery, and you have an old-fashioned bow and arrow, you know, the kind where the limbs bend forward and up and under, and you pull that string back, and you've got the arrow in your hand, and you're getting the sight of where you're trying to hit the target, and you pull really tight, and if you pull too hard, you can sometimes break the bow, where the string is attached. And that little part of the bow will just kind of hang there on the string. That's an avulsion fracture, and it's coded in AIS-15 as a ligament injury. So don't shoot the messenger, because a lot of people are like, uh-uh, that's how it's coded, all right? It's coded as a ligament injury. You can refer to page 123 in your AIS-15 dictionary. And then pelvic dislocations. So what do we see most of the time? Hip dislocation is how it's documented. And so in AIS-08 and 15, there's the page numbers there. But if you dislocate the ring, the pelvic ring, all right, that's going to be coded as a pelvic fracture, 856100.2. It's not actually in the 08 dictionary. We tell you to write that in, but it is spelled out for us in the 15 dictionary, okay? So that's the ring, not the hip, but the ring, okay? And so just a couple more little facts. 3% of all falls cause fractures, 95% of hip fractures are people greater than 65, and 20% of hip and pelvic fractures never return home. That's sad. Five to 20% of people with a hip fracture are more likely to die in the first year following the injury than any other reason in the same age group. It's referred to as the beginning of the end. And that set of statistics is very sad when you think about it. And what's a large population in a lot of our facilities? Elder falls. So there's a huge opportunity from an injury prevention standpoint to make a difference. I think we should wrap them all in bubble wrap and not let them do anything, but be in bubble wrap and smile, be like Betty White. You know? So classifications. You saw some of those in that first table that I shared with you. And so the Young and Burgess classifications, this one is most commonly used. It's emphasizing the mechanism of injury by the vector score and the severity, all right? And then you also have the tile classification. It's more biomechanical, and it looks at the stability of the pelvis. So that posterior portion and not so much the mechanism. All right? So you can see over on the right side of each one of these slides, you've got the pictures that equate to the different classes and then in the bottom left corners, you can see stable versus partially versus totally unstable. And then coding guidelines. The acetabulum can have two different AIS fracture codes depending upon whether it's unilateral or bilateral. So again, you've got on the left side of the screen, the picture of the pelvis, and it's pointing to you the acetabular socket and basically that's where the head of the femur articulates. Turn to the side and you can see it much better and you get that crazy looking shape that you see in the drawings in your AIS dictionary. And it might make better sense now that you look at the pelvis, turn it to the side, and that's what you're seeing. And then this also is in the AIS 15 dictionary and you're welcome to write it in your 08 dictionary. These are common terms that are describing acetabular fractures. Not gonna spend a lot of time on acetabular fractures because it is part of the pelvis, but it's not from an AIS perspective. So this is just here for reference pieces for you. When you have time, sit down and take a look at it. So the coding guidelines for AIS, you've heard me say it probably five or six times. Stable, partially stable, unstable pelvic fractures. Those are the definitions. They're in both dictionaries in case you're wondering, but it's all about that SI joint, that posterior portion of the pelvis, what's going on with that. I decided to throw in some ICD codes for you because what are the common things that we do from a procedural standpoint to help stabilize an unstable pelvic fracture? Sometimes they'll do an X-fix. Sometimes they'll do pelvic binders. They'll do x-rays, CTAs, retrograde urethrograms, reboa, those types of things, open reductions, internal fixations, or an infix. So those are, again, there for your use. If you have any questions about it, my contact information's at the end of the slide deck. You can always shoot me over an email note. So biomechanics, again, just talking a little bit about the biomechanics of things. There's a classification called the O'Brien zones, which basically divides into three different zones. And there you can kind of determine the strength of the fixation. It's like an instrumentation point. And so there at zone three, it's the highest strength area, which makes sense the deeper down into the pelvis itself. So I don't know if you tried to code or not, but we had a comminuted fracture of the left pelvis. We had a left iliac wing fracture. And so just stop there for a second. You have a comminuted fracture of the left pelvis. So we know it's comminuted, but we don't know the location in that first description. We know specifically it's the left iliac wing. Do we code them both? Do we code just one? Our third line is retroperitoneal hemorrhage. There is a code for retroperitoneal hemorrhage in the ICD book. It starts with the letter R, but we can't code it because the rule in AIS says we have a pelvic fracture that associates the bleeding. So it negates the ability to assign an AIS code. A lot of people mess that up when they're trying to do their code assignments. And generally what I see in validations of folks' work is people are picking the retroperitoneal code because it's mentioned and they forget about the rule or maybe they're just coding from the database and not looking at the rule boxes within the book. That happens sometimes. And so that's a good PI process for you. Go back to your database, make a list of all the patients, look at last year's data, make a list of all the patients who had retroperitoneal hemorrhage and pull it up by the AIS code. And then save that list. And then recall the list when you're ready and look at the ICDs that were assigned. So if they had a pelvic fracture or they had an injury to, there's a whole list of things, the spine, vertebral fracture, sorry. If they have pelvic fractures and vertebral fractures are the number one and two causes for retroperitoneal hemorrhage. If there's any patients on your list that have retroperitoneal hemorrhage AIS and a pelvic fracture or one of those other items, then you've over-coded and now you've got a good PI opportunity to go back and correct those records, write it up in your PI process, then resubmit your data to whoever you're sharing with and then monitor it over a period of time to see if you have any, an educate, I forgot the educate part, educate those you're working with and then monitor it over a period of time and look at your data again. And if it doesn't happen again, that's awesome. You can show loop closure for that, but you're looking at the data to be sure that it's accurate because it's driving force of your process improvement, your protocols and things to that nature. So it's important to have good solid data. Displaced medial wall of the left acetabulum was mentioned and then the occipital, scalp laceration and hematoma. So if you are playing alone, the comminuted fracture of the left pelvis, the iliac wing, there's your ICD and your AIS code, and it goes to the body region of lower extremity. If you coded the acetabulum, there's your information for that, okay? It is displaced. And then 856251.2, again, going to the lower extremity. And then you also have your occipital scalp laceration. Notice it starts with the number one because it is in the head chapter that you find the code, but it's assigned to the ISS body region of external. And we know that because that's what the rule box tells us to do. And then our last injury is our occipital scalp hematoma, and it gave us a great measurement, 10 by 10 centimeters squared. And so again, that's also found in the head chapter, but assigned to the external. So when we go to calculate an ISS, and you know your database does that for you, and if you've been through AIS training, you know that the mean faculty that teach you makes you do a manual calculation of ISS. And why do we do that? Because we want you to understand how it is configured so that number one, you can sit in a meeting and be able to respond to a question of what would that patient's ISS be if they had this or that. It also helps you if you're taking CSTR and CAISS credentialing, because both of those credentialing exams have little questions that you have to calculate it manually. So you're ahead of the game. So this ISS score would be what? Just popping in the chat there, I'm looking at the chat. What would the ISS for this patient be? What do you think? All right, I'm seeing lots of good answers there. Oh, I saw one that was 21. Oops, I saw one that said 13. So if you answered 17, you get a prize, yay. I don't know what the prize will be, but you get a prize because you're correct. So you're gonna take the three highest postdoc values, and we only have two body regions involved. We have the lower extremity and the external. So our highest value is a four. We square it, four times four is 16. One times one is one, 16 and one is 17. All right, so the three highest values for ISS. Now, if we were doing the new ISS, the new ISS, then you would be able to take the three highest regardless of the body regions. So you would have 16, four, and one to add together, but we're not gonna go down that posy path or whatever. What am I trying to say? We're not gonna go there right now talking about new ISS. We'll save that for a later time. And so the left iliac wing fracture is represented within that S32 code, and the retroperitoneal hemorrhage is not coded because of the rules that are in both the dictionaries of 05 and 08. Here's the PCS codes that you would have, fall from a non-moving wheelchair in the bedroom of private residents, and then your other codes for the additional items that were listed previously on a few slides. Here's the references and the resources that you can follow up on if you're interested, and that's what I use to put this together. And I just wanna say thank you for your attention and do a quick little commercial. Don't forget to really consider becoming certified in AIS, becoming a certified AIS specialist. This is the link of where to find more information about it. The testing periods are March and September, and so the open enrollment for the exam is through February 12th, I think. And it's always March and September every year, and you do have to register ahead of time a month in advance, and then you'll get all your paperwork together. And PTCNY, the Professional Testing Corporation in New York actually added a virtual opportunity for you. So with the pandemic and everything being closed down and difficulties getting to a physical testing center, they did introduce that ability as well. So that's been a wonderful addition, especially for our folks that are abroad in foreign countries, a little more difficult to find testing centers there. So I am just gonna leave my contact information up there for a minute, and let's run through some of the questions that you have. And if I'm not able to instantly answer your questions, I've got a piece of paper here. I will definitely write it down and get back to you, okay? Okay, so I will, I've been monitoring the chat, everyone, so I think we'll get all of you. So here's the first one, Kathy. This is from Vicky Tegman. Do they need to receive blood products to code the blood loss? No, they don't. And you can't use the infusion of blood to consider the amount of blood loss. Sometimes folks wanna do that. They'll say, well, they were given this many units of blood, so that means that it was this, we can't go there. It's the description of the pelvic hematoma. Good question, thank you. Okay, so the next one is, do you code the injury to the artery on the pelvic fractures? You can, yes, and you should. If it's distinctly injured and described and they've done something to that, absolutely. All right, thank you. Here's the next one. If the pelvic fracture's stable posterior arch intact, can we account for the blood loss or is that just the AIS 856151? Oh, now you're quoting numbers and you want me to have those memorized. If it's a stable fracture and they have blood loss, unfortunately, it's all encompassed. You don't get any extra outcoding for it. So you would take your stable fracture that's closed. And I'm assuming that's the code. I'm sorry, I don't have the codes memorized. I can grab my book real quick, but you would take the codes and you can't do anything about the blood loss for stable fractures. Great question. Okay, next one. Why do you use the reposition root operation for a pelvic binder instead of the immobilization root operation? Well, and that's a great question and that's controversial. It goes back and forth because you really are repositioning it as you're tightening it up. You're aligning it because you don't wanna keep it mal-aligned. It's kind of like in the days when I was a medic, we had mass trousers, you know, and everybody was like, well, mass trousers, this and that and this. So pelvic binders are intended to align and you're tightening up that binder, whether it's a sheet or an official binder apparatus, that's the rationale behind it. But again, we can always talk about it offline if you'd like, be more than happy. They've got my email right there. Okay, all right. So here is the next question. I think it's more of a clarification from the exercise, but I thought that this posterior arch was intact. So I used AIS 856151.2. So that's another specific. Okay, and let's see, go back here. So communuted, we have multiple fracture fragments. Let me get my little book out here from behind me. Pardon me. And you know what? I always like to double check myself because I am known to be human and make mistakes. So let's take a look at that and see what we got going on. So 163.4, communuted fracture, symphysis pubis, depression of the sacrum. I'd have to go back to the scenario now. That means going backwards. And so this will be a fun slide if you guys decide to go back and look at this later on, because I don't have it printed out. So hold, please. Let's come back here and see what we have. Displaced fracture, interruption of the acetabulum, okay, so we have a displaced fracture, but you're right, it's not really saying it's communuted. Fracture planes of the wing extending through the acetabulum, the hemorrhage in the left hemipelvis straining. Well, I can see your rationale behind it, honestly. And I think what we probably did when we were putting this together, and I'm saying we, and it's actually me, I probably just took the displaced. So I will take your code and accept that, okay? And I'm human. Good point, there we are. It's awesome. Thank you, Kathy. Okay, here's the next one. And this is related to the CAISS certification. You have to have a BS, right, is the question. So it's like, don't you have to have a BS to take the? No, you do not, not for CAISS. It's not required. You have to have a high school education or the equivalent. You have to understand anatomy and medical terminology, but no, it does not require BS. I believe that might have been in the nomenclature of CSTR. It's not required, but it's preferred, but it's not in the language for CAISS. Okay, thank you for that. All right, I'm gonna pop, there's a couple other ones in the, so let me flip to the other screen. Is there any sort of CAISS exam prep course or book anywhere? I can't seem to find one. This is from Kim Taylor. Okay, and you know, I would love to say that we had a prep course, but we don't. Professional Testing Corporation manages the way that the test is structured and how the questions are organized. As a matter of fact, when I get off of this call, we've got a CAISS board meeting that starts promptly at two and we're going through test questions and we write the questions. Well, I don't write, I'm just an advisor. The board writes the questions and then the Professional Testing Corporation representative tells us whether or not it's a legitimate way to write the questions. So you can't have any, you know, trick questions and no easy give me that kind of thing. And, but they don't allow us to have any study prep because of the way that they do their structure of testing. However, if you go to that website here for the Professional Testing Corporation, there is a handbook that you can download. And in the back of that handbook is an outline that's provided. And if you study those things in the outline, you'll do really well on your test. Okay, so there's different anatomy things, there's medical terms, there's coding recommendations, read your rule boxes. You don't have to memorize things, but you have to understand what the rules are saying. And that's a really good reference piece. So I would direct you to their website to look at that. Okay, so I think this answers more of this question. Any advice on studying for the CAISS? There's not a lot of information beyond broad breakdown on the subject matter. So I think that, and go ahead, sorry. Yeah, I was just going to say, you know, it's a good outline if you follow through that outline. And if you've taken a course before, go back through your course materials. You've got your dictionary, obviously, but go back through your student materials too. There's some helpful pieces there. Okay, all right. And I think we have a few, just a few more. Okay. Can you explain again the avulsion pelvic fracture not being a real fracture? It's because the ligament or the muscle has pulled off, pulled off and snapped. So I think the most common location, not so much pelvis, but think of the tib-fib. You know where that ligament connects at the bottom of the tibia and the fibula. And if you twist your ankle just so right, that little thing is going to go snap and sometimes you can even hear it go ping, you know, and snap and it's not really breaking the bone. It's pulling the ligament from the bone. And sometimes a little piece of it comes off with it. All right. So it's the ligamentous injury or the muscle injury and not a fracture of the bone. It's that pulling that's causing the bone piece to come off. I hope that's helpful. I need a good visual. I don't have one. Sorry. Okay. So here's another one. Is the online testing open to anyone in the U.S. too? The online test? Oh yes, absolutely. Yes, absolutely. They have some strict rules about it, but yes, it's available to everybody. How long before the CAISS test will be only AIS 2015? That's an awesome question. And it's gonna be several years. And the reason that I say that, the majority of you have yet to begin using AIS 15. And that's because there's a delay with the software vendors. They have had the code since 2016. They just have not implemented it. And it's now 2022. So as soon as everyone is using 2015, then about two to three years after that, then we can incorporate a new test, but it's not fair to have an AIS 15 exam when the majority of the population is not using that dictionary. So it'll be several years. Okay. Yeah, and I think that probably answers this question. Is there a specific course, latest version they're requiring? If I had a class in 2011 in St. Louis, what would I need to take? The O8 class, the O8 training, or not the training, the O8 dictionary. This guy right here is the one that you're tested on. It says AIS 2005 update O8. That's the one that the certification exam is gonna be on at least another three years. Okay. So if AIS 15 was implemented tomorrow, it would still be three years before they would switch dictionaries. Okay. It takes that long to turn over testing. Is the avulsion fracture being coded as ligament injury, not fracture only in the AIS 2015? It is spelled out specifically in 2015, but you can use it in O8. There's just not a call out in your dictionary. You'll also notice it in the O8 dictionary when you're looking at the, it says ligament muscle and something else. So, but yes, you could still code it there. It's just not called out in your book. Okay, thank you. And then also notice that the code in the slide for the scalp hematoma is not correct. Just a repeat of the scalp laceration. Okay, thank you for that. We'll make sure it gets corrected and I will send over a corrected PDF. So thank you. That's my bad. And then I wrote myself a note. And then did we, okay. So really quickly, cause we do have to wrap up. Do we have to, so I'll just do them two in one. Do we have to bring our own code book? So it's for the test. And do we need a refresher class every five years? So you cannot take a book to the test. It is nothing in the room with you. All you can bring in is your test confirmation that you're allowed to sit for it and your driver's license to prove who you are. That's all you're allowed to bring into a testing center. They will give you a pencil and they will give you a blank piece of paper. You do not need your dictionary. All of the questions are in a fashion that you have multiple choice responses. And so if there is a scenario with a patient has this injury and it's a liver, this, this, and that, the codes are only gonna be about the liver. All right, so you don't need your book because of the way that the questions are formulated. And I forgot the second part of that question. I apologize. That's okay, I probably should have just waited. So did we need a refresher class every five years? That's not a bad idea, but it's not set in stone anywhere at this point. It's not a bad idea though. Okay, I think we caught all of them, it looks like. So thank you, Kathy. That was great. It was a great, as a trauma program manager, it was a great review for me. I will make sure to get those codes corrected. Thank you so much. And I apologize for the errors and they're all my fault. And I will get those corrected and make sure that the group here at TCAA gets the corrected PDF so that you can distribute the correct information. It was great. All right, so thank you all for participating. We really appreciate your participation and your questions as a matter of fact. So thank you everybody, have a good day. All right, thanks everybody. Bye now, stay warm and safe.

Kathy Cookman

trauma expert

pelvic fractures

AIS system

ICD system

mechanisms of injury

anatomy of the pelvis

types of pelvic fractures

coding guidelines