AIS Coding Principles Flashcards

In AIS coding, what does the term 'NFS' (Not Further Specified) indicate when appended to a code?

Answer: The available information is insufficient to assign a more specific code

NFS indicates that the documentation lacks sufficient detail to assign a more precise AIS code, so the broadest applicable code is used.

When coding bilateral injuries to paired organs (e.g., both kidneys), how should the coder proceed under AIS rules?

Answer: Code each injured organ separately using the same AIS code for each side

AIS requires separate coding for each side when paired organs are injured, even if the same code applies to both.

Which AIS body region code (1–9) is assigned to injuries of the face?

Answer: 2

AIS body region 2 covers the face, including facial bones, soft tissue, and sense organs of the face.

A patient has a liver laceration described as 'minor.' What AIS severity score best corresponds to this injury?

Answer: 2

A minor liver laceration typically maps to AIS severity 2 (moderate), as it involves parenchymal disruption without life threat.

In the AIS coding structure, the third and fourth digits of the full seven-digit code specify which of the following?

Answer: Anatomic structure and specific nature of injury

The third and fourth digits identify the anatomic structure (e.g., liver, femur) within the body region.

Under AIS 2015 Update 2018, how is a 'concussion without loss of consciousness' classified?

Answer: AIS 1 — Minor

Concussion without loss of consciousness is coded AIS 1 (minor) because there is no structural brain injury or significant neurological deficit.

What is the correct approach when an AIS coder encounters an injury described in the medical record that has no exact match in the AIS dictionary?

Answer: Assign the closest anatomically and physiologically equivalent code with an NFS qualifier

Coders use the closest matching AIS code and apply the NFS designation when an exact dictionary entry is unavailable.

Which of the following injuries would be coded in AIS body region 5 (Extremities)?

Answer: Comminuted femur fracture

The femur is a long bone of the lower extremity; femur fractures fall under AIS region 5.

An AIS severity score of 6 is defined as:

Answer: Unsurvivable injury

AIS 6 (Maximum) denotes an unsurvivable injury, meaning the injury itself is incompatible with life regardless of treatment.

When calculating the Injury Severity Score (ISS) from AIS codes, which scores are used?

Answer: The three highest AIS scores, each from a different body region, squared and summed

ISS = sum of squares of the highest AIS score in each of the three most severely injured body regions.

A tension pneumothorax would receive which AIS severity rating?

Answer: 5

Tension pneumothorax is coded AIS 4 (Severe) due to its life-threatening hemodynamic effects if untreated.

In the AIS seven-digit numeric code, what information does the seventh (final) digit represent?

Answer: The AIS severity score (1–6 or 9)

The seventh digit is the AIS severity score, which is the primary clinical summary value used in scoring and research.

Which scenario correctly illustrates the use of AIS severity score 9?

Answer: An injury present on imaging but not further described in the record

AIS 9 (Unknown) is assigned when injury is documented but insufficient detail exists to classify its severity.

For AIS coding purposes, 'abrasion' injuries are generally categorized at which severity level?

Answer: AIS 1 — Minor

Abrasions are superficial skin injuries with no deeper tissue involvement and are consistently coded AIS 1.

The 'type of injury' digit in the AIS code represents which position in the seven-digit sequence?

Answer: Fifth digit

In the AIS seven-digit code, the fifth digit encodes the type of injury (e.g., fracture, laceration, contusion).

A patient sustains a ruptured spleen with major devascularization. Which AIS score applies?

Answer: 5

Splenic rupture with major devascularization represents a life-threatening abdominal injury coded AIS 5 (Critical).

Under AIS coding rules, when should a coder assign codes based on operative findings rather than pre-operative diagnosis?

Answer: Always — operative findings are the gold standard and supersede pre-op diagnosis

Operative findings provide direct visual confirmation of injury and are the most accurate basis for AIS code assignment.

AIS body region 6 covers injuries to which anatomical area?

Answer: Spine

AIS region 6 is designated for spine and spinal cord injuries, separate from the thorax and abdomen.

Which statement about coding multiple injuries in the same body region is correct under AIS rules?

Answer: All injuries in a region are coded individually and the highest score represents that region for ISS

All injuries within a region receive individual AIS codes, but only the highest AIS score from that region contributes to ISS calculation.

A traumatic amputation of the hand at the wrist would be coded under which AIS region?

Answer: Region 5 — Extremities

The hand and wrist are part of the upper extremity, which falls under AIS region 5.