CAISS AIS Coding Principles Practice Questions — Questions and Answers

Question 1: In AIS coding, what does the term 'NFS' (Not Further Specified) indicate when appended to a code?

The injury is fatal and requires immediate escalation
The available information is insufficient to assign a more specific code (Correct answer)
The injury is not covered under the current AIS dictionary
The coder must seek physician clarification before proceeding

Correct 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.

Question 2: When coding bilateral injuries to paired organs (e.g., both kidneys), how should the coder proceed under AIS rules?

Assign a single code with severity doubled
Code each injured organ separately using the same AIS code for each side (Correct answer)
Code only the more severely injured side
Use a bilateral modifier appended to one code

Correct 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.

Question 3: Which AIS body region code (1–9) is assigned to injuries of the face?

1
2 (Correct answer)
3
4

Correct answer: 2

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

Question 4: A patient has a liver laceration described as 'minor.' What AIS severity score best corresponds to this injury?

1
2 (Correct answer)
3
4

Correct answer: 2

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

Question 5: In the AIS coding structure, the third and fourth digits of the full seven-digit code specify which of the following?

Anatomic structure and specific nature of injury (Correct answer)
Severity score and ISS conversion factor
Body region and type of injury only
Mechanism of injury and intent

Correct 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.

Question 6: Under AIS 2015 Update 2018, how is a 'concussion without loss of consciousness' classified?

AIS 1 — Minor (Correct answer)
AIS 2 — Moderate
AIS 3 — Serious
AIS 4 — Severe

Correct 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.

Question 7: 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?

Assign AIS 9 (unknown) for all unmatched injuries
Assign the closest anatomically and physiologically equivalent code with an NFS qualifier (Correct answer)
Leave the injury uncoded and document the gap
Escalate to the trauma medical director for a custom code

Correct 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.

Question 8: Which of the following injuries would be coded in AIS body region 5 (Extremities)?

Fractured sternum
Ruptured diaphragm
Comminuted femur fracture (Correct answer)
Pulmonary contusion

Correct answer: Comminuted femur fracture

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

Question 9: An AIS severity score of 6 is defined as:

Critical with uncertain survival
Unsurvivable injury (Correct answer)
Maximum survivable injury
Severe but fully treatable

Correct answer: Unsurvivable injury

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

Question 10: When calculating the Injury Severity Score (ISS) from AIS codes, which scores are used?

The highest AIS score from all body regions combined
The three highest AIS scores, each from a different body region, squared and summed (Correct answer)
All AIS scores squared and summed across every region
The two highest AIS scores from the most severely injured region

Correct 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.

Question 11: A tension pneumothorax would receive which AIS severity rating?

2
3
4
5 (Correct answer)

Correct answer: 5

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

Question 12: In the AIS seven-digit numeric code, what information does the seventh (final) digit represent?

Mechanism of injury
The AIS severity score (1–6 or 9) (Correct answer)
The body region number
The injury year of occurrence

Correct 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.

Question 13: Which scenario correctly illustrates the use of AIS severity score 9?

A spinal cord injury with complete paralysis
An injury present on imaging but not further described in the record (Correct answer)
A cardiac rupture incompatible with survival
A pelvic fracture requiring surgical fixation

Correct 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.

Question 14: For AIS coding purposes, 'abrasion' injuries are generally categorized at which severity level?

AIS 0 — No injury
AIS 1 — Minor (Correct answer)
AIS 2 — Moderate
AIS 3 — Serious

Correct answer: AIS 1 — Minor

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

Question 15: The 'type of injury' digit in the AIS code represents which position in the seven-digit sequence?

First digit
Second digit
Fifth digit (Correct answer)
Sixth digit

Correct answer: Fifth digit

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

Question 16: A patient sustains a ruptured spleen with major devascularization. Which AIS score applies?

3
4
5 (Correct answer)
6

Correct answer: 5

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

Question 17: Under AIS coding rules, when should a coder assign codes based on operative findings rather than pre-operative diagnosis?

Never — initial triage diagnosis always takes precedence
Always — operative findings are the gold standard and supersede pre-op diagnosis (Correct answer)
Only when the pre-op diagnosis was made without imaging
Only when the operative report is signed by the attending surgeon within 24 hours

Correct 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.

Question 18: AIS body region 6 covers injuries to which anatomical area?

Abdomen
Spine (Correct answer)
Thorax
Lower extremity

Correct answer: Spine

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

Question 19: Which statement about coding multiple injuries in the same body region is correct under AIS rules?

Only the highest severity injury in a region is coded
All injuries in a region are coded individually and the highest score represents that region for ISS (Correct answer)
Injuries in the same region are summed to create a combined severity score
A maximum of two injuries per body region may be coded

Correct 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.

Question 20: A traumatic amputation of the hand at the wrist would be coded under which AIS region?

Region 4 — Abdomen
Region 5 — Extremities (Correct answer)
Region 7 — External
Region 8 — Unspecified

Correct answer: Region 5 — Extremities

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

Question 21: What distinguishes AIS 3 (Serious) from AIS 4 (Severe) in clinical terms?

AIS 3 injuries are not life-threatening; AIS 4 injuries are life-threatening but survivable (Correct answer)
AIS 3 requires surgery; AIS 4 does not
AIS 3 is limited to soft tissue; AIS 4 always involves bone
AIS 3 applies to pediatric patients only; AIS 4 applies to adults

Correct answer: AIS 3 injuries are not life-threatening; AIS 4 injuries are life-threatening but survivable

AIS 3 injuries are serious but not immediately life-threatening, whereas AIS 4 injuries carry a significant life threat but are survivable with treatment.

CAISS AIS Coding Principles Practice Questions

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

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