CAISS AIS Coding Principles 2 — 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.
CAISS AIS Coding Principles 2
In AIS coding, what does the term 'NFS' (Not Further Specified) indicate when appended to a code?