11.01.06
November Question of the Month
Q: The patient is an unrestrained passenger admimtted following a high speed MVC. He has been unconscious without sedation of paralytic medications since admission 48 hours ago. His CT demonstrates petechial hemorrhages in the area of the corpus callosum and basal ganglia. The neurosurgeon diagnoses diffuse axonal injury (DAI). What is the correct AIS code?
A: In AIS 98 the correct code is 140628.5
In AIS 2005, there are two areas in which DAI may be coded. The correct code in AIS 2005 is 140627.5 Cerebrum, DAI involving corpus callosum. If the CT had noted only hemorrhages in the basal ganglia, or more broadly, petechial hemorrhages in the cerebrum, the correct codes would have been 140625.4 (for the basal ganglia) or 140628.4 (note the change in severity between AIS 98 and AIS 2005 for this code) for the cerebrum NFS.
AIS 2005 also makes the distinction as to whether an anatomical site has been noted for the DAI. If the chart simply states DAI (confirmed by both radiologic and clinical diagnoses) it should be coded in the Concussive Injury section of the chapter, in this case the correct code being 161011.5.
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