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CAISS Exam 2 Questions and Answers A+ Grade 2025-
Boxed & Bold Text - ✔✔Represent AIS coding rules and conventions and contain directives to assist in the appropriate use of specific descriptions.
Brackets - ✔✔Denote inclusive or exclusive information.
Parentheseses - ✔✔Include synonyms or occasionally, non-clinical terms and provide a definition for the injury description.
Semicolons - ✔✔Separate injury descriptors that are comparable in severity.
Bold Type - ✔✔Identifies an anatomical structure
Italics - ✔✔Are used for proper-named anatomical structures or injuries, and for OIS grades.
AIS .1 - ✔✔Minor
AIS .2 - ✔✔Moderate
AIS .3 - ✔✔Serious
AIS .4 - ✔✔Severe
AIS .5 - ✔✔Critical
AIS .6 - ✔✔Maximum
Range of AIS severity codes - ✔✔1-
Is "DEATH" part of the AIS severity scale? - ✔✔No
Does a linear relationship exist between AIS severity codes? - ✔✔No
(T/F) Injuries within the same code may not be strictly compatible. - ✔✔T
AIS .9 - ✔✔Unknown
(T/F) The AIS single digit severity number indicates the relative severity of injury in an "average person" who sustains the coded injury as his only injury. - ✔✔T
Average Patient - ✔✔Adult 25-40 years of age
Free of pre-existing conditions
Free of treatment complications
Receiving timely, appropriate care for the injury
Pre-dot Code - ✔✔6 digits to the left of decimal point
AIS Severity Number - ✔✔A single digit to the right of the decimal point.
Body Region - ✔✔The first number in the pre-dot code stands for?
Type of Anatomic Structure - ✔✔The second number in the pre-dot code stands for?
Specific Anatomic Structure - ✔✔The third & fourth numbers in the pre-dot code stands for?
Level of injury within the specific body region and anatomic structure - ✔✔The fifth & sixth numbers in the pre-dot code stands for?
(T/F) There are 9 ISS body regions? - ✔✔F
(T/F) Asphyxia is assigned to the ISS Chest region? - ✔✔F
(T/F) Drowning is assigned to the Head & Neck region? - ✔✔f
Abdomen and Pelvic Area - ✔✔Include injury to Lumber spine lesions.
External - ✔✔Injuries that include lacerations, contusions, abrasions, hypothermia, electrical injury, whole body injury and burns are assigned to what region?
1-75 - ✔✔The ISS score ranges from what to what?
(T/F) An ISS of 75 can be derived in 2 ways: one AIS .5 injury in each of three body regions or a single AIS .6 injury. - ✔✔T
Should patients with a AIS .9 code be included in research studies? - ✔✔No
Underestimation of the ISS score - ✔✔Assigning injuries to too few body regions can result in what?
Overestimation of the ISS Score - ✔✔Assigning injuries to too many ISS body regions can result in what?
Injury - ✔✔The anatomic lesion resulting from a transfer of energy rather than a complication or immediate sequelae is what?
Blunt, Penetration, Burns & Selected other Trauma - ✔✔The AIS includes injuries from the what mechanisms?
(T/F) The AIS sometime permits the coding of immediate sequelae, but withing strictly defined rules? - ✔✔T
(T/F) You can code suspected, possible or rule out diagnosis? - ✔✔F
(T/F) Clinical diagnosis alone are not codable for certain injuries. - ✔✔T
(T/F) In order to code clinical diagnosis, there must be back-up with a CT, MRI or autopsy documentation. - ✔✔T
(T/F) Cranial Nerve Injuries or Basilar Skull Fractures are an exception to coding clinical diagnosis. - ✔✔T
Basilar Skull Fracture - ✔✔Physical signs of raccoon eyes, Battle signs, CSF rhinorrhea, CSF otorrhea and Hemotympanum are indications of what?
(T/F) AIS allows coding of cranial nerve "contusion" if there is documented cranial nerve weakness/paresis or subtotal loss of function? - ✔✔T
(T/F) AIS allows coding of cranial nerve "laceration" if there is documented cranial nerve paralysis, or total loss of function? - ✔✔T
(T/F) Coding a basilar skull fracture based on physical signs or manifestations is only permitted if there is evidence of traumatic head injury or the physical manifestations cannot be related to a peripheral or facial injury (e.g., facial fractures)? - ✔✔T
(T/F) Complications are coded as injuries? - ✔✔F
(T/F) Do not assume that a specific injury has occurred simply because a particular outcome occurred. - ✔✔T
(T/F) Death is an automatic AIS .6. - ✔✔F
Sprain - ✔✔Injury to joints
Strain - ✔✔Injury to muscles, tendons
Crush - ✔✔Massive destruction of body part with damage to underlying body systems (e.g., skeletal, organ and vascular)
Amputation - ✔✔Total loss of body part from trauma or burn
Vessel Laceration - ✔✔Same as puncture or perforation
Minor vessel laceration - ✔✔Superficial, incomplete circumferential involvement, blood loss less than or equal to 20% by volume
Major vessel laceration - ✔✔Rupture, transection, segmental loss, complete circumferential involvement, blood loss > 20% by volume
Thrombosis - ✔✔Includes any injury to the vessel resulting in its occlusion
Muscle laceration - ✔✔same as rupture, tear or avulsion
20% blood loss in adults - ✔✔> 1000 cc
Nerve paresis (palsy) - ✔✔Subtotal loss of function
Nerve paralysis - ✔✔Total loss of function
Transection, Laceration, Contusion & Segmental Spasm, Aneurysm/Pseudoaneurysm, A-V Fistula, Intimal Flap - ✔✔Types of Arterial Injuries
(T/F) You should code conservatively. - ✔✔T
(T/F) Foreign bodies are not injuries and therefore not coded. - ✔✔T
(T/F) You should base the injure severity based on procedure or treatment interventions. - ✔✔F
(T/F) Multiple fractures to the same bone but in different regions of the bone are coded separately. - ✔✔T
(T/F) "Crush" should only be used when vascular, skeletal and soft tissue injury occur with an injury. - ✔✔T
(T/F) If "crush" code is used, you should also code the injuries separately. - ✔✔F
(T/F) Transection should be coded as a complete transection. - ✔✔T
(T/F) An incomplete transection should be coded one AIS code less severe than a complete transection. - ✔✔T
(T/F) If a vessel injury occurs in combination with an organ injury, the vessel injury is not coded separately if it is already included in the organ injury descriptor. - ✔✔T
(T/F) Branches of vessels are not coded unless they are named vessels and/or are listed within a specific vessel descriptor. - ✔✔T
(T/F) When more than one injury claims the qualifier "blood loss > 20%", the blood loss is assigned to the most severe associated injury. - ✔✔T
Abrasion - ✔✔A rubbed or scarped area on skin or mucous membrane caused by contact with a rough surface or object with sufficient force to remove surface layers.
Contusion - ✔✔A black and blue mark resulting from a blunt force which causes tiny underlying blood vessels to burst and leak blood into the skin without causing a break in the skin.
Scratch, Scrap, Graze, Road Rash, Friction Burn - ✔✔Abrasions
Bruise, Contused Wound, Ecchymosis, Subcutaneous Hematoma, Bump, Subgaleal Hematoma - ✔✔Contusions
Laceration - ✔✔Tear or ripping apart of tissues resulting from blunt or penetrating force.
Open Flesh Wound, Scrub Wound, Cut, chop Wound, Gash - ✔✔Laceration
Avulsion - ✔✔Ripping or tearing away all of the layers of the skin in which a portion is separated from underlying tissues often creating a flap.
Degloving - ✔✔Traumatic removal of skin and subcutaneous tissue separating tissue planes from blood supply, especially from a limb.
(T/F) Degloving injuries can be open or closed. - ✔✔T
Decollement Injury - ✔✔Closed degloving injury
(T/F) If a skin injury, including penetrating injury, occurs in isolation (i.e., no underlying injury), it is coded under the appropriate AIS section BUT assigned to the External Body region when calibrating ISS.
(T/F) The AIS External and Thermal Injuries chapter should only be used if no information is available locating the injury on a specific body part or area. - ✔✔T
(T/F) When a skin injury occurs in combination with an underlying injury, except open fractures and penetrating injuries, both are coded under the specific body region. - ✔✔T
1st Degree Burn - ✔✔Superficial
2nd Degree Burn - ✔✔Partial Thickness
3rd Degree Burn - ✔✔Full Thickness
(T/F) If burns are only described in combined degrees you should code to the most severe. - ✔✔T
(T/F) Varying degrees of burns should be coded to the most severe. - ✔✔F
(T/F) When burns occur in varying degrees, assign first degree burns separately from second and third degree burns. - ✔✔T
(T/F) If second degree burns are less than 10% TBSA and/or third degree burns are less than ore equal to 100 cm2 or > 100 cm2 but < 10%, both second and third degree burns should be coded separately. - ✔✔T
(T/F) If combined second and third degree burns cover greater or equal to 10% TBSA, assign the AIS code based on their combined TBSA. - ✔✔T
(T/F) If a burn amputation is the direct result of the event, code as an amputation using the specific body region and do not code the burn separately. - ✔✔T
(T/F) If an electrical burn includes "flash" burns code both the electrical and flash burn separately. - ✔✔F
LeFort II Fracture - ✔✔(Pyramidal Disjunction) Fracture line passes through the nasal bone, lacrimal bone, floor of orbit, infraorbital margin, across the upper portion of the zygomatic-maxillary suture line and maxillary sinus and pterygoid plate along the lateral wall fo teh maxilla into the ptergopalatine fossa. Two fracture lines result in a floating maxilla and nose with a possible cribiform plate fracture.
LeFort III Fracture - ✔✔(Craniofacial disjunction), Complete separation of the facial bones (three fracture lines) from their cranial attachments creating the most complex of all facial fractures. Fracture passes through the nasofrontal suture, the junction of the ethmoid and frontal bone, the superior orbital fissure, lateral wall of the orbit, zygomaticofrontal and temporal suture, with a high fracture of the ptergoid plate producing a dish face deformity that is difficult to correct secondarily.
(T/F) Bilateral injuries should be coded separately except where specifically noted in the dictionary. - ✔✔T
Eye Avulsion - ✔✔Traumatic enucleation of the eye
(T/F) Alveolar ridge fracture, including injury to teeth, is coded as a single injury. - ✔✔T
(T/F) Bilateral fractures to the maxilla or mandible are coded as single injuries with location assigned to the fracture located in the largest mass area of the bone. - ✔✔T
(T/F) Nose fractures that accompany a LeFort I fracture should not be coded as a separate injury. - ✔✔F
(T/F) Nose fractures that accompany Lefort II and II fractures are, by definition, included in the LeFort fracture and therefore are not coded separately. - ✔✔T
(T/F) Facial fractures must be significantly displaced to be coded as "displaced". - ✔✔T
(T/F) Minimal displacement facial fractures should be coded as displaced fracture. - ✔✔F
Panfacial Fracture - ✔✔Multiple and complex fractures that may involve the middle and lower face, upper and middle face or all these locations but are not LeFort fractures.
(T/F) You do not have to have a fracture line running through eh ptergoid plates to have a LeFort fractures. - ✔✔F
(T/F) The trachea and esophagus below the sternal notch are considered part of the AIS Chest region. - ✔✔T
Open Chest Wound - ✔✔Also defined as a "sucking" chest wound.
Parietal Pleura - ✔✔A slick membrane that lines the chest cavity.
Viceral Pleura - ✔✔The portion of parietal pleura that envelops the viscera.
Intrapleural Space - ✔✔The space between the parietal and visceral pleura.
Pneumothorax - ✔✔When the intrapleural spaces fills partly or completely with air.
Hemothorax - ✔✔When the intrapleural spaces fills partly or completely with blood.
Hemopneumothorax - ✔✔When the intrapleural spaces fills partly or completely with air and blood.
(T/F) If a flail chest is documented on one side and fractured ribs are documented on the other side you should code two separate injuries. - ✔✔T
Flail Chest - ✔✔Three or more adjacent ribs each fractured in two or more places.
(T/F) Costal cartilage fracture or tear should be coded as rib fracture. - ✔✔T
(T/F) Branches of vessels are not coded unless they are named vessels or are listed within a specific vessel descriptor. - ✔✔T
(T/F) Aorta or Vena Cava injuries only occur in the Chest region. - ✔✔F
(T/F) Aorta or Vena Cava injuries occur in either the Chest or Abdomen regions. - ✔✔T
Incomplete Circumferential Involvement - ✔✔A vessel that is documented as "incomplete transection".
(T/F) If a vessel injury is described as "incomplete transection", it is coded as incomplete circumferential involvement. - ✔✔T
(T/F) Esophagus should be coded to the Abdomen region. - ✔✔F
Avulsion, Complex, Rupture, Tissue Loss & Deep - ✔✔Synonyms for massive organ laceration.
No Preforation - ✔✔Defined as partial thickness laceration, such as a serosal tear.
Perforation - ✔✔Defined as full thickness laceration, but not complete transection.
Transection - ✔✔Defined as complete separation of tow parts of a structure.
(T/F) Organ injury scale (OIS) grades are included for many abdominal organ and vessel injuries, but grades should not be used as a substitute for clinical descriptions of injuries. - ✔✔T
(T/F) If retroperitoneal hemorrhage or hematoma occurs in combination with other thoracic or abdominal injury, code it separately only if it can be determined that it is unrelated to the other injury. - ✔✔T
Pancreas, Duodenum, Kidney, Aorta, Vena Cava, Mesenteric Vessel or Pelvic & Vertebral fractures - ✔✔Organs or structures that, when injured, may cause retroperitoneal hemorrhage.
(T/F) Vessel injuries are coded as separate injuries if: (1) they are isolated injuries or (2) if they are not included in an organ injury description. - ✔✔T
(T/F) If an injury occurs at the junction of the duodenum and jejunum, code to the jejunum. - ✔✔T
(T/F) Bilateral organ (e.g., kidney) injuries are not coded separately. - ✔✔F
(T/F) The term "rupture" is used for kidney, liver or spleen injury ONLY when more detailed information is not available. - ✔✔T
(T/F) The terms "minor", "major", or "massive" are accepted as severity descriptions ONLY when they are the only terms available in the medical record to describe the injury. - ✔✔T
(T/F) Positive peritoneal lavage is not codeable information, the bleeding must be linked to a specific injury. - ✔✔T
(T/F) If an organ sustains both a contusion and laceration, assign each injury the appropriate AIS code if they are unrleated. - ✔✔T
(T/F) If an organ laceration has an accompanying contusion or hematoma, code only the laceration. - ✔✔T
(T/F) Fetal demise as a result of abdominal injury to a pregnant female is a consequence and therefore not coded. - ✔✔T
(T/F) Abdominal compartment syndrome is a consequence of trauma and there is not coded. - ✔✔T
(T/F) Duct involvement applies to gallbladder, liver and pancreas. - ✔✔T
(T/F) The severity of the pelvic ring fracture is not related to the extent of damage to the posterior arch and any resulting instability. - ✔✔F
Anterior Column and Posterior Column - ✔✔The two columns of the acetabulum.
Anterior Acetabulum Column - ✔✔Extends from the anterior half of the iliac crest to the pubis.
Posterior Acetabulum Column - ✔✔Extends from the greater sciatic notch to the ischium.
Partial Articular Acetabulum Fracture - ✔✔A fracture of the acetabulum that may be one of two types; a fracture involving only one column, or a fracture with a transverse component but with a part of the articular surface remaining attached to the ilium.
Complete Articular Acetabulum Fracture - ✔✔A fracture of the acetabulum that is one in which both columns are disrupted form each other and the attachment between the articular surface and the posterior ilium no longer exists.
Eponyms - ✔✔Provided in italics, where appropriate, to describe certain lower extremity joint and bone injuries.
(T/F) Bilateral proximal amputations are assigned only one code. - ✔✔T
Partially Unstable Pelvic Fracture - ✔✔Sacroiliac joint with anterior disruption
Partially Unstable Pelvic Fracture - ✔✔Lateral compression fracture
Partially Unstable Pelvic Fracture - ✔✔"Open book" fracture <2.5 cm
Partially Unstable Pelvic Fracture - ✔✔,Wide symphysis pubis separation greater than or equal to 2.5 cm
Partially Unstable Pelvic Fracture - ✔✔Anterior compression fracture of sacrum
Partially Unstable Pelvic Fracture - ✔✔Fracture involving posterior arch with posterior ligamentous integrity partially maintained.
Partially Unstable Pelvic Fracture - ✔✔Fracture involving posterior arch, but pelvic floor intact
Partially Unstable Pelvic Fracture - ✔✔Bilateral fractures with posterior ligamentous integrity partially maintained
Stable Pelvic Fracture - ✔✔Isolated simple fracture of Pubis Ramus
Stable Pelvic Fracture - ✔✔Isolated simple fracture of Ilium
Stable Pelvic Fracture - ✔✔Isolated simple fracture of Ischium
Stable Pelvic Fracture - ✔✔Transverse fracture of sacrum and coccyx with or without sacrococcygeal dislocation
Stable Pelvic Fracture - ✔✔Minor symphysis pubis separation < 2.5cm
Totally Unstable Pelvic Fracture - ✔✔Sacroiliac joint with posterior disruption
Totally Unstable Pelvic Fracture - ✔✔Vertical shear fracture
Totally Unstable Pelvic Fracture - ✔✔Pubic ramus fracture with sacroiliac fracture/dislocation
Totally Unstable Pelvic Fracture - ✔✔Fracture involving posterior arch with complete loss of posterior osteoligamentous integrity
