2004 NEISS Coding Manual Updates All Trauma Manual

2004 NEISS Coding Manual Updates All Trauma Manual

New Coding Manual effective July 1 st, 2004

Deleted Codes (as of 6/30/04) n 0202 Electric counter-mounted cooking surfaces 0204 Gas counter-mounted cooking surfaces 0257 Counter-mounted cooking surfaces, not specified 0259 Electric ranges (with ovens) 0260 Gas ranges (with ovens) 0261 Electric ovens (excl. counter-top ovens) 0262 Gas ovens 0265 Other ovens (excl. counter-top ovens, broilers and toaster ovens) 0266 Ovens, not specified 0267 Other ranges (with ovens) 0273 Ranges, not specified n 0684 Unattached appliance or lamp cords n n n n n

New Codes (as of 7/1/04) n 0278 0279 0280 0281 Electric ranges or ovens (excl. counter-top ovens) Gas ranges or ovens Other ranges or ovens Ranges or ovens, not specified n 4081 Cords, electrical, other or not specified n 1895 Tree stands (hunting) n 1939 Illegal drugs (incl. cocaine, crack, heroin, marijuana, PCP, and hallucinogens) n n n

Product Code Title Changes n n n 1402 Manual push mowers (unpowered) 1884 Ceilings and walls (interior part of completed structure) 3248 Gas or LP grills or stoves (for outdoor use)

Other Coding Manual Changes Fire Involvement Use codes 1, 2, or 3 to show whether the incident involved: smoke inhalation n unexpected flames or smoke, or n unexpected spread of flames or smoke. n

Changes in Coding Diagnosis n n n n Carpal Tunnel Syndrome Internal Derangement of Knee Internal Derangement (other than knee) choose among: Muscle Spasm Epistaxis Rupture Whiplash Code 61 Nerve Damage 55 Dislocation or 64 Strain/sprain 71 Other 66 Hemorrhage 64 Strain/sprain

Errors for 2003 n n n n n 27% 20% 16% 7% 6% 5% 2% 1% 1% 15% Product Codes Body Parts Diagnosis Intent Locale Gender Work Age Fire Other ( Race, Disp. , Occ)

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . DISP. . 051 MALE OTHER LTRUNK TR/REL PRODUCT: PRODUCT 2: 7878 0000 INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N NO PRODUCT/PRODUCT NOT LISTED RACE: WHITE RACEOTH: SLIPPED ON WET KITCHEN FLOOR & FELL. INJURED RT HIP/ELBOW/ SHOULDER. NUMBNESS IN ARM & HIP.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . DISP. . 051 MALE OTHER LTRUNK TR/REL PRODUCT: PRODUCT 2: 1807 0000 INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N FLOORS OR FLOORING MATERIALS RACE: WHITE RACEOTH: SLIPPED ON WET KITCHEN FLOOR & FELL. INJURED RT HIP/ELBOW/ SHOULDER. NUMBNESS IN ARM & HIP. Product code 7878 should not be used when a codeable product is mentioned. In this example, use product code 1807 for coding the floor.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 024 MALE ST/SP L TRUNK TR/REL PRODUCT: PRODUCT 2: 1901 1865 INTENT. . LOC. . FMV. . . OCC. . UNINT/? STREET NO/? N MOTOR VEHICLES (4+ WHEELS) POLES RACE: WHITE RACEOTH: IN MVA. HIT A POLE. DRIVER, +SB. HIT HEAD ON STEERING WHEEL. DX: LUMBAR STRAIN/THORACIC STRAIN/MULT CONTUSIONS.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 024 MALE ST/SP L TRUNK TR/REL PRODUCT: PRODUCT 2: 1901 0000 INTENT. . LOC. . FMV. . . OCC. . UNINT/? STREET NO/? N MOTOR VEHICLES (4+ WHEELS) RACE: WHITE RACEOTH: IN MVA. HIT A POLE. DRIVER, +SB. HIT HEAD ON STEERING WHEEL. DX: LUMBAR STRAIN/THORACIC STRAIN/MULT CONTUSIONS. When a scenario involves an MVA, or if the locale is street or highway, assume the pole mentioned is a telephone pole or a light pole and do not code. These type of poles are excluded from product code 1865.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 044 FEMALE IOI HEAD TR/REL PRODUCT: PRODUCT 2: 1901 1873 INTENT. . LOC. . FMV. . . OCC. . UNINT/? STREET NO/? N MOTOR VEHICLES (4+ WHEELS) WINDOWS OR WINDOW GLASS, NS RACE: WHITE RACEOTH: ON A BUS, LOST BALANCE, HIT HEAD ON BUS WINDOW. DX: CHI HEAD INJURY.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 044 FEMALE IOI HEAD TR/REL PRODUCT: PRODUCT 2: 1901 0000 INTENT. . LOC. . FMV. . . OCC. . UNINT/? STREET NO/? N MOTOR VEHICLES (4+ WHEELS) RACE: WHITE RACEOTH: ON A BUS, LOST BALANCE, HIT HEAD ON BUS WINDOW. DX: CHI HEAD INJURY. Do not code the component part of a product separately. Use the code for the entire product. For example, a car window or car door should be coded as the car (1901).

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 010 MALE LAC HEAD TR/REL PRODUCT: PRODUCT 2: 1233 0000 TRAMPOLINES INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: JUMPING ON TRAMPOLINE AND HIT FOREHEAD ON METAL FRAMEWORK. DX - LACERATION TO FOREHEAD.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 010 MALE LAC FACE TR/REL PRODUCT: PRODUCT 2: 1233 0000 TRAMPOLINES INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: JUMPING ON TRAMPOLINE AND HIT FOREHEAD ON METAL FRAMEWORK. DX - LACERATION TO FOREHEAD. According to Appendix C of the Coding Manual, forehead should always be coded as 76 - Face.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 026 MALE PUNCT U/TRK TR/REL PRODUCT: PRODUCT 2: 1401 0000 INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N POWER LAWN MOWERS, NS RACE: BLACK RACEOTH: PIECE OF METAL FLEW OUT OF LAWN MOWER AND PUNCTURED UPPER ABDOMEN AT HOME. DX – PW ABDM.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 026 MALE PUNCT L/TRK TR/REL PRODUCT: PRODUCT 2: 1401 0000 INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N POWER LAWN MOWERS, NS RACE: BLACK RACEOTH: PIECE OF METAL FLEW OUT OF LAWN MOWER AND PUNCTURED UPPER ABDOMEN AT HOME. DX – PW ABDM. According to Appendix C of the Coding Manual, abdomen should always be coded as Lower Trunk - 79.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 012 MALE OTHER FINGER TR/REL INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N DXO: NO DX DOCUMENTED PRODUCT: PRODUCT 2: 1893 0000 DOORS, OTHER OR NOT SPECIFIED RACE: WHITE RACEOTH: PT SLICED RIGHT MIDDLE FINGER ON INSIDE OF DOOR – PT FORGOT AND DOOR SLAMMED ON FINGER. D: NO DX DOCUMENTED.

Answer AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . INTENT. . LOC. . FMV. . . OCC. . 012 MALE LACR FINGER TR/REL UNINT/? HOME NO/? N PRODUCT: PRODUCT 2: 1893 0000 DOORS, OTHER OR NOT SPECIFIED RACE: WHITE RACEOTH: PT SLICED RIGHT MIDDLE FINGER ON INSIDE OF DOOR – PT FORGOT AND DOOR SLAMMED ON FINGER. D: NO DX DOCUMENTED. If the record contains no diagnosis by medical personnel, review the patient’s complaint and the treatment given to arrive at the most logical diagnosis.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 040 FEMALE IOI HEAD TR/REL PRODUCT: PRODUCT 2: 7878 0000 NO PRODUCT INTENT. . LOC. . FMV. . . OCC. . LEGAL INT UNK NO/? Y RACE: WHITE RACEOTH: DURING ALTERCATION WRESTLING W/SUSPECT, OFFICER GOT KICKED IN LEFT SIDE OF HEAD. LOC (1 -2 SEC. ) HEADACHE, CLOSED HEAD TRAUMA.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 040 FEMALE IOI HEAD TR/REL PRODUCT: PRODUCT 2: 7878 0000 NO PRODUCT INTENT. . LOC. . FMV. . . OCC. . INT UNK NO/? Y RACE: WHITE RACEOTH: DURING ALTERCATION WRESTLING W/SUSPECT, OFFICER GOT KICKED IN LEFT SIDE OF HEAD. LOC (1 -2 SEC. ) HEADACHE, CLOSED HEAD TRAUMA. When a police officer is injured while making an arrest, it should be coded as an intentional assault - 1.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 039 MALE POIS ALL TR/REL PRODUCT: PRODUCT 2: 1903 0000 ALCOHOL (BEVERAGE) INTENT. . LOC. . FMV. . . OCC. . INT PUB NO/? N RACE: WHITE RACEOTH: DURING ALTERCATION AT BAR, PT WAS PUNCHED IN NOSE. AND ETOH INTOXICATION. FX TO NOSE

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 039 MALE FRACT FACE TR/REL PRODUCT: PRODUCT 2: 1903 0000 ALCOHOL (BEVERAGE) INTENT. . LOC. . FMV. . . OCC. . INT PUB NO/? N RACE: WHITE RACEOTH: DURING ALTERCATION AT BAR, PT WAS PUNCHED IN NOSE. AND ETOH INTOXICATION. FX TO NOSE Code the diagnosis/body part to reflect the reason for the visit to the emergency room.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 015 MALE FRACT HAND TR/REL PRODUCT: PRODUCT 2: 1884 CEILINGS OR WALLS 0000 INTENT. . LOC. . FMV. . . OCC. . INT UNK NO/? N RACE: WHITE RACEOTH: PAIN IN RIGHT HAND THAT STARTED AFTER PUNCHING A WALL. RIGHT 5 TH METACARPAL BONE FX.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 015 MALE FRACT HAND TR/REL PRODUCT: PRODUCT 2: 1884 CEILINGS OR WALLS 0000 INTENT. . LOC. . FMV. . . OCC. . UNINT/? UNK NO/? N RACE: WHITE RACEOTH: PAIN IN RIGHT HAND THAT STARTED AFTER PUNCHING A WALL. RIGHT 5 TH METACARPAL BONE FX. If a patient is injured when they punch an object (excluding another person) in anger, the case should be coded as unintentional (0), except in the case of an assault, when it should be coded as intentional (1).

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 013 FEMALE OTHER WRIST TR/REL PRODUCT: PRODUCT 2: 1272 0000 GYMNASTICS INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: RT WRIST INJURY SUSPECTED TENDON INJURY DOING BACK SOMERSAULT AND LANDED WRONG ON HER WRIST, SWOLLEN.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 013 FEMALE OTHER WRIST TR/REL PRODUCT: PRODUCT 2: 7878 0000 NO PRODUCT INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: RT WRIST INJURY SUSPECTED TENDON INJURY DOING BACK SOMERSAULT AND LANDED WRONG ON HER WRIST, SWOLLEN. Do not code gymnastics activity if described as playing or if the locale is home and there is no indication of practicing the sport.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 010 FEMALE LAC HEAD TR/REL PRODUCT: PRODUCT 2: 4050 4057 PILLOWS TABLES INTENT. . LOC. . FMV. . . OCC. . INT HOME NO/? N RACE: WHITE RACEOTH: PT WAS PLAYING PILLOW FIGHT W/SISTER & WAS HIT WITH A PILLOW. SHE FELL BACK, HITTING HEAD ON A TABLE. DX - LAC HEAD.

Answer AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 010 FEMALE LAC HEAD TR/REL PRODUCT: PRODUCT 2: 4050 4057 PILLOWS TABLES INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: PT WAS PLAYING PILLOW FIGHT W/SISTER & WAS HIT WITH A PILLOW. SHE FELL BACK, HITTING HEAD ON A TABLE. DX - LAC HEAD. If injury appears to have resulted during horseplay, the intent should be coded as unintentional - 0.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 025 MALE CT/ABR FACE TR/REL PRODUCT: PRODUCT 2: 7878 0000 NO PRODUCT INTENT. . LOC. . FMV. . . OCC. . INT UNK NO/? N RACE: WHITE RACEOTH: ALLEGEDLY ASSAULTED BY POLICE. HIT ON BOTH SIDES OF FACE. HEADACHE & BRUISING. MULTIPLE FACIAL CT/AB, BRUISE RT KNEE.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 025 MALE CT/ABR FACE TR/REL PRODUCT: PRODUCT 2: 7878 0000 NO PRODUCT INTENT. . LOC. . FMV. . . OCC. . LEGAL INT UNK NO/? N RACE: WHITE RACEOTH: ALLEGEDLY ASSAULTED BY POLICE. HIT ON BOTH SIDES OF FACE. HEADACHE & BRUISING. MULTIPLE FACIAL CT/AB, BRUISE RT KNEE. When an injury or poisoning was caused by police or other legal authorities during law enforcement activities, code intent as legal intervention - 3.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 028 MALE ST/SP U TRUNK TR/REL PRODUCT: PRODUCT 2: 7878 0000 NO PRODUCT INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: MALE OBTAINED ACUTE THORACIC MUSCLE STRAIN. SHOVELING DIRT TODAY. INJURED UPPER BACK.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 028 MALE ST/SP U TRUNK TR/REL PRODUCT: PRODUCT 2: 1403 0000 INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N OTHER UNPOWERED GARDEN TOOLS RACE: WHITE RACEOTH: MALE OBTAINED ACUTE THORACIC MUSCLE STRAIN. SHOVELING DIRT TODAY. INJURED UPPER BACK. Product code 7878 should not be used when a codeable product is mentioned. In this example, use product code 1403 - Other unpowered garden tools for coding the shovel.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 008 MALE ST/SP PU/REG TR/REL PRODUCT: PRODUCT 2: 7878 0000 NO PRODUCT INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: AC GROIN STRAIN AFTER DOING THE SPLITS. HE HAS MILD GROIN PAINS.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 008 MALE ST/SP L TRUNK TR/REL PRODUCT: PRODUCT 2: 7878 0000 NO PRODUCT INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: AC GROIN STRAIN AFTER DOING THE SPLITS. HE HAS MILD GROIN PAINS. According to Appendix C of the Coding Manual, Groin should be coded as Lower Trunk - 79

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 052 FEMALE ST/SP U TRUNK TR/REL PRODUCT: PRODUCT 2: 1807 0000 FLOORS INTENT. . LOC. . FMV. . . OCC. . UNINT/? UNK NO/? N RACE: BLACK RACEOTH: SLIPPED AND FELL TO FLOOR FROM STANDING POSITION. DX - CERVICAL STRAIN.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 052 FEMALE ST/SP NECK TR/REL PRODUCT: PRODUCT 2: 1807 0000 FLOORS INTENT. . LOC. . FMV. . . OCC. . UNINT/? UNK NO/? N RACE: BLACK RACEOTH: SLIPPED AND FELL TO FLOOR FROM STANDING POSITION. DX - CERVICAL STRAIN. According to Appendix C of the Coding Manual, Cervical should always be coded as 89 - Neck.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 210 MALE FRACT FINGER TR/REL PRODUCT: PRODUCT 2: 4057 0000 TABLES INTENT. . LOC. . FMV. . . OCC. . UNINT/? UNK NO/? N RACE: WHITE RACEOTH: PULLED WROUGHT IRON TABLE ONTO LEFT HAND. DX - CLOSED METACARPAL FRACTURES LEFT HAND.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 210 MALE FRACT HAND TR/REL PRODUCT: PRODUCT 2: 4057 0000 TABLES INTENT. . LOC. . FMV. . . OCC. . UNINT/? UNK NO/? N RACE: WHITE RACEOTH: PULLED WROUGHT IRON TABLE ONTO LEFT HAND. DX - CLOSED METACARPAL FRACTURES LEFT HAND. According to Appendix C of the Coding Manual, Metacarpal should always be coded as hand -82.

What Is Wrong With This Case? AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 061 MALE FRACT TOE TR/REL PRODUCT: PRODUCT 2: 1842 0000 STAIRS OR STEPS INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: PATIENT FELL AT HOME ON BACK STEP. DX - FRACTURE 3 RD METATARSAL.

Answer: AGE. . SEX. . . DIAG. . . BDYPT. . . DISP. . 061 MALE FRACT FOOT TR/REL PRODUCT: PRODUCT 2: 1842 0000 STAIRS OR STEPS INTENT. . LOC. . FMV. . . OCC. . UNINT/? HOME NO/? N RACE: WHITE RACEOTH: PATIENT FELL AT HOME ON BACK STEP. DX - FRACTURE 3 RD METATARSAL. According to Appendix C of the Coding Manual, metatarsal should always be coded as Foot - 83.