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Introduction
Once you have collected and reconciled the ED records, the
next step is to extract and code the relevant surveillance data.
There are 16 NEISS data variables. They are:
- Treatment Date
- Case Number
- Age/Birthdate
- Sex
- Diagnosis
- Body Part Affected
- Disposition of Case
- First Product Mentioned
|
- Second Product Mentioned
- Intent
- Location of Incident
- Fire Involvement
- Whether Work-Related
- Race and Ethnicity
- Race Other and/or Ethnicity
- Comments
|
Each data variable has a set of associated codes used to
describe the specific circumstances of an ED case. Data variables
also have associated coding rules to help you select the
proper codes for each case.
Lesson Topics
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Introduction
- The Coding Sheet
The NEISS coding sheet gives you a convenient way to code
surveillance data for each ED case prior to entering it into
the NEISS computer. The coding sheet organizes and presents the
surveillance data variables in the order in which they are entered
into the NEISS computer. The coding sheet has space enough to
code several cases.
Lesson Topics
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Coding
Treatment Date
Code the date on which the patient was seen for treatment.
Treatment date is coded in the format MM/DD/YYYY with a zero
added to days and months that are one digit numbers.
For example:
Date of Treatment |
|
Code |
July 17, 2000
November 3, 2001
December 20, 2000
March 12, 2005
|
|
07/17/2000
11/03/2001
12/20/2000
03/12/2005 |
Lesson Topics
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Coding
Case Number
Each case treated on a specific date must have a unique
number of up to 8 digits.
- If your hospital uses more than eight digits for
its case numbers, code only the last eight digits.
- Do not code any letters of the alphabet
which may appear in your hospital's case number. Instead, substitute zeros
for any letters.
For example:
ED Case # |
NEISS Case # |
Reason |
9553432166
123 ED 456
12345
|
53432166
12300456
12345
|
Last eight digits only.
Replace letters with zero.
Less than 8 digits is acceptable. |
Lesson Topics
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Coding Age
PC-NEISS will automatically calculate and insert the age
of a patient if you enter the date of birth. If the date of birth
is not available, the age of the patient must be entered.
- For a patient two years of age or older, record age in
years.
Example:
|
45 years old
7 years old
Not recorded
|
= 45
= 7
= 0 |
- For a patient under two years of age, code the age in
months and put a “2” in the first block of the age field.
Example:
|
12 months old
22 months old
1 month old
|
= 212
= 222
= 201 |
Lesson Topics
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Coding Gender
Indicate the gender of the patient with one of the codes
listed below:
Code |
Gender |
1
2
0 |
Male
Female
Not recorded |
Lesson Topics
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Coding Diagnosis
The two (2) digit diagnosis codes are listed in Appendix B and
D of the NEISS Coding Manual
located in the course Tool Kit. For coding purposes, always use
the most specific diagnosis/diagnostic information provided by medical
personnel. If specific information is not available, review the
patient’s complaint and the treatment given to arrive at the most
logical diagnosis.
Other considerations for coding diagnosis are:
- When more than one diagnosis appears on
the emergency department record, code the one that seems to
be the most severe and note the other diagnoses in the “Comment” field.
- If diagnosis code 71 (Other/Not
stated) is entered, the cursor automatically tabs to the “Diagnosis
Other” text field. You are required to enter a text string
in this field to describe the “other” diagnosis.
- If diagnosis states R/O (Rule out), code this as the diagnosis
only if there is no other specific diagnosis to code.
- If there is a poisoning or chemical
burn to a child under 5 years old from a product
which is not listed in the coding manual, or if the product
code is underlined, use code 5555.
Lesson Topics
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Coding Diagnosis
- Burns
There are several types of burns and associated codes. If
the attending physician's diagnosis is inadequate, one can sometimes
deduce the type of burn from the kind of incident and product(s)
involved.
Code |
Burn |
Description |
46
47
48
49
51
73 |
Electrical
Not Specified
Scald
Chemical
Thermal*
Radiation
|
contact with electrical current
all other burns
contact with liquid or steam
contact with caustics, acids, or alkalies
contact with flames or hot surfaces
cell damage by ultraviolet, x-ray, microwave, laser, etc. |
* For thermal burns, indicate in the “Comment” field
if the burn came from flame or hot surface.
Lesson Topics
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Coding Diagnosis
- Poisoning
Code 68 (Poisoning) should be used when
a patient:
When diagnosis code 68 (Poisoning) is used, always
use body part code 85 (All parts of body).
Lesson Topics
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Coding Diagnosis
- Anoxia
Code 65 (Anoxia) should be used when
the patient cannot obtain sufficient oxygen, either due to hampered
breathing or lack of oxygen itself.
Code anoxia when:
- The diagnosis is strangulation, suffocation
or asphyxia.
- The patient has inhaled products of combustion,
such as carbon monoxide (CO), smoke, soot, etc. (e.g., from
a house fire, heating appliance, or camping equipment).
When you use diagnosis code 65 (Anoxia), you should
also used the body part code 85 (All parts of body).
Lesson Topics
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Coding Diagnosis
- Ingested Foreign Object
Code 41 (Ingested foreign object) must
only be used when both of the following conditions
are met:
- The patient has swallowed an insoluble,
solid object; i.e., an item that will not dissolve in liquid.
- The swallowed object is not likely to cause
poisoning.
When you use diagnosis code 41 (Ingested foreign
object), you should also use the body part code 00 (Internal).
Some commonly swallowed objects are coins, toy parts, buttons,
nails, crayons. The foreign object may or may not have lodged
somewhere inside the body.
Lesson Topics
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Coding Diagnosis
- Aspirated Foreign Objects
Code 42 (Aspirated foreign object) should
be used when an object causes choking or is caught in the nose,
lungs, or airway in between the nose and the lungs, and
should generally be one that does not lead to
poisoning or anoxia (inability to obtain oxygen). Examples
of such objects are thumbtacks, beads, miniature light bulbs,
and even pills.
If the victim chokes while being fed liquids and the hospital
record describes the event as an aspiration, then the aspiration
code may be used.
When you use diagnosis code 42 (Aspirated foreign
object), you should also use body part code 00 (Internal).
Lesson Topics
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Coding Diagnosis
- Other / Not Stated
Code 71 (Other/not stated) is used if
none of the listed diagnoses in the NEISS
Coding Manual are appropriate. Whenever you use diagnosis code
71 (Other/not stated), the PC-NEISS software requires that the
actual diagnosis, if stated in the ED record, be noted in the “Diagnosis
Other” text field. If the diagnosis is not stated, enter “unknown”
in the “Diagnosis Other” text field.
Lesson Topics
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Coding Body
Parts
The two (2) digit body part code is used to locate an injury
on the patient’s body. See the NEISS
Coding Manual, Appendix C in the course Tool Kit for a list
of the body part codes. The body part diagram in Appendix D will
also help you visualize more clearly the boundaries between body
parts.
In general, if an injury affects more than one body part,
code the body part that seems to be most seriously hurt.
Then, mention other affected body parts in the “Comment” text
field.
Occassionally, a report will say "Lacerations to the right side,"
where many body parts are involved but none is specifically mentioned.
In such a case, you may use body part code 84 (25-50% of body)
or body part code 85 (All parts of body); i.e., more than 50% of
the body.
Use body part code 84 (25%-50% of body) when a burn
injury scenario specifically states that 25-50% of the body was
burned, or when the record states that multiple body parts are
involved but does not identify any specific body part.
Lesson Topics
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Coding Body
Parts - Special Injuries
Back Injuries
For a diagnosed back injury, determine if the upper trunk, lower
trunk, or cervical vertebrae was/were involved:
- Use the waist or navel as the dividing
line to differentiate between upper and lower trunk.
- Use code 31 (Upper trunk/Thoracic
vertebrae) for upper back involvement.
- Use code 79 (Lower trunk/Lumbar
vertebrae) for lower back involvement.
- Use code 89 (Neck) for cervical
vertebrae involvement.
Burn Injuries
- If only one body part was injured, code
that body part. If more than one body part was injured, generally
code the body part with the most severe injury.
- For burns involving up to 25% of the body,
code the most severely burned body part.
- For burns covering 25% to 50% of the body,
use code 84.
- For burns covering more than 50% of the
body surface, use code 85.
Eye Injuries
- For injuries to eyelids, eyebrows, or the
area immediately around the eyes, use code 76 (Face).
- For an injury to the eye itself, use code
77 (Eyeball).
Head Injuries
- When coding head injuries, code the most
specific diagnosis given.
- Code 62 (Internal organ) when there
is no specific diagnosis for a head injury.
- Coding the most specific diagnosis should
not take precedence over coding the most severe injury. For
example, for internal head injuries such as subdural hematoma,
hemorrhaging, etc., use code 62 (Internal organ).
- Code 58 (Hematoma) if the diagnosis
only states “hematoma to the head.”
- When there are two injuries even
to the head, code the most severe.
Lesson Topics
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Coding Disposition
Use the codes listed below to indicate the disposition of
a case:
Code |
Disposition |
1
|
Treated and released, or examined and released without
treatment. |
2
|
Treated and transferred to another hospital. |
4
|
Treated and admitted for hospitalization (within the
same facility). |
5
|
Held for observation. |
6
|
Left without being seen. |
8
|
Fatality, including DOA, died in the ED. |
9
|
Not recorded. |
Lesson Topics
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Coding Products
There are two coding fields for products, “First Product”
and “Second Product.” Use these fields to code the consumer product(s)
associated with an illness or injury. All product codes are listed
alphabetically in the NEISS
Coding Manual in the course Tool Kit.
Here are some general guidelines to follow when coding products:
- When only one product is associated with an injury, enter
the code for that product in the “First Product” field and
fill in the “Second Product” field with four zeros (0000).
- Whenever possible, report specific products
rather than general types of products. For example, code hand saw
and gas oven vs. saw and oven.
- Use the “other” product codes, as in “Other
baby carriers,” only when the ED record identifies a specific
product but there is no code given for that particular product.
Consult the NEISS
Coding Manual for a detailed discussion of product coding.
Lesson Topics
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Coding Products
- Two Product Injuries
When two products are associated with an injury, either
product may be coded as the first product and the other as the
second product.
Example: An 11-year old boy riding a bicycle ran
into a swing
Product 1 = code 5040 (Bicycle) and Product 2 = code
3246 (Swings) or
Product 1 = code 3246 (Swings) and Product 2 = code
5040 (Bicycle)
Exception:
When two products involved in an incident are the same product,
do not code a second product; simply fill in the “Second Product” field
with zeros. For example, if two skateboard riders collide, code
1333 (Skateboard) for “First Product” and code 0000 for “Second
Product.”
Lesson Topics
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Coding Products
- Code 7878
Code 7878 is used if a product is unknown, not
mentioned, is not a consumer product; e.g.., sidewalk
or driveway, or you cannot find an appropriate code. Code
7878 may only be used as a firstproduct code
and is always followed by code 0000 in the second
product position.
Do not use code 7878 if a case also mentions
a second product that is a codeable product. Code only the
codeable product.
Lesson Topics
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Coding Products
- Code 9999
Code 9999 is used if:
- You believe a case involves a consumer
product, but you cannot determine an appropriate product code.
- You have a coding question about any case
and are not able to discuss the case with your NEISS representative.
Headquarters staff will review these cases and determine
whether a current NEISS product code can be used, or if a new
product code should be added to the coding manual. In either
case, your NEISS representative will contact you after reviewing
the case.
Lesson Topics
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Coding Products
- Special Incidents
Flammable Fabric
If a burn or smoke inhalation injury results directly from
a flammable fabric, use the product codes for the source of
the fire (e.g.., stove, portable room heater, camping lantern,
etc.) and the first item to ignite (e.g.., blanket, clothing,
draperies, slipcover, etc.).
In addition, you must enter the appropriate code 1, 2,
or 3 in the “Fire” coding field to indicate that the incident
involved smoke inhalation, unexpected flames or smoke, or unexpected
spread of flames or smoke. (See the section on coding fire.)
House Fire
Code 1866 (General home or room involvement
in fire) is used as the “First Product” code in the case of a
house fire and/or smoke inhalation where no specific product
is identified. For example; use code 1866 when the
emergency department record describes the incident as "house
fire" or "fire in the basement" and no other information
is available.
- If a specific consumer product is identified,
code only the specific consumer product.
- If a fire involves an out of scope product
(denoted by an underlined product code in the coding manual)
or a drug/medication, use both code 1866 and the out
of scope product code.
Also, whenever code 1866 is used:
- State the particular room involved, if
known, in the “Comment” text field.
- Enter the appropriate code 1, 2, or 3 in
the “Fire” coding field to indicate that the incident
involved smoke inhalation, unexpected flames or smoke,
or unexpected spread of flames or smoke. (See the section
on coding fire.)
Product Fire
- Code the specific product(s) involved in
a product fire. A product fire can be extensive; e.g., fire/flames
or limited; e.g., with smoldering/smoke.
- Enter appropriate code 1, 2 or 3 in
the “Fire” coding field to indicate that the incident involved
smoke inhalation, unexpected flames or smoke, or unexpected
spread of flames or smoke. (See the section on coding fire.)
Hot Water
Code 1934 (Hot water) is used for hot
water injuries.
- When an injury involves hot water, code
the source of the water (e.g.. tea kettle, sink, bathtub, etc.)
as one product and use code 1934 (Hot water) as the
other product code.
- If the source of the hot water is unknown,
use code 1934 (Hot water) as the product.
Lesson Topics
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Coding Intent
Use the codes in the table below to indicate whether an
injury resulted from a confirmed or suspected intentional act. An
intentional injury or poisoning is one that is inflicted with
the aim of injuring or killing. The injury may be
either one that was inflicted by one person on another or one
that was self-inflicted.
Code |
|
Description |
1 |
|
Assault/intentional injury inflicted by
one person on another person. |
2 |
|
Self-inflicted injury (confirmed or suspected). |
3 |
|
Injury related to legal intervention due
to law enforcement activities. |
0 |
|
Unintentional (accidental) injury or
intent not known or recorded.
|
Lesson Topics
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Coding Intent
- Assault / Intentional Injury
Code 1 (Assault/Intentional injury)
includes all confirmed or suspected cases of injuries
and poisonings inflicted by one person on another person regardless of:
- The age of the victim.
- Involvement of a product.
- Occurrence on the job.
This rule includes intended and unintended victims of violent acts.
Also included are injuries resulting from civil disorders and
other conflict situations; e.g.., riots, strikes, terrorist
activities, etc.
Lesson Topics
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Coding Intent
- Self Inflicted Injury
Code 2 (Self inflicted injury) includes
suicides and suicide attempts, both confirmed and suspected,
where the medical record indicates that the person was trying
to take their life. It also includes a deliberate violent act
inflicted on oneself with the intent to harm oneself.
Lesson Topics
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Coding Intent
- Legal Intervention
Code 3 (Legal Intervention) includes
injuries or poisonings caused by police or other legal authorities
during law enforcement activities.
Includes:
- Burglar shot by police.
- Demonstrator sprayed with tear gas or pepper
spray by police.
- Suspect injured by police baton while being
arrested.
Excludes:
- Police injured someone, but not in
the line of duty (code 1).
- Police injured spouse or partner during
domestic dispute (code 1).
- Policeman injured by suspect while trying
to make an arrest (code 1).
Lesson Topics
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Coding Intent
- Unintentional (accidental) Unkown Intent
Code 0 (Unintentional/Accidental or
unknown) includes all injuries and poisonings not
inflicted by deliberate means including incidents described as "accidents" regardless
of who inflicted the injury. Also included are cases where the
emergency department record contains no indication of intent.
Includes:
- 8 year old accidentally shot self with
handgun.
- Painter fell off of ladder and fractured
foot.
- 80 year old experienced adverse reaction
to prescribed drug.
- Driver of motor vehicle rear ended at stop
light.
Lesson Topics
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Coding Locale
Use the codes listed below to indicate where an incident
took place:
Code |
Locale |
1
2
4
5
6
7
8
9
0
|
Home
Farm/Ranch
Street or highway
Other public property (store, office, etc.)
Manufactured (mobile) home
Industrial place
School/Day care
Place of recreation or sports
Not recorded
|
Lesson Topics
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Coding Fire
Use the following codes to show whether the incident involved
smoke inhalation, unexpected flames or smoke, or unexpected
spread of flames or smoke:
Code |
Fire Involvement |
1
|
Fire involved and/or smoke inhalation fire
department attended. |
2
|
Fire involved and/or smoke inhalation fire
department did not attend. |
3
|
Fire involved and/or smoke inhalation fire
department attendance not recorded. |
0
|
No fire or no flames/smoke spread.
|
Lesson Topics
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Coding Occupational
(Work Related) Injury
Use the following codes to indicate that an injury or illness
occurred while the victim was involved in a work-related activity:
Code |
Work-Related |
1
|
Work-related; occurred on the job (excluding
active military duty). |
2
|
Not work-related; did not occur
on the job. |
3
|
Work-related; active military duty. |
0
|
Not recorded.
|
Lesson Topics
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Race
Use the following codes to indicate the patient’s race as
it is indicated in the ED record. Use “Other” for the race if
it is not white or black.
Code
|
Work-Related |
1
2
3
0
|
White
Black
Other
Not stated in ED record
|
Lesson Topics
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Comment Line
Every case must include descriptive comments or remarks.
Enter these notes on the two lines labeled "Comment" that
immediately follow the coded entries in PC-NEISS. The comments
should include:
- A description of what the victim was doing
when the injury occurred (sequence of events).
- The product(s) involved.
- The locale of the incident.
- Verbatim quotes of the words actually used
in the emergency department record.
- A description of the patient’s complaints
and treatment received if the ED record contains no diagnosis
by medical personnel.
Refer to the ED notes of the physician, nurse, and clerk
for pertinent information.
Lesson Topics
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Comment Line
- Product Description
In the “Comment” text field, please include the brand name
or manufacturer of the product associated with an injury whenever
such information is available. Remarks like "doll made in
Taiwan" or "English bicycle" are helpful in the
absence of any other product identification.
Whenever possible, report specific products rather than general
types of products:
Product
|
Specify |
Stove
Saw
Tableware
|
Gas, electric, wood, etc.
Hand, table, electric, chain, etc.
Plate, tea cup, sugar bowl, etc.
|
In addition:
- Product codes for sports also require identification
of the game involved as well as any equipment or apparel associated
with the injury.
- Whenever code 1866 (General home
or room involvement in fires) is used, the comments should
include the room involved (such as bedroom or kitchen), if
known.
Lesson Topics
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FAQ - Products & Product
Codes
Q: How should we code a T-ball injury?
A: Use the code for baseball (5041).
Q: How do we code child car seat injuries?
A: Report all child car seat injuries. If the
child car seat was involved in a MVA, only code the vehicle (1901).
Q: How should I code injuries involving antifreeze?
A: Report all injuries associated with antifreeze. If the
report mentions a motor vehicle as the source of
the antifreeze, only code the motor vehicle. Otherwise
use code 0966.
Q: How should I code injuries associated with car jacks?
A: Report all injuries associated with car jacks using product
code 0814. If the vehicle is specifically mentioned,
also code 1901.
Q: How should we code injuries associated with child
safety devices such as outlet covers,
cabinet latches and table guards?
A: Use the code for the associated product and mention the child
safety feature by using the word protective in the
narrative .
Q: How do we code injuries associated with store displays or
signs?
A: Report injuries associated with store displays or store
signs using the product code for public use items (1738).
Q: How do we code the product in a case which indicates "victim
fell off standard adult bed"?
A: Use product code 4076 for "Beds or bedframes, other
or not specified". This code covers regular adult beds as
well as beds, not specified.
Q: How should we code cases where the record indicates the
patient was walking or running and
sustained an injury if no other activity or product is mentioned?
A: Report all walking or running injuries. When there is
some indication that the walking or running was an exercise activity,
use product code 3299. Otherwise, use product code 7878.
Q: How should we code cases where the victim was hunting at
the time of the injury?
A: Report hunting injuries using product code 7878.
Q: How should we code combination
products such
as crib/playpens and combination sofa/recliner chair?
A: If the coding manual has no code for the combination
product, code it according to the description of usage at the
time of the injury. For example, “Pt got hand caught in recliner
portion of sofa” should be coded as recliner chair (0670).
Q: How should I code a case where a product mentioned in the
scenario is not present at the time of the incident? For example;
victim
stepped on rusty nail – was not wearing shoes.
A: Do not code non-existent products or activities, but be sure
to mention such products in the narrative.
Q: How should we code logs (for example, jogging down a path and
tripping over a log, or burned throwing a log onto a bonfire)?
A: Wooden logs should be coded as 7878. They are not considered
fireplace equipment. Non-wood logs that are sold specifically to
be burned in a fireplace should be coded as fireplace equipment
(0663). Q: How should we code
cases where the diagnosis states “substance
abuse”?
A: In cases where only “substance abuse” is stated,
use product code 1929 for drugs or medications not specified. If
substance abuse is mentioned and the record specifically states
either drug use or alcohol involvement, then the drugs or the alcohol
should be coded (1929 or 1903). Do not use both codes unless both
alcohol and drugs are specifically mentioned.
Q: How should we code poles?
A: In general, code poles as 1865. When scenario involves an
MVA, or if the locale is street or highway (4), assume the pole
mentioned
is a telephone pole or light pole and use 7878 or do not code
if another product is mentioned. These types of poles are excluded
from product code 1865. Q:
When and how do we report injuries associated with "cement"?
A: Code all injuries associated with cement. Code cement as household
structures (1876) if it is being used as a construction material.
A finished structure made of cement should be coded with a specific
product code (walls) or if there is no specific product code (such
as sidewalks), use 7878.
Q: When should the code for construction materials be used to code
items such as pieces of tin,wood, brick or cement?
A: In general, such items are reportable using product code 7878.
Use the construction materials code only when there is indication
that the material is being used or is planned to be used in a
construction project Q: When should we use the various codes for two-wheeled
vehicles (bicycles)?
A: If the vehicle has no motor, use the code for bicycles (5040)
unless the record specifically states mountain bike (all terrain
bike), and then use the mountain bike code (5033).
A: If the vehicle has a motor, use one of the following codes:
1) if the vehicle is described as a dirt bike or trail bike,
use the dirt bike code (5036). 2) if the rider pedals and uses
the
motor only for assistance, use the moped code (3215). 3) if the
vehicle is described as a minibike or pocket bike, use the minibike
code (5035).
Q. When should I use product code 2200 for industrial
equipment?
A: Product code 2200 should only be used to cover products
used in work environments for which there is no other appropriate
product code in the manual.
Q: When should the product code for wrestling be
used?
A: The code should be used for injuries associated with
participating in or practicing for the sport of
wrestling. The code should not be used for situations where the
word wrestling is used to describe playing or fighting.
Specifically, use the code when there is any indication of the
formal sport. Do not use the code when the locale is home and
there is no indication that the victim was practicing the sport.
Q: When should we code signs? A: If a sign is mentioned in the comment and the locale
is street or highway (4), or the scenario involves an MVA, then
assume the sign is a traffic sign and do not code. If the sign
is specified as being anything other than a traffic sign, use
product code 1738 public use items.
Q: What product code should be used for grass?
A: When coding grass (e.g.., patient slipped on grass), use
product code 7878.
Q: How should we code a new consumer product that does
not have a product code in the manual?
A: If you believe a case involves a consumer
product, but you cannot determine an appropriate product code, you
may use code 9999 temporarily. NEISS Headquarters staff will review
these cases and determine whether a current NEISS product code can
be used, or a new product code should be added to the Manual. In
either case, your NEISS representative will contact you after reviewing
the case.
Q: How should we code the component part
of a product? For example, how should I code a car window or a car
door?
A: Do not code a component part separately.
Use the code for the entire product. In the example, a car window
or car door would be coded as the car (1901).
Q: Should we code batteries when
they are mentioned as a part of another product (e.g.., hot
batteries
in a flashlight or a battery in an automobile)?
A: Batteries are an exception to the component part rule,
and should be coded separately from the product. For the examples
above, both the flashlight (0639) and the batteries (0884) should
be coded, and both the automobile (1901) and the battery (0884)
should be coded.
Q: How should safety playground surfacing be coded?
A: If the victim falls from an item of playground equipment
to a safety surface below (e.g. mulch, manufactured mats, pea gravel,
etc.), code the item of playground equipment and mention the type
of surfacing in the comment line. If no equipment is mentioned,
do not code the surfacing.
Lesson Topics
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FAQ - Coding
Diagnosis and/or Body Parts
Q: When should I use the codes for poisoning,
aspiration, ingestion,
foreign body and anoxia?
A: Use poisoning (68) for ingestion
of a soluble substance and inhalation of vapors,
gases or fumes, except carbon monoxide and
smoke from fires. A: Use aspiration (42) when a
substance is caught in the nose, throat or
lungs (e.g. choked on a dime). Also
use aspiration when the patient choked on a liquid and the record
indicates the victim aspirated. A: Use ingestion (41) when
above diagnoses do not apply, and the victim has swallowed a
non-soluble substance (e.g. swallowed a dime). A: Use anoxia (65) when above
diagnoses do not apply but the victim was unable to obtain sufficient
oxygen either because breathing was hampered (e.g. suffocation,
strangulation) or not enough oxygen was available
(e.g. carbon monoxide, smoke from fires). A: Use foreign body (56) when above diagnoses do
not apply and object is embedded in victim by force (splinter lodged
in arm).
Q: When should the body part code 84 - (25-50%
of body) be used?
A: In general, code the specific body part (and
injury) associated with the most severe injury. Use body part
code 84 when a burn injury scenario specifically
states that 25-50% of the body was burned, or when the record
states that multiple body parts are involved but does not identify
any specific body part.
Q: When is it appropriate to use the diagnosis “Not
Stated” ?
A: Use the diagnosis code 71 for ‘Other/Not Stated’ when
there is no information on the injury. Use this diagnosis code
for comments such as ‘Left without being seen’ or ‘Normal Exam’.
Q: How should we code diagnosis when the only
information on the ER record is that the patient was suffering
pain, swelling, infection or
other symptoms?
A: When the only injury information
on the ER record is that the patient was suffering pain, swelling,
or other
symptoms, and there is an external cause of injury, code the
diagnosis as “Other/Not Stated” (71), and mention the pain, swelling,
or other symptom in the ‘Diagnosis Other’ narrative field.
Q: What diagnosis code should be used for insect
bites or animal bites dermatitis,
poison, or other?
A: Use the diagnosis code 71 for ‘Other/Not Stated’ unless
a more specific diagnosis is provided in the ED record. Where
dermatitis or poisoning is specified, use the more specific diagnosis
code.
Q: How should we code the diagnosis for excessive alcohol
consumption?
A: Emergency room visits related to excessive alcohol consumption
should be coded using diagnosis 68 for ‘Poisoning’.
Q: What diagnosis code should be used for drug
reactions?
A: Emergency room visits related to drug reactions should
be coded as 68 for ‘Poisoning’ if the drugs were ingested, and
71 for ‘Other/Not Stated’ if it is not clear that the drugs were
ingested. Code legal and illegal drugs with the same rule.
Q: How should we code a diagnosis of hematuria or ‘blood
in the urine’?
A: If the record shows a diagnosis of hematuria, the diagnosis
and body part should be coded as 62 ‘internal organ injury’ and
79 ‘lower trunk’.
Q: How should a diagnosis of carpal tunnel syndrome be
coded?
A: Code all cases of carpal tunnel syndrome as 61 ‘nerve
damage’.
Q: How should we code the body part when the comment
states “multiple
contusions or abrasions”?
A: Code the body part for multiple contusions or
abrasions as 87 not stated unless more specific body parts
are mentioned in the hospital record.
Q: How should we code head injuries?
A: When coding head injuries, code the most
specific diagnosis given. When there is no specific diagnosis
for a head injury, it should be coded as an internal organ injury
(62). Coding the most specific diagnosis should not take precedence
over coding the most severe injury. For example, “internal” head
injuries such as subdural hematoma, hemorrhaging, etc. should
also be coded as internal organ injury (62). If the diagnosis
only states ‘hematoma to the head’, then the diagnosis should
be coded as hematoma (58). When there are two injuries even to
the head, code the most severe.
Q: How do we code the diagnosis of “foreign
body sensation”?
A: If the foreign body sensation is from ingesting
a substance, use the diagnosis code for aspiration (42). If the
foreign body sensation is mentioned (such as may occur with conjunctivitis),
with no external cause or event, the case is considered out of
scope.
Q: How should we code the body part and diagnosis
for diaper rash?
A: Code diaper rash as diagnosis 74 - dermatitis and
body part as 79 lower trunk.
Q: What diagnosis code should be used for rashes
that are described as "hives" or "urticaria"?
A: If a rash is described in the ER record as hives or urticaria,
use the diagnosis code 71 for "Other/Not Stated", and
mention the hives or urticaria in the "Diagnosis Other"
narrative field.
Q: How should we code a diagnosis when the record states
that a specific diagnosis is "possible" or is being "ruled
out"?
A: When the record states that a diagnosis is "possible"
or it is being "ruled out", code the possible diagnosis
only if there is no other specific diagnosis to code.
Lesson Topics
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FAQ - Coding
Intent
Q: When should we report an intentional injury?
A: Report all confirmed or suspected cases of injuries and
poisonings inflicted by one person on another person. This includes
intended and unintended victims of violent acts, including self-inflicted
injuries.
Q: Should we report an injury to a bystander in
an assault scenario?
A: Yes, report all injuries to a bystander resulting from
assaults or suicide attempts. These cases would be coded as intentional
(1).
Q: How do we code intent when the patient hit
a wall or other object in anger?
A: When a patient is injured punching 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).
Q: How do we code intent when a
police officer is injured while making an arrest?
A: When a police officer is injured while making
an arrest, it should be coded as an intentional assault (1).
Q: When do we code intent as legal intervention (3)?
A: Use the legal intervention code only when an injury or
poisoning was caused by police or other legal authorities during
law enforcement activities.
Q: How do we code intent for dog bites?
A: In general, report dog bites as unintentional
(0). If the dog was ordered by another person, code it as intentional
(1). If the dog was working as a police or security dog, code
it as legal intervention (3).
Lesson Topics
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FAQ - Other
Questions
Q: When is it appropriate to use the "home" locale? A: Use the home locale when the record contains information
that the injury occurred at a home. Code "home" when
the record contains phrases such as "in backyard", "at
sister's apartment", or "in his garage".
Q: When the record states “left without
being seen” or “eloped”, what disposition code should
be used? A: Use disposition code 6 ‘left without being seen’ when
the record states that the patient left against medical advice
or left without being seen.
Q: How do we
code cases that state “rabies exposure”?
A:
Rabies is considered an infectious illness caused by a virus, and
is not considered in-scope unless the
external cause is a consumer product/activity or the incident
is work-related. Code a dog bite if the injury is
the reason for the visit, and the injury is treated it doesn’t
matter whether the victim received rabies treatment. Do not code
the dog bite if fear of rabies is the reason for the visit. It
doesn’t matter whether rabies is treated.
Lesson Topics
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- End of Coding Section -
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