CAISS-AIS FAQs coding Exam Latest Actual Exam
And Practice Exam 2026-2027 With Complete
Questions And Correct Detailed Answers| Brand New
Version!
Q: You have the following finding on a patients MRI - "small epidural
hematoma from C7-T1 which is likely emanating from the compression
fracture of T1? " He does not have a C7 fracture. What would you code
especially considering it involves the cervical and thoracic spine? -
ANSWER-A: You should code the epidural at the highest level (C7)
unless you have evidence of deficit at a lower level. You may not
"double dip" and code the epidural again in the T-spine. Again, if there
is no deficit, code 640200.3 for the epidural hematoma and 650430.2
for the compression fracture of T 1. If there would be a deficit with this
injury then you would code the deficit at the level that it occurs.
Q: What is the correct code for epidural hematoma extending to various
levels of the spine, for example T12-L2, or C1-2-3-4 FXs with an epidural
at level C2? - ANSWER-A: A spinal epidural with no deficit is coded at
the most superior level at which it is found. In the case of the first
example T12-L1 it would be coded under the T-spine codes. If the
patient has a deficit it makes a difference in the coding. 640200.3 is
where you would code the C2 epidural, C1 gets the fx code only, C3
through C4 fxs are each coded individually. The problem is that the
descriptor for C - spine fractures reads "Fx with or without dislocation
but no cord involvement. If you follow the rules strictly you should not
1|Page
,code the C2 fx on p 104, but if there is no deficit you can"t code the C2
fx with the epidural code; you would have to pick between transient,
incomplete and complete on that page to get to a fx code. You will lose
one or the other finding (the C2 fx or the epidural).
Q: How and when can I code "concussion"? - ANSWER-A: You may only
code "concussion" (specifically codes 161000.1 and 161001.1) when the
word "concussion" is given by the MD as the only brain injury diagnosis.
Q: How do you code cerebral shear injuries that have loss of
consciousness less than 6 hours? - ANSWER-A: The correct code is
140643.2 found under "Cerebrum: hematoma, intracerebral, tiny -
petechial hemorrhage(s) [includes radiographic "shearing" lesions] not
associated with coma > 6 hours."
Q: What do I code if the patient has LOC and an associated anatomical
head lesion? - ANSWER-A: If the patient has an anatomic injury to the
brain (e.g. SDH, IVH, SAH, etc.) in addition to LOC, the LOC will only be
acknowledged by AIS if there is a coma modifier listed with the injury.
Remember that in AIS 2008 LOC/coma can only be assigned to one
injury [rule page 40] so if you have two injuries with coma modifiers,
use the one that provides the highest AIS value for coma and code the
other as NFS.
2|Page
,Q: A patient arrives to the ED with a severe head injury; he is
transported to the ICU in anticipation of organ donation and while the
brain death evaluation is completed. His final diagnoses include the
expected head injury and brain death. What do you do when coding
this chart regarding the brain death itself? - ANSWER-A: Brain death is a
situation not an injury. The coder would appropriately code the lesions
identified on CT as well as any edema. However, brain death is a
sequelae of those injuries. If the patient had no codeable injuries in the
brain, the only option in that situation would be to evaluate the chart
for a traumatic anoxic event.
Q: What is the correct code for an internal carotid artery occlusion? -
ANSWER-A: This is impossible to answer correctly unless you have more
information. The internal carotid artery can be coded under HEAD
121004.4 if the occlusion occurs in that portion of the artery, or under
NECK 320220.3 if the occlusion occurs lower.
Q: A patient with diffuse axonal injury (DAI), confirmed by both clinical
and radiologic evidence, also has an intraventricular hemorrhage and
subarachnoid hemorrhages. This patient remained unconscious from
the time of the insult until discharge from the ICU 7 days after
admission. How would you code the intraventricular hemorrhage and
subarachnoid hemorrhages in AIS 2005? - ANSWER-A: These injuries
should not be coded. DAI is an example of a global injury which may or
may not be accompanied by other radiologic findings. A clarification for
coding DAI is now included on page 40.
3|Page
, Q: What is the correct code for the diagnosis "Subdural hematoma
7mm thickness"? - ANSWER-A: The correct code is 140652.4. If the
specific region of the brain (brain stem, cerebellum or cerebrum) is not
indicated, the injury should be assigned to the cerebrum.
Q: A patient sustains a basilar skull fracture, fractured L zygoma and a
nasal fracture. She has bilateral periorbital ecchymosis. There is no
mention in the chart of cerebral spinal fluid (CSF) leak. How would you
code the basilar skull fracture? - ANSWER-A: The correct code is
150202.3. If the patient has a CSF leak, the treating physician(s) will
always mention it in the chart. When there is no mention of CSF leak,
the coder may use the "without CSF leak" code. The periorbital
ecchymosis could be due to the nasal fracture and is not necessarily a
sign of bleeding from the base fracture.
Q: How would you code the following injury; small intraventricular
hemorrhage in the third and fourth ventricles with associated
obstructive hydrocephalus? - ANSWER-A: The only codes for IVH are
located within the cerebrum chapter of the dictionary and are listed on
page 48 of your dictionary, but the answer will depend upon whether
the patient is unconscious. There are 3 separate codes and if you
patient was unconscious for > than 6 hours you would use the code
140677.4. You can only apply this coma modifier one time when you are
coding your injuries. There us no code for the obstructive
hydrocephalus which is a consequence of the hemorrhage, and a
sequela that cannot be coded.
4|Page
And Practice Exam 2026-2027 With Complete
Questions And Correct Detailed Answers| Brand New
Version!
Q: You have the following finding on a patients MRI - "small epidural
hematoma from C7-T1 which is likely emanating from the compression
fracture of T1? " He does not have a C7 fracture. What would you code
especially considering it involves the cervical and thoracic spine? -
ANSWER-A: You should code the epidural at the highest level (C7)
unless you have evidence of deficit at a lower level. You may not
"double dip" and code the epidural again in the T-spine. Again, if there
is no deficit, code 640200.3 for the epidural hematoma and 650430.2
for the compression fracture of T 1. If there would be a deficit with this
injury then you would code the deficit at the level that it occurs.
Q: What is the correct code for epidural hematoma extending to various
levels of the spine, for example T12-L2, or C1-2-3-4 FXs with an epidural
at level C2? - ANSWER-A: A spinal epidural with no deficit is coded at
the most superior level at which it is found. In the case of the first
example T12-L1 it would be coded under the T-spine codes. If the
patient has a deficit it makes a difference in the coding. 640200.3 is
where you would code the C2 epidural, C1 gets the fx code only, C3
through C4 fxs are each coded individually. The problem is that the
descriptor for C - spine fractures reads "Fx with or without dislocation
but no cord involvement. If you follow the rules strictly you should not
1|Page
,code the C2 fx on p 104, but if there is no deficit you can"t code the C2
fx with the epidural code; you would have to pick between transient,
incomplete and complete on that page to get to a fx code. You will lose
one or the other finding (the C2 fx or the epidural).
Q: How and when can I code "concussion"? - ANSWER-A: You may only
code "concussion" (specifically codes 161000.1 and 161001.1) when the
word "concussion" is given by the MD as the only brain injury diagnosis.
Q: How do you code cerebral shear injuries that have loss of
consciousness less than 6 hours? - ANSWER-A: The correct code is
140643.2 found under "Cerebrum: hematoma, intracerebral, tiny -
petechial hemorrhage(s) [includes radiographic "shearing" lesions] not
associated with coma > 6 hours."
Q: What do I code if the patient has LOC and an associated anatomical
head lesion? - ANSWER-A: If the patient has an anatomic injury to the
brain (e.g. SDH, IVH, SAH, etc.) in addition to LOC, the LOC will only be
acknowledged by AIS if there is a coma modifier listed with the injury.
Remember that in AIS 2008 LOC/coma can only be assigned to one
injury [rule page 40] so if you have two injuries with coma modifiers,
use the one that provides the highest AIS value for coma and code the
other as NFS.
2|Page
,Q: A patient arrives to the ED with a severe head injury; he is
transported to the ICU in anticipation of organ donation and while the
brain death evaluation is completed. His final diagnoses include the
expected head injury and brain death. What do you do when coding
this chart regarding the brain death itself? - ANSWER-A: Brain death is a
situation not an injury. The coder would appropriately code the lesions
identified on CT as well as any edema. However, brain death is a
sequelae of those injuries. If the patient had no codeable injuries in the
brain, the only option in that situation would be to evaluate the chart
for a traumatic anoxic event.
Q: What is the correct code for an internal carotid artery occlusion? -
ANSWER-A: This is impossible to answer correctly unless you have more
information. The internal carotid artery can be coded under HEAD
121004.4 if the occlusion occurs in that portion of the artery, or under
NECK 320220.3 if the occlusion occurs lower.
Q: A patient with diffuse axonal injury (DAI), confirmed by both clinical
and radiologic evidence, also has an intraventricular hemorrhage and
subarachnoid hemorrhages. This patient remained unconscious from
the time of the insult until discharge from the ICU 7 days after
admission. How would you code the intraventricular hemorrhage and
subarachnoid hemorrhages in AIS 2005? - ANSWER-A: These injuries
should not be coded. DAI is an example of a global injury which may or
may not be accompanied by other radiologic findings. A clarification for
coding DAI is now included on page 40.
3|Page
, Q: What is the correct code for the diagnosis "Subdural hematoma
7mm thickness"? - ANSWER-A: The correct code is 140652.4. If the
specific region of the brain (brain stem, cerebellum or cerebrum) is not
indicated, the injury should be assigned to the cerebrum.
Q: A patient sustains a basilar skull fracture, fractured L zygoma and a
nasal fracture. She has bilateral periorbital ecchymosis. There is no
mention in the chart of cerebral spinal fluid (CSF) leak. How would you
code the basilar skull fracture? - ANSWER-A: The correct code is
150202.3. If the patient has a CSF leak, the treating physician(s) will
always mention it in the chart. When there is no mention of CSF leak,
the coder may use the "without CSF leak" code. The periorbital
ecchymosis could be due to the nasal fracture and is not necessarily a
sign of bleeding from the base fracture.
Q: How would you code the following injury; small intraventricular
hemorrhage in the third and fourth ventricles with associated
obstructive hydrocephalus? - ANSWER-A: The only codes for IVH are
located within the cerebrum chapter of the dictionary and are listed on
page 48 of your dictionary, but the answer will depend upon whether
the patient is unconscious. There are 3 separate codes and if you
patient was unconscious for > than 6 hours you would use the code
140677.4. You can only apply this coma modifier one time when you are
coding your injuries. There us no code for the obstructive
hydrocephalus which is a consequence of the hemorrhage, and a
sequela that cannot be coded.
4|Page
