AIS Receiving Facility Diagnoses

Use of Receiving Facility Data in Referring Facility Registry Coding

Position Statement by the AIS Content Subcommittee

There is an understanding that the sending facility, no matter what level trauma center, may not acquire the full list and severity of all injuries prior to transfer for higher level or specialized care. It is the rule for AIS coding, that only the injuries identified during the time spent at the referring facility should be coded and entered into the trauma registry for that facility. The severity of the injury should be coded to that which was known prior to transfer.

The receiving facility may use the documentation and radiographic/operative findings from the referring facility in their registry diagnosis coding. These should, however, be confirmed through additional films or the over-reads by the trauma surgeons and/or radiologists for accuracy and detail.

For the purposes of performance improvement (PI), the receiving facility may send a list of injuries, severity, and/or AIS codes to the referring facility. These should be noted in the PI modules of the registry, however, not entered into the diagnosis codes as they were not diagnosed at that referring hospital. PI should review for any missed injuries, misdiagnosed injuries, and or alternate severity of injury for learning and identification of any opportunity for improvement.

Accurate coding continues to be expected with documentation of support as per the current version AIS requirements, documentation hierarchy, and evidence of the injury (acceptable clinical diagnoses per the AIS rule). Coding must reflect the injuries and severity identified at the time of care within the relevant facility.

Kathy J. Cookman, BS, CSTR, CAISS, EMT-P, FMNP

AIS Business Director/International Technical Coordinator AAAM

For any questions on this statement, please contact info@aaam.org.

Published: June 13, 2024