Note from the CCDS Coordinator: Coding an avian ski mishap

CDI Blog - Volume 11, Issue 6


The ski accident victims

by Penny Richards

Gold metal dreams were dashed Monday evening for a pair of Olympic hopefuls during a skiing mishap that one first responder says was likely caused by an over-indulgence in egg nog.

ACDIS CDI Education Director Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, reports that when she woke, dressed in her power suit, and came down stairs to start her day, she found two victims of the ski accident on the living room floor.

She dialed 911 and then set about stabilizing a male fuzzy bird and his female companion. Prescott said the pair were able to tell her that they had tumbled from an elevated ski run. She stabilized each and assisted transporting the pair for medical repair.

After consulting on the case with medical professionals, Prescott noted the following in the medial records:

Mister Bird:

S72.461C Traumatic displaced open supracondylar fracture with intracondylar extension of lower end of right femur, initial encounter for type IIIB open fracture

S06.5X2A Traumatic subdural hemorrhage with loss of consciousness of 38 minutes, initial encounter

S37.021A Traumatic renal contusion, major. Initial encounter.

Y93.23 Activity-Snow skiing

Y90.5 Evidence of alcohol involvement, BAL 115 mg/100ml

MS-DRG 965 Multiple Significant Trauma without CC/MCC

Lady Bird:

S02.2XXB Open nasal fracture, initial encounter

S62.132A Displaced, closed fracture of left wrist, initial encounter

S42.452A Closed fracture, lateral condyle of humerus

Y93.23 Activity-Snow skiing

Y90.5 Evidence of alcohol involvement, BAL 115 mg/100ml

MS-DRG 155 other ear, nose, mouth and throat diagnoses with CC

“Both victims had elevated blood alcohol levels,” Prescott said, “and I noticed that an empty bottle of rum stuffed in the trash basket. I hadn’t had a drop myself.”

Both birds are expected to recover but may have to retire their Olympic dreams. Police are considering charging the pair with SUI (skiing under the influence).

Editor’s note: Richards is the CCDS coordinator at ACDIS. Contact her at prichards@acdis.org.

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ACDIS Guidance, Clinical & Coding