For coding severity, which source should the coder reference?

The correct source for reference when determining coding severity is the AIS definition. The Abbreviated Injury Scale (AIS) provides a standardized system for classifying and scoring the severity of injuries. It is widely recognized and utilized in clinical settings to ensure consistency in the assessment of injuries and their associated impacts.

Using the AIS definition allows coders to accurately assess and document the severity of injuries based on objective criteria rather than subjective accounts. This contributes to the reliability and validity of the coding process, aiding in the provision of high-quality patient care and supporting healthcare reimbursement processes.

Other sources, such as the patient's description, the physician's description, or insurance guidelines, may provide valuable information or context but are not as standardized or universally applicable as the AIS definition. These resources can be influenced by personal perceptions or may vary in terminology and interpretation, which can lead to inconsistencies in coding if relied upon primarily.