When determining the severity of an injury, what should a coder select if uncertain?

When determining the severity of an injury, selecting the least severe AIS code in situations of uncertainty allows for a conservative approach to coding. This method prioritizes patient safety and appropriate resource allocation, assuming the least traumatic impact in unclear cases. By choosing the least severe code, the coder avoids overstating the severity of the injury, which could lead to unnecessary escalations in treatment or costs.

Additionally, employing the least severe code aligns with coding guidelines that often advocate for accuracy and caution when clinical details are ambiguous. This choice underscores the importance of making conservative coding decisions, particularly in complex scenarios where the full extent of the injury might not be immediately evident.