Coding For Multi-System Trauma Patients
Coding for Multi-SystemTrauma PatientsAudio Seminar/WebinarApril 9, 2009Practical Tools for Seminar Learning Copyright 2009 American Health Information Management Association. All rights reserved.
DisclaimerThe American Health Information Management Association makes norepresentation or guarantee with respect to the contents herein andspecifically disclaims any implied guarantee of suitability for any specificpurpose. AHIMA has no liability or responsibility to any person or entity withrespect to any loss or damage caused by the use of this audio seminar,including but not limited to any loss of revenue, interruption of service, lossof business, or indirect damages resulting from the use of this program.AHIMA makes no guarantee that the use of this program will preventdifferences of opinion or disputes with Medicare or other third party payersas to the amount that will be paid to providers of service.CPT five digit codes, nomenclature, and other data are copyright 2009American Medical Association. All Rights Reserved. No fee schedules, basicunits, relative values or related listings are included in CPT. The AMAassumes no liability for the data contained herein.As a provider of continuing education the American Health InformationManagement Association (AHIMA) must assure balance, independence,objectivity and scientific rigor in all of its endeavors. AHIMA is solelyresponsible for control of program objectives and content and the selectionof presenters. All speakers and planning committee members are expectedto disclose to the audience: (1) any significant financial interest or otherrelationships with the manufacturer(s) or provider(s) of any commercialproduct(s) or services(s) discussed in an educational presentation; (2) anysignificant financial interest or other relationship with any companiesproviding commercial support for the activity; and (3) if the presentation willinclude discussion of investigational or unlabeled uses of a product. Theintent of this requirement is not to prevent a speaker with commercialaffiliations from presenting, but rather to provide the participants withinformation from which they may make their own judgments.The faculty has reported no vested interests or disclosures regarding thispresentation.AHIMA 2009 Audio Seminar Series http://campus.ahima.org/audioAmerican Health Information Management Association 233 N. Michigan Ave., 21st Floor, Chicago, Illinoisi
FacultyJoanne M. Becker, RHIT, CCS, CCS-PJoanne M. Becker is associate director, Joint Office for Compliance, at the University ofIowa Healthcare, in Iowa City, IA. She is also an independent HIM consultantspecializing in hospital and physician coding, education, and compliance. Ms. Beckerhas over 20 years experience in HIM, including education, compliance, physicianoffices, long-term care, and acute care hospital settings.Karen G. Youmans, MPA, RHIA, CCSKaren G. Youmans is president of YES HIM Consulting, Inc. in Largo, FL. Ms.Youmans has been an HIM and coding consultant in various capacities, includingall aspects of HIM operations, interim management, revenue cycle improvement,coding education, and electronic health records. She has also written numerousarticles on HIM topics, and is the author of Basic Healthcare Statistics for HealthInformation Management Professionals, published by AHIMA.AHIMA 2009 Audio Seminar Seriesii
Table of ContentsDisclaimer . iFaculty . iiObjectives . 1Injuries and E-CodesInjury and Poisoning . 1-2Polling Question #1 . 2External Causes. 3-5E-Codes with Injuries . 5-6External Causes – Late Effects . 6Polling Question #2 . 7Principal DX . 7-9Fractures .9-11Fractures - Stress . 11-12Fractures - Dislocation .12Fractures - Pathological. 13-14Polling Question #3 .14Acute Fracture vs. AftercareKey Point .15Aftercare .15Examples of Aftercare .16Active Treatment .16Example . 17-18Complications of Trauma Including Fractures .18Compartment Syndrome . 19-20Complications of Surgical Treatment of Fractures . 20-21Malunions and Non-unions .22Late Effects.22Late Effect of Fracture .23Pain After Injury .24Polling Question #4 .25PathophysiologyPathophysiology Disruption Wound .25Pathophysiology Head Injuries . 26-29Pathophysiology Post-Traumatic Headaches.29Pathophysiology Joint Replacement Complications. 30-31Pathophysiology Pneumothorax . 31-32Pathophysiology Post-Traumatic Seroma .32Pathophysiology Acute Respiratory Distress Syndrome (ARDS) .33Pathophysiology SIRS .34BurnsPolling Question #5 .34(CONTINUED)AHIMA 2009 Audio Seminar Series
Table of ContentsBurn Classification Codes .35Other Codes.35Degrees of BurnsFirst Degree .36Second Degree .37Third Degree .38Burn Sequencing . 39-40Non-healing Burns .41Late Effect of Burns . 41-42Late Effects and Current Burns .42Rules of Nines .43Rules of Nines Diagrams .44Category 948 . 45-46Complications of Burns .47Rules of Nines .47Trauma Registry IssuesPolling Question #6 .48Trauma Registry . 48-52ED CodingPolling Question #7.52ED Coding Issues . 53-54Case StudiesCase Study #1 .55Case Study #1: Multiple Chest Trauma.55Case Study #2 .56Case Study #2: Frontal Sinus Fractures .56Case Study #2: Frontal Bone .57Case Study 32: Frontal Sinus Fracture . 57-59Resource/Reference List .59Audio Seminar Discussion .60Become a Member Today ! .60Audio Seminar Information Online .61Upcoming Audio Seminars .61Thank You/Evaluation Form and CE Certificate (Web Address) .62Appendix.63Resource/Reference List .64CE Certificate InstructionsAHIMA 2009 Audio Seminar Series
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsObjectives Identify typical disease processes andcorrect ICD-9-CM diagnosis codes fortrauma patients Review trauma diagnostic coding andreporting guidelines formultidisciplinary providers andCoding Clinic References1Injury and PoisoningCoding Clinic 4Q 2008ICD-9-CM Official Guidelines for Coding and ReportingEffective October 1, 2008Chapter 17: Injury and Poisoning (800-999) Coding of Injuries When coding injuries, assign separate codes for eachinjury unless a combination code is provided, in whichcase the combination code is assigned. Multiple injurycodes are provided in ICD-9-CM, but should not beassigned unless information for a more specific code is notavailable. These codes are not to be used for normal,healing surgical wounds or to identify complications ofsurgical wounds. The code for the most serious injury, as determined by theprovider and the focus of treatment, is sequenced first.2AHIMA 2009 Audio Seminar Series1
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsInjury and Poisoning1) Superficial injuriesSuperficial injuries such as abrasions orcontusions are not coded when associated withmore severe injuries of the same site.2) Primary injury with damage tonerves/blood vesselsWhen a primary injury results in minor damage toperipheral nerves or blood vessels, the primaryinjury is sequenced first with additional code(s)from categories 950-957, Injury to nerves andspinal cord, and/or 900-904, Injury to bloodvessels. When the primary injury is to the bloodvessels or nerves, that injury should be sequencedfirst.3Polling Question #1Which of the following best describesthe type of facility where you areworking/coding?*1*2*3*4*5Level I trauma centerAcute carePhysician (profee)Trauma RegistryOther4AHIMA 2009 Audio Seminar Series2
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsExternal CausesChapter 19. Supplemental Classification ofExternal Causes of Injury and Poisoning (Ecodes, E800-E999) Introduction: These guidelines are provided forthose who are currently collecting E codes inorder that there will be standardization in theprocess. If your institution plans to begincollecting E codes, these guidelines are to beapplied. The use of E-codes is supplemental tothe application of ICD-9-CM diagnosis codes. Ecodes are never to be recorded as principaldiagnoses (first-listed in non-inpatient setting)and are not required for reporting to CMS. 5External Causes Some major categories of E-Codes include: transport accidents poisoning and adverse effects of drugs,medicinal substances and biologicals accidental falls accidents caused by fire and flames accidents due to natural and environmentalfactors late effects of accidents, assaults or self injury assaults or purposely inflicted injury suicide or self inflicted injury6AHIMA 2009 Audio Seminar Series3
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsExternal Causes These guidelines apply for the coding andcollection of E-codes from records inhospitals, outpatient clinics, emergencydepartments, other ambulatory caresettings and provider offices, and nonacute care settings, except when otherspecific guidelines apply.7External Causes General E-Code Coding Guidelines1) Used with any code in the range of 001V892) Assign the appropriate E-code for allinitial treatments3) Use the full range of E-codes4) Assign as many E-codes as necessary8AHIMA 2009 Audio Seminar Series4
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsExternal Causes General E-Code Coding Guidelines(con’t)5) The selection of the appropriate E-code6) E-code can never be a principaldiagnosis7) External cause code(s) with systemicinflammatory response syndrome (SIRS)9E-Codes with InjuriesMultiple Cause E-Code Coding Guidelines The E-code listed first should correspond tothe cause of the most serious diagnosis. Sequencing for E-Codes: E-Codes for child and adult abuse takeprecedence over all other E-Codes E-Codes for cataclysmic events take priority overall E-Codes except child and adult abuse.Include storms, floods, hurricanes, tornadoes,blizzards, volcanic eruptions, earthsurfacemovements and eruptions.10AHIMA 2009 Audio Seminar Series5
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsE-Codes with Injuries When an transportation accidentoccurs that involves more than onetype of vehicle, the Tabular notes thefollowing order of precedence: Aircraft and spacecraft Watercraft Motor vehicle Railway Other road vehicles11External Causes – Late Effects Late Effects of External Cause Guidelines1) Late effect E-codes2) Late effect E-codes (E929, E959, E969,E977, E989, or E999.1)3) Late effect E-code with a related currentinjury4) Use of late effect E-codes forsubsequent visits12AHIMA 2009 Audio Seminar Series6
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsPolling Question #2Do you assign E-codes (external causes)routinely for your trauma cases?*1 Yes*2 No13Principal DX The principal diagnosis is defined inthe Uniform Hospital Discharge DataSet (UHDDS) as “that conditionestablished after study to be chieflyresponsible for occasioning theadmission of the patient to thehospital for care.” CC4Q200814AHIMA 2009 Audio Seminar Series7
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsPrincipal Dx When there are two or more interrelatedconditions (such as diseases in the sameICD-9-CM chapter or manifestationscharacteristically associated with a certaindisease) potentially meeting the definitionof principal diagnosis, either condition maybe sequenced first, unless the circumstancesof the admission, the therapy provided, theTabular List, or the Alphabetic Indexindicate otherwise. CC4Q200815Principal Dx When the admission is for treatment ofa complication resulting from surgeryor other medical care, the complicationcode is sequenced as the principaldiagnosis. If the complication isclassified to the 996-999 series andthe code lacks the necessaryspecificity in describing thecomplication, an additional code forthe specific complication should beassigned. CC4Q200816AHIMA 2009 Audio Seminar Series8
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsPrincipal Dx Sequencing for Injury Codes If the encounter/admission is due toinjury and several injuries are present,the code for the most severe injury isdesignated as the principal diagnosis. If the diagnostic statement is not clear,the physician should be queried.17Fractures Coding of Traumatic Fractures CC4Q2008 The principles of multiple coding ofinjuries should be followed in codingfractures. Fractures of specified sites are codedindividually by site in accordance withboth the provisions within categories800-829 and the level of detail furnishedby medical record content.18AHIMA 2009 Audio Seminar Series9
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsFractures Combination categories for multiplefractures are provided for use whenthere is insufficient detail in themedical record (such as trauma casestransferred to another hospital), whenthe reporting form limits the numberof codes that can be used in reportingpertinent clinical data, or when thereis insufficient specificity at the fourthdigit or fifth-digit level.19Fractures Closed fracture is a fracture that does notproduce an open wound in the skin. Open fracture is a fracture in which awound, through the adjacent or overlyingsoft tissues, communicates with the site ofthe break.20AHIMA 2009 Audio Seminar Series10
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsFracturesMore specific traumatic fractureguidelines are as follows:1) Acute Fractures vs. Aftercare2) Multiple fractures of same limb3) Multiple unilateral or bilateral fracturesof same bone4) Multiple fracture categories 819 & 8285) Multiple fractures sequencingCC4Q200821Fractures - Stress Definition: a fracture caused by unusual orrepeated stress on a bone, such as withsoldiers or athletes. Called also fatigue ormarch fracture.Dorland’s Medical Dictionary22AHIMA 2009 Audio Seminar Series11
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsFractures - Stress Effective October 1, 2008, subcategory 733.9,Other and unspecified disorders of bone andcartilage, has been further revised to include newcodes for stress fracture of femoral neck(733.96); stress fracture of shaft of femur(733.97); and stress fracture of pelvis(733.98). Also, new “use additional code” notes have beenadded at each code in subcategory 733.9, to “useadditional external cause code(s) to identify thecause of the stress fracture.”23Fracture s- Dislocation Question: While the ICD-9-CM category for fracturesincludes dislocation, many area orthopedic surgeons insist thediagnosis of fracture-dislocation can be coded to both thefracture and the dislocation. Should both reduction of afracture and reduction of a dislocation be coded if it is of thesame site? Answer: Under Dislocation, the Alphabetic Index directs thecoder to "see fracture, by site." Under the main term,Fracture, dislocation is included in parentheses as anonessential modifier. For purposes of classification, ICD-9CM assigns only the fracture code to fracture-dislocations ofthe same site. It is incorrect to also code the dislocation.Reduction of fracture-dislocation is coded to reduction offracture. No additional code is assigned for reduction ofdislocation. CC3Q199024AHIMA 2009 Audio Seminar Series12
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsFractures - Pathological Definition: fracture due to weakeningof the bone structure by pathologicprocesses, such as neoplasia,osteomalacia, osteomyelitis, and otherdiseases. Called also secondaryfracture and/or spontaneous fracture.Dorland’s Medical Dictionary25Fractures - Pathological Assign a code within subcategory 733.1when the fracture is newly diagnosedand while the patient is receiving activetreatment for the fracture. Examples of active treatment are: surgical treatment emergency department encounter evaluation and treatment by a newphysician.CC4Q2008AHIMA 2009 Audio Seminar Series2613
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsFractures - PathologicalQuestion: When a SNF patient has multiple problemsincluding a chronic vertebral pathological fracture withorders for pain medication, what is the appropriatecode to assign to identify the chronic pathologicalvertebral fracture? Answer: Assign code 733.13, Pathologic fracture ofvertebrae, for a chronic vertebral fracture for whichthe patient is receiving medication. Note that code V54.27 would not be assigned as theaftercare codes are limited to follow-up care duringthe healing or recovery phase of an acute fracture. Also note code 338.2 would not be assigned since theunderlying condition is known. CC3Q2008 27Polling Question #3Do your physicians clearly documenttraumatic versus pathological fractures?*1 Yes*2 No28AHIMA 2009 Audio Seminar Series14
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsAcute Fracture vs. Aftercare Key Point: There is no time frame associated with an“acute”, “chronic”, or “late-effect”29Acute Fracture vs. Aftercare Aftercare: Codes from the subcategories V54.0,V54.1, V54.8 or V54.9 are for encountersafter the patient has completed activetreatment of the fracture and is receivingroutine care for the fracture during thehealing or recovery phase.30AHIMA 2009 Audio Seminar Series15
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsAcute Fracture vs. Aftercare Examples of aftercare include: Cast changes or removal Removal of external or internal fixationdevices Medication adjustment Follow up visits following fracturetreatment31Acute Fracture vs. Aftercare Active treatment includes: Surgical treatment Emergency department encounter Evaluation and treatment by a newphysician32AHIMA 2009 Audio Seminar Series16
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsAcute Fracture vs. Aftercare Example: Patient is admitted to Hospital A withsevere fracture of shaft of the femur;transferred to Hospital B for treatment. Both Hospital A and B would assign821.01 – Fracture, shaft of femur and theappropriate E-code. AHA Coding Clinic (CC) 1Q 200733Acute Fracture vs. Aftercare Example: At Hospital A, a patient presents with severetraumatic fracture and soft tissue injury.The physician applies an external fixationdevice and discharges the patient to allowthe soft tissue swelling to resolve. Thepatient is later readmitted for ORIF. The acute fracture is assigned for bothadmissions, along with the appropriate Ecode(s). AHA Coding Clinic (CC) 1Q 200734AHIMA 2009 Audio Seminar Series17
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsAcute Fracture vs. Aftercare Example: Patient presents to hospital fordistal radial traumatic fracture. ORIFperformed. The patient follows up in thesurgeon’s office two weeks later. An x-rayis taken to confirm stability.The acute fracture code is assigned for boththe hospital and surgeon for the ORIF. Thefollow-up diagnosis at the surgeon’s officeand for the x-ray service is coded to followup healing traumatic fracture.AHA Coding Clinic (CC) 1Q 200735Complications of TraumaIncluding Fractures Complications can include air or fatembolism, traumatic shock,compartment syndrome, hemorrhageand many others. Early complications of trauma that arenot included in the code for the injuryare classified in category 958, Certainearly complications of trauma36AHIMA 2009 Audio Seminar Series18
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsCompartment Syndrome Compartment Syndrome Common causes of compartmentsyndrome include fractures and severecontusions Begins with tissue edema after injury If edema develops within a closed fascialcompartment, there is little room forexpansion37Compartment Syndrome Example: Patient was playingbasketball, fell and twisted his leftlower leg. Patient’s ankle waswrapped and continued playing.Three days later the patient presentsto the ER for increased pain, swelling,and feeling “hard”. Patient isdiagnosed with distal fibular fractureand early compartment syndrome.38AHIMA 2009 Audio Seminar Series19
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsCompartment Syndrome 824.8 – Fracture distal fibula 958.92 – Traumatic compartmentsyndrome of lower extremity39Complications ofSurgical Treatment of Fractures Care for complications of surgicaltreatment for fracture repairs arecoded with the appropriatecomplication code(s).40AHIMA 2009 Audio Seminar Series20
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsComplications ofSurgical Treatment of Fractures Example: Patient is status post ORIFof left ankle, now presenting withareas of infection surroundingembedded screws. 996.67 – Infection and inflammatoryreaction due to internalorthopedic device, implantand graft41Complications ofSurgical Treatment of Fractures Example: Patient suffers a heavilycontaminated open fracture of thelateral malleus and undergoes ORIF.Patient presents two weeks later withevidence of infection. 958.3 – Posttraumatic wound infection42AHIMA 2009 Audio Seminar Series21
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsMalunions and Non-unions Care of complications of fractures,such as malunion and nonunion, arereported with the appropriate codes. 733.81 – Malunion of fracture 733.82 – Nonunion of fracture43Late Effects Late Effects A late effect is the residual effect after theacute phase of an illness or injury hasterminated. There is no time limit on when a lateeffect code can be used. Late effects may occur early, or months oryears later, such as that due to a previousinjury.44AHIMA 2009 Audio Seminar Series22
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsLate Effect of Fracture Example: Patient suffered nasalfracture 20 years ago. No definitivetreatment performed at that time.Patient presents now with nasalairway obstruction, difficultybreathing and external nasaldeformity.45Late Effect of Fracture Coding: 738.0 – Acquired deformity of nose 905.0 – Late effect of fracture ofskull/face bones46AHIMA 2009 Audio Seminar Series23
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsPain After Injury Codes from the 338 category aresequenced based on thecircumstances of the encounter If the encounter is for pain control orpain management, assign the codefrom the 338 category followed by thesite of the pain47Pain After Injury Example: Neck pain from trauma 338.11 Acute pain due to trauma 723.1 Cervicalgia48AHIMA 2009 Audio Seminar Series24
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsPolling Question #4When coding trauma cases, which of thefollowing do you consider the mostchallenging?*1*2*3*4*5Principal/first-listed diagnosis selectionAcute vs. aftercareProcedure codingDocumentation issuesOther49Pathophysiology Disruption Wound Effective October 1, 2008, codes in category 998.3,Disruption of operation wound, were revised andtwo new codes 998.30, Disruption of wound,unspecified, and 998.33, Disruption of traumaticinjury wound repair, were created to further clarifythe reporting of a wound dehiscence. Disruption of traumatic injury wound repair(998.33) refers to disruption or dehiscence of apreviously closed traumatic laceration, whetherexternal or internal. By contrast, codes 998.31 and998.32 are used for operative or surgical wounds.50AHIMA 2009 Audio Seminar Series25
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsPathophysiology Head Injuries The diagnosis of concussion, category850, refers to cerebral bruising leadingto transient unconsciousness or noloss of consciousness. Patients withhead injuries are often confused ordisoriented for a short period after thehead injury impact. At times, it isdifficult to determine ifunconsciousness occurred for one ormore minutes.51Pathophysiology Head Injuries Many times, the physician relies onother clinical findings in making thediagnosis of concussion. Note thatICD-9-CM provides for the diagnosis ofconcussion to be coded without knownloss of consciousness (code 850.0)which can be based on clinical featuresof mental confusion or disorientation.CC2Q199252AHIMA 2009 Audio Seminar Series26
Coding for Multi-System Trauma PatientsNotes/Comments/QuestionsPathophysiology Head Injuries Note that when the closed or open headinju
Coding ClinicReferences 1 Injury and Poisoning Coding Clinic 4Q 2008 ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2008 Chapter 17: Injury and Poisoning (800-999) Coding of Injuries When coding injuries, assign separate codes for ea
Bruksanvisning för bilstereo . Bruksanvisning for bilstereo . Instrukcja obsługi samochodowego odtwarzacza stereo . Operating Instructions for Car Stereo . 610-104 . SV . Bruksanvisning i original
Behind the Term: Trauma Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. 1 Behind the Term: Trauma Related terms: complex trauma, historical trauma, human-caused trauma, naturally caused trauma, trauma,
categories of trauma as a framework for trauma assessment. “Little t” trauma “Big T” trauma Complex trauma “Little t” Trauma “Little t” trauma involves events that we encounter day to day that can make life difficult but are not out of the ord
The assessed content included prima - ry survey, secondary survey, airway and ventilation, circulation, shock, thoracic trauma, head/spinal trauma, abdomen/pelvis trauma, musculoskeletal trauma, paediatric trauma, geriatric trauma, obstetric trauma, trans - fer of care, and other course specific inclusions.
LEVEL I PEDIATRIC TRAUMA CENTER The Level I Regional Pediatric Trauma and Burn Center at Children’s Hospital Colorado is a large, multi-disciplinary program. We provide timely, comprehensive, cost- . Trauma/Burn Medical Director Trauma/Burn Program Manager Trauma Coordinators Trauma Registrars Staff Assi
10 tips och tricks för att lyckas med ert sap-projekt 20 SAPSANYTT 2/2015 De flesta projektledare känner säkert till Cobb’s paradox. Martin Cobb verkade som CIO för sekretariatet för Treasury Board of Canada 1995 då han ställde frågan
service i Norge och Finland drivs inom ramen för ett enskilt företag (NRK. 1 och Yleisradio), fin ns det i Sverige tre: Ett för tv (Sveriges Television , SVT ), ett för radio (Sveriges Radio , SR ) och ett för utbildnings program (Sveriges Utbildningsradio, UR, vilket till följd av sin begränsade storlek inte återfinns bland de 25 största
Hotell För hotell anges de tre klasserna A/B, C och D. Det betyder att den "normala" standarden C är acceptabel men att motiven för en högre standard är starka. Ljudklass C motsvarar de tidigare normkraven för hotell, ljudklass A/B motsvarar kraven för moderna hotell med hög standard och ljudklass D kan användas vid
