Question

A 56-year-old woman is admitted to an acute-care facility from a skilled nursing facility. The patient has multiple sclerosis and hypertension. During the course of hospitalization a decubitus ulcer is found and debrided at the bedside by a physician. There is no typed operative report and no pathology report. The coder should:

Answer 1

The coder should assign the appropriate codes based on the documentation available, including the bedside debridement procedure for the decubitus ulcer. They should also assign codes for the patient's multiple sclerosis and hypertension.

Step-by-step explanation:

The coder should assign the appropriate codes based on the documentation available. Since there is no operative report and no pathology report, the coder should still assign the codes for the decubitus ulcer based on the documentation of the bedside debridement procedure. The coder should also assign codes for the patient's multiple sclerosis and hypertension, as well as any other relevant diagnoses or procedures mentioned in the documentation.