Question

The patient is an elderly woman with dementia who was brought to the ED for a suspected hip fracture. She is evaluated and found to have a left trochanteric fracture, dementia, malnourishment, stage 1 pressure ulcer on right buttock. She undergoes surgical repair of the fracture. On Day 5, the ulcer is noted to be stage 2 and the wound care staff begins treatment.

Which of the following statements is correct for this case?
A. The stage 1 pressure ulcer on right buttock is coded in addition to a stage 2 pressure ulcer on right buttock.
B. Only the stage 1 pressure ulcer on right buttock is coded because it was the one present on admission.
C. Only the stage 2 pressure ulcer on right buttock is coded because it is the more severe of the two.
D. Neither stage of the pressure ulcer is coded because the wound care staff has begun treating it while the patient is still in the hospital.

Answer 1

The correct code for this scenario is for the stage 2 pressure ulcer, as coding guidelines require reflecting the highest stage diagnosed during the patient's admission, regardless of the treatment initiated.

Step-by-step explanation:

The correct statement for this case is: Only the stage 2 pressure ulcer on right buttock is coded because it is the more severe of the two. When coding for pressure ulcers, the highest stage diagnosed during the admission should be coded. In this scenario, even though the patient was admitted with a stage 1 pressure ulcer, it progressed to a stage 2 during her hospital stay.

Therefore, the coding would reflect the most severe condition, which is the stage 2 ulcer. The treatment by the wound care staff does not affect the coding; coding reflects the condition of the patient during the stay. Treatment provided in the hospital is essential for the patient's recovery but is separate from the issue of documentation and coding. Medical coding must accurately reflect the severity of the patient's conditions, and in the case of pressure ulcers, it is crucial to code the most severe stage noted in the medical record during the stay.