Question

A patient is admitted from a nursing home with pneumonia following a long period of immobilization due to hip surgery for a fracture. Also noted in the history and physical is "an area over the sacrum with partial-thickness skin loss of epidermis."

Admission diagnoses: Pneumonia, dementia, sacral decubitus ulcer.
How will the coder report this case?
A. Pneumonia, stage 2 sacral decubitus ulcer, dementia
B. Pneumonia, sacral decubitus ulcer unspecified stage, dementia
C. Pneumonia, stage 1 sacral decubitus ulcer, dementia
D. Pneumonia, unstageable sacral decubitus ulcer, dementia

Answer 1

The coder should report this case as Option A: Pneumonia, stage 2 sacral decubitus ulcer, dementia.

Step-by-step explanation:

The coder should report this case as Option A: Pneumonia, stage 2 sacral decubitus ulcer, dementia. The patient's admission diagnoses include pneumonia, dementia, and a sacral decubitus ulcer with partial-thickness skin loss of the epidermis. The stage of the sacral decubitus ulcer is specified as stage 2. It's important for the coder to include all relevant diagnoses and their corresponding stages, as this provides a comprehensive picture of the patient's condition.